I read an article a few months back in one of the freebie podiatry magazines that had an article about music in the OR.  I didn’t think much about the article at first since music is just one of the norms for me in the OR.  But later talking to a few patients, most are surprised to see the relaxed attitude in our OR.  Much of that comfort zone is created by music.  

The feel of the OR is something that is very important to me.  As captain of the ship, I want to create a work environment that is positive.  I’ve had my bad OR experiences and actively work to avoid them.  What’s a bad OR experience?  What I find to be most important is the simple fact that people care.  For instance, what about the OR where the scrub tech is more interested is getting their break than they are focusing on the case?  I’ve had experiences where in a short 30-40 minute case, I’ve had three scrub tech come and go.  To me that’s disruptive. 

What’s all this have to do with music in the OR?  It’s all about setting the mood.  It’s the mood where the surgeon can focus and the staff is engaged.  When the mood is good, the case will progress well and the outcome is going to be better. 

So if you like blues, jazz or Phish, you’ll be doing great in my little OR.

Jeffrey A. Oster, DPM
Chief Medical Officer
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

Uncompensated rearfoot varus is one of the many conditions that need to be evaluated when defining the surgical plan for a high arch foot (cavus foot) or in cases of lateral ankle instability.  Rearfoot varus is evaluated with the patient facing away from you while standing.  In cases of rearfoot varus, the heels will appear to roll in as follows;  \  /.  Uncompensated rearfoot varus describes rearfoot varus that cannot be manually reduced to a vertical position; l l .  The degree of rearfoot varus is often evaluated with x-ray view called a ski jump or Isherwood view. 

If uncompensated rearfoot varus is found to be a contributing factor to the cavus deformity or lateral ankle instability, surgical treatment choices include either a Dwyer osteotomy of transpositional osteotomy of the calcaneus.  Let’s take a look at both of these and see how they compare.

The Dwyer osteotomy is performed with the patient in a lateral position.  The incision is placed parallel to the peroneal tendons.  Dissection is carried down to bone and periosteum is reflected.  A saw is then used to perform a wedge in the calcaneus.  The wedge is wide on the lateral side of the heel.  Typical size of the wedge is 1-2 cm.  Upon removal of the wedge, the foot can be dorsiflexed against the resistance of the Achilles to close the wedge.  With an intact medial hinge, the wedge will close.  The wedge is then feathered with a saw and fixated.  Alternatives for fixation include a table staple, fixation plate or screws.

A transpositional osteotomy, or what is often referred to as a calcaneal slide follows the same surgical approach and dissection.  The transpositional osteotomy requires minimal dissection of periosteum and can therefore use a smaller incision.  The osteotomy is intentionally through and through meaning that there is no need to try to maintain a medial hinge.  The amount of transposition can be easily seen by the surgeon prior to fixation.  Fixation is achieved by use of staples, screws of specially designed plates that can be fixated in pre-determined amount of step down.

Which osteotomy is better?  I think the answer will vary on a surgeon by surgeon basis, but you’ll tend to see that more doctors are using the calcaneal slide procedure and less the Dwyer.  The Dwyer will tend to have several disadvantages.  First, the Dwyer requires more dissection.  Second, resection of the wedge in the Dwyer will shorten the heel.  Shortening of the heel will no be measurable on x-ray or when the patient returns to shoes, but it will none-the-less affect stability and gait.  The Dwyer is also a more difficult osteotomy to perform.  And lastly, the rotational motion created by removal of the wedge in the Dwyer will result in a change in the weight bearing surface of the heel.  I’ve not see complications due to a change in the weight bearing surface of the heel post Dwyer, but I think this change would be subtle.  Symptoms may include changes in the gait pattern or the sensation of pain in the way that load is applied to the plantar fat pad of the heel once a patient returns to weight bearing.

There’s really no right or wrong in the choice of Dwyer v.s. transpositional osteotomy of the calcaneus, but from the standpoint of ease of the procedure and getting folks back on their feet sooner, I think you’ll see the calcaneal slide being used by most surgeons these days.

Jeffrey A. Oster, DPM
Chief Medical Officer
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

I had an interesting conversation with a family following a surgery yesterday.  The patient is a 56 y/o female with a history of multiple sclerosis.  As a result of her disease, she’s developed progressive loss of strength of her extremities.  She is a paraplegic with little ability to lift herself in bed.  She completely non-ambulatory and confined to a wheelchair.  She was at one time married and has a son.  She lives in a group home.

Over the past several months the patient developed a pressure sore over the left heel.  Although she had good circulation and no history of diabetes, the patient developed a bone infection in the heel that required surgical excision of the infected bone.  I followed the patient in the hospital for several weeks as she developed pneumonia and was admitted to ICU.  Once she was out of ICU and feeling better, I were cleared by medicine to complete the surgery.  

The surgery went well and included a partial resection of the calcaneus with wide excision of the ulcer.  The wound was packed open and a wound VAC will likely be applied in the next few days.  

Following surgery I had a chance to meet with the patient’s family which consisted of two of her siblings.  The family was appreciative of all care provided.  But what struck me about the conversation was something the family told me.  With the extensive history of health problems that the patient has been managing over the years, they told me that this was an issue that really concerned the patient.  Although the patient had been non-ambulatory for years, she was deeply concerned about the possible loss of her leg.  The family told me that loss of her leg would have been a psychological blow to the patient that they said that she just wouldn’t be able to bear.  

At the heart of this conversation is the simple fact that life is what you make of it.  This patient has transitioned from being a parent and spouse to a life of a paraplegic in a group home.  But you know, she still has her self esteem.  I came to find out that she has a boy friend in the group home.    She misses her man. 

I hope when my day comes I can be so tough.

Jeffrey A. Oster, DPM
Chief Medical Officer
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

Insertional Achilles tendonitis describes one of the two types of Achilles tendonitis that occur at the posterior heel.  Insertional Achilles tendonitis will result in a tug-of-war at the posterior heel where the Achilles is essentially trying to pull away from the heel bone.  The result is often an enlargement (hypertrophy) of the posterior heel and chronic pain.  Pain is described as significant when first starting to walk or run.  Pain seems to subside over the first few steps only to become worse as the day progresses. 

When conservative care for Achilles tendonitis fails, surgical care includes a partial resection of the posterior heel with or without a lengthening of the Achilles tendon.  Why lengthen the Achilles?  I think you’ll find this to be a controversial point among foot docs in that some will advocate maintaining the original length of the Achilles.  I’m in the other camp in that with every surgery I perform for insertional Achilles tendonitis, I invariably, and purposively perform a lengthening of the Achilles.

My logic for performing a lengthening is simple.  You have to consider the primary reason why insertional tendonitis occurred in the first place.  Achilles tendonitis, whether at the insertion or in the body of the tendon is due to tightness in the calf and unsustainable tension within the Achilles tendon.  If correction of chronic Achilles tendonitis does not include a tendon lengthening, I don’t think you’ve really addressed the primary issue that is at the heart of the problem; tightness of the Achilles. 

Does the lengthening need to be significant?  No, not really.  But a centimeter of lengthening can really go a long way to address the problem. 

What’s the downside to lengthening the Achilles?  There will be those who argue that the lengthening will result in smaller calf circumference and weakened push-off in gait.  To a degree, that may be true and I’ll agree with that point.  But other studies have shown that progressively, the weakness in the calf that is the result of the lengthening is progressively taken up by tissue contraction.  Interestingly, the tendon will actually shorten to its’ optimal length over the course of 1-2 years. 

So is a lengthening of the Achilles necessary when surgically treating insertional Achilles tendonitis?  You bet. 

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

I received a referral several months ago from a new primary care doc in our area.  The patient was a 60 year old over the road trucker who had a 4 month hx of right foot pain.  The patient was a recent widower.  He worked full time but complained of severe pain of the right foot.  The family doc had worked hard to try to understand the reason for the continued pain.  he had ruled out gout, fractures and arthritis.

Past medical hx was normal with the exception of poorly controlled diabetes.  Although the patient was not insulin dependant, he stated that prior to being put on oral hypoglycemics, he had been poorly controlled.  A bone scan of the right foot showed diffuse uptake the technicium indicating the presence of osteomyelitis or neuropathic arthropathy.  With no hx of infection, we had our diagnosis; Charcot arthropathy.

I had a long and serious discussion with the patient regrading the natural progression of Charcot joints.  The patient was placed in a non-weight bearing cast and taken off work.  Within the first week the patient called with a sore at the proximal, anterior shin.  This sore was from walking on the cast.  As you walk on the tip of the cast beneath the forefoot, the cast will rock back against the shin causing the sore as described. 

We never saw the patient again.  He called to say that he was going to f/u with his family doc.

Unfortunately, the track record for patients like this is not a good one.  Charcot arthropathy can be controlled with the appropriate care, but if left untreated the arch of the foot will collapse.  The collapse of the arch will result in a prominence of the plantar foot and resultant ulceration.  The next stage is an infection of the bone of the plantar foot and loss of limb.

I don’t think it’ll be unusual to see this patient in the years ahead.  But unfortunately, his denial of treatment today will likely result in much more treatment in the future.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

One of the advantages of my corner office is that I can see patients come and go.  My vantage point allows me a unique view of our office entry, surgery center entry and entry to our local O&P lab.  At first glance it may seem a little bit sneaky, but I really do get to learn a lot about a patients by the family members in the parking lot, the kind of car they drive and what they do as they leave our office.

One of the constants of modern health care is that smoking has a number of negative ways in which it can impact care.  In addition to the obvious health care problems caused by smoking such as emphysema, lung CA and coronary artery disease, smoking can have a huge impact on the success or failure of surgery.  Research has proven that smoking has a significant effect on the viability of bone grafts.  The success of a graft depends upon neovascularization.  The ingrowth of new blood flow into the graft is inherent in the survival of the graft and the fusion that the graft is being used to achieve.

Out my window I’ve watched one particular patient.  He’s 7 weeks out on a metatarsal cuneiform revision of a failed fusion performed by another doctor.  Today I watched this patient get out of his car to go to O&P for a new cast.  Upon exiting the car, they pitched a smoke.  I also saw them come out of the building and light up another smoke.  I shake my head and mutter under my breath….

I guess I should spend more time working and less time at the window.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

Let’s say hypothetically that you’re a doctor, podiatrist or orthopedist, and you’re in a plane crash that lands you in a region where you need to provide medical care and where you have no advanced testing modalities.  No x-ray, no MRI.  You basically were forced to rely on your clinical diagnostic skills.  How would you fare?  I’d be interested to see how an ‘old school provider’ would stack up against a ‘new school provider’. 

The reason for my hypothetical question is simple and two part.  First, how often do providers rely on tests to make their diagnoses.  And second, is there a difference in young vs older providers in how often they request a test to make that diagnosis? 

As an example, does every suspected stress fracture require an MRI?  Could we alternatively monitor the suspected stress fracture for several weeks and confirm the presence of the fracture with plain films with the onset of bone callus on plain films?  I’d suspect that the older practitioner would monitor the problem while the younger provider would order an MRI.  Is this true in every case?  No, not by any means.  But my experience with providers of all ages seems to show that younger providers need to make the diagnosis.  They can’t just rely on clinical diagnostic skills but rather they need to nail the diagnosis with by confirming it with a test.

That then brings up the issue of who’s right and who’s wrong.  Do we always need to nail a diagnosis?  Or is what we really do a process of making illness better and making injuries heal?  I often see patients drive this process.  Many patients are quit content to know that their injury will heal in time while others need confirmation of the diagnosis with a test.  But again, I’d be inclined to think that the younger provider would be more inclined to opt for the MRI to nail a diagnosis.

Who’s right?  Tough to say.  Part of the decision making is about clinical care and part of it is about cost.  An MRI can provide a wealth of information but at a cost that is often the lion’s hare of a patient’s annual deductible. 

At the heart of this conversation is communication.  And again, that may be an age related issue where an older provider may be inclined to spend a bit more time with a patient while a younger doc is moving on to the next problem that needs to be solve.

Communication.  So it gets back to communication.  It always seems to get back to good communication.  Even with our hypothetical plane crash, it’d still be about good communication.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

Working with patients really is a rewarding part of my day.  In many ways I’m a teacher.  I help patients understand a problem and how they can work to make that problem better.  As in any educational setting, communication is the single most important aspect of the interaction.  Effective communication involves a presentation and a period of listening. 

Communication is different in every interaction with patients.  But one of the most challenging interactions is with the patient that I call the alpha male.  Sometimes I wonder why the alpha male has com into the office.  He typically knows more about how to treat his condition even though he doesn’t know what the condition is.  He’s a communicator alright – he’s set on broadcast with no capacity to listen.

Health care literacy is a term that describes the knowledge or literacy a patient has regarding their health.  It’s important that providers focus on patient literacy in each and every interaction.  But with the alpha male patient, health care literacy is a tough task.  If there’s no capacity to listen, how can you go about improving health care literacy?

The alpha male patient can be tough.  But as a provider, just just have to be tougher.  You repeat instruction.  You may even need to interrupt.  The alpha male patient may get upset.  But you know, usually by the second visit, the alpha male may just be ready to listen.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

OK, I’ll come right out and say it – shoes are a good thing.  Shoes are not a bad thing.  Shoes were made to enable people to do more with fewer injuries. 

I had a friend that to catch a fish, he had to build a fly rod.  Another friend raises his own chickens.  Me, I grow my own hops for beer.  I’m fully aware of the trend to get at the heart of your activity whether it be running, fishing or brewing.  But to my knowledge, I’ve never injured myself  by too aggressively growing hops.  That’s what makes me scratch my head about minimalist shoes.  Folks are just setting themselves up for injury by using a shoe that is designed to be no more that a second layer of skin. 

What kinds of injuries do I see?  Within my own family we’ve had two metatarsal stress fractures while jogging and using minimalist shoes.  This afternoon I saw a young lawyer who had a case of plantar fasciitis secondary to the use of minimalist shoes.  How is that the case?  The low heel on minimalist shoes definitely enables greater force generated by the calf and subsequently increase mechanical load applied to the plantar fascia.  It’s not about heel strike, it’s all about the height of the heel.

From someone who treats runners everyday, my vote is to use minimalist shoes for limited runs and during work-outs that are close to the gym.  If you’re going to be putting some miles on the chart, steer clear of the minimalist shoes.  Or maybe relax, have a home brew and catch a nice rainbow on that custom fly rod.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.

I performed an elective bunionectomy on a patient this morning.  The patient has had a long history of rheumatoid arthritis and had found that the best method of controlling her symptoms has been to use 5mg of prednisone daily.  Although she feels better while on prednisone and was limiting the progression of her rheumatoid disease, the number of side effects from long term prednisone use may make it a poor choice in the long run.

What does prednisone have to do with wound healing?  Healing from trauma, including surgical trauma, can be described as a series of steps.  The first step of healing is coagulation – to seal bleeding vessels and halt any hemorrhage.  Fortunately in surgery, we’re able to take careful steps to ligate vessels and limit bleeding.  In the general spectrum of wound healing, hemostasis is a huge advantage in that the less bleeding under the skin, the less the wound needs to work at healing.

The second stage of healing is known as the inflammatory stage.  This is the stage of healing that is most affected by prednisone.  Prednisone will limit the inflammatory response in the wound.  Limiting the inflammatory response can be helpful to a degree, but how much is too much?  That’s a question that I used to debate with my residents and I don’t think that there really is a definative answer.  The inflammatory response in wound healing will vary based upon a patient’s general health, smoking status, etc. 

The reason that the inflammatory phase of wound healing is so important is that the act of inflammation is a beacon for healing cells.  Trauma to cells releases histamine and serotonin.  These two chemicals are chemotactic, meaning that their release draws other cells to help in the initial phases of healing.  Without this chemotactic response, inflammation is stalled, hence wound healing can be stalled.

Will 5mg of prednisone stall healing to a degree that healing may simply not take place?  Perhaps.  But again, that depends upon the patient.  When possible, it is good medicine to take a patient off of their prednisone prior to their surgery to insure healing.

In this particular case, the patient is young (36 y/o) and is in otherwise good health.  We chose to stay on the prednisone to inhibit a rheumatoid flare.

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

Dr. Oster follows the Myfootshop.com on-line communication policy and cannot answer clinical questions or provide medical care through this blog.