This week we will focus on the types of surgical procedures used to correct for rigid and progressed bunion deformities. It is important to keep in mind when reviewing these procedures that your Podiatrists will select a procedure based on their clinical knowledge, one they deem the most appropriate and one that will provide the longest lasting results. The procedures as they are described are clear-cut, but no patient is clear-cut and decisions are also based on the patient’s subjective presentation, physical examination and radiographic evaluation.
Capsule Tendon Balance Procedures (CTB): Can be performed as a sole procedure in cases of mild deformity, but are always performed in conjunction with more corrective procedures.
• Most Common CTB: “Modified McBride Procedure”
• Indications: Mild deformity, with medial bump pain and no deep joint pain; slightly increased Intermetatarsal (IM) Angle on X-ray; minimal joint range of motion restriction
• Procedure: Dorsomedial skin incision over the hallux; release of the metatarsal-phalangeal joint (MPJ) capsule; resection/removal of the medial bone prominence; release of the adductor hallucis and flexor hallucis brevis conjoined tendon; medial capsulorrhaphy (removal of a wedge of capsule from the medial side); closure
• Complications: Hallux Varus (the opposite of HAV); recurrence of deformity; stiffness
• Recovery Period: 2 weeks in a surgical shoe; transition to a sneaker
Metatarsal Osteotomies: Procedures that make cuts into the 1st metatarsal. Some procedures make through-and-through cuts, while others remove or add a wedge of bone. All metatarsal osteotomies are performed in conjunction with a CTB, but not all CTB are performed with a metatarsal osteotomy.
• Most Common Osteotomy: “Austin”
• Indications: Mild to moderate deformity; mild increase in the IM Angle; good range of motion with no arthritic changes.
• Procedure: Dorsomedial incision; release of the MPJ capsule; release of the adductor hallucis tendon; V-cut made through the bone at a 60 degree angle; shifting of the head of the metatarsal laterally; fixation with a Kirschner wire; medial capsulorrhaphy; closure.
• Complications: Non-union; shortening of the metatarsal; fracture of the metatarsal; transfer metatarsalgia.
• Recovery Period: 4 weeks in a surgical shoe; transition to sneaker and normal activity by 8 weeks.
Phalangeal Osteotomies: Often performed in conjunction with other HAV procedures when the proximal phalanx is a contributing factor in the deformity.
• Most Common Phalangeal Osteotomy: Akin
• Indications: Depending on the location of the osteotomy cut, this procedure can be used for abnormal DASA (radiographic angle), a high hallux abductus interphalangeal angle (radiographic angle) or an abnormally long proximal phalanx.
• Procedure: Dorsomedial skin incision; release of the MPJ capsule; reflection of periosteum; osteotomy cuts made; fixation with a Kirschner wire; medial capsulorrhaphy; closure.
• Complications: Displacement of the bone fragments; stiffness; non-union; fracture.
• Recovery Period: 4 to 6 weeks in a surgical shoe.
Arthrodesis of the 1st Metatarsal-Phalangeal Joint: Fusion of the joint, which ultimately prohibits movement and eliminates pain.
• Most Common Arthrodesis: McKeever
• Indications: Hallux Rigidus/Limitus; failed previous HAV surgery; Neuromuscular disorders
• Procedure: Medial-linear incision; resection of cartilage from the base of the proximal phalanx and the head of the 1st metatarsal; fixation with Kirschner wires; joint alignment in 5-10 degrees of abduction in relation to lesser digits and 5-10 degrees of dorsiflexion off the weight-bearing surface; closure
• Complications: Poor positioning; lack of 1st toe purchase; fracture; degenerative joint disease of the proximal and distal joints.
• Recovery Period: Cast immobilization for 6 weeks with transition to a surgical shoe and eventually sneaker.
Tuesday, February 23, 2010
Achoo! The Common Cold of the Foot
Achoo! The Common Cold of the Foot
Onychomycosis, also known as a fungal infection of the toenails, is the Common Cold of the foot, as it is easily seen 10 times per day in a Podiatrists office. It may not be the patient’s chief complaint, but it does make up about 50% of toenail related complaints that a podiatrist will see in a year. So, how does one contract it, what are signs to look for and how can it be treated?
Fungal infections of the toenails typically present as a gradual thickening and discoloration of the nails. The change in color and thickness may also be associated with a crumbly texture, noticed when the patient trims their toenails. Infection often goes unnoticed at first and will not appear on all toenails, leading patients to avoid seeking treatment until the thickening has markedly increased and they may or may not have pain with shoe wear. It is important that if you do notice such changes and suspect fungal infection, see your Podiatrist as soon as possible. The earlier the infection is identified and treated, the greater your chances of treatment success.
Most patients have difficulty understanding how they contracted toenail fungus, as they are “clean their feet and shower regularly!” Unfortunately, the fungus that infects the toenails is everywhere and often contraction of onychomycosis is luck of the draw; it is in no way a reflection of poor hygiene. It can be picked up from carpets, showers, or shoes harboring the organism. If you have had injury to the nail and expose the nail to a moist environment, you are also more likely to develop a fungal infection, as the injury provides a portal for the fungus to invade. Elderly, diabetics and men seem to have a greater predilection for onychomycosis, but it is not exclusive to them and can be seen in anyone, including children. Individuals susceptible to athlete’s foot and those who have previously been infected with toenail fungus also seem to have a greater chance of suffering.
To better decrease your chances of developing fungal toenail infections avoid re-wearing socks and do your best to keep feet clean and dry, especially after times when the foot has perspired. Do not apply moisturizers to the nails mistaking the fungus as dry skin and do not apply toenail polish in attempt to hide the color change. Both of those “treatments” tend to trap moisture into the nail and lead to an increase in growth of the fungus! It might also be helpful to carry an extra clean, dry pair of socks with you and to wear “shower-shoes” when using public showers, creating a barrier between your feet and the shower floor.
Treatment of onychomycosis can be tricky! Over the counter topicals generally are not successful, thus it is best to see your Podiatrist for treatment. Various treatment options include oral medications such as Lamisil and nail lacquers such as Penlac. Depending on the severity of infection it may be recommended that you combine a nail lacquer with an oral medication to attack the fungus systemically and topically, increasing chances of successful treatment. Other treatment options have been suggested including laser therapy, UV light therapy and several topicals that are all undergoing FDA trials. The effectiveness of these treatment methods has yet to be determined, but they do suggest promising evidence for success.
Onychomycosis is extremely difficult to treat and even after successful clearing of infection, reoccurrence rates are high. Be patient while your podiatrist works with you on an effective course of treatment!
Onychomycosis, also known as a fungal infection of the toenails, is the Common Cold of the foot, as it is easily seen 10 times per day in a Podiatrists office. It may not be the patient’s chief complaint, but it does make up about 50% of toenail related complaints that a podiatrist will see in a year. So, how does one contract it, what are signs to look for and how can it be treated?
Fungal infections of the toenails typically present as a gradual thickening and discoloration of the nails. The change in color and thickness may also be associated with a crumbly texture, noticed when the patient trims their toenails. Infection often goes unnoticed at first and will not appear on all toenails, leading patients to avoid seeking treatment until the thickening has markedly increased and they may or may not have pain with shoe wear. It is important that if you do notice such changes and suspect fungal infection, see your Podiatrist as soon as possible. The earlier the infection is identified and treated, the greater your chances of treatment success.
Most patients have difficulty understanding how they contracted toenail fungus, as they are “clean their feet and shower regularly!” Unfortunately, the fungus that infects the toenails is everywhere and often contraction of onychomycosis is luck of the draw; it is in no way a reflection of poor hygiene. It can be picked up from carpets, showers, or shoes harboring the organism. If you have had injury to the nail and expose the nail to a moist environment, you are also more likely to develop a fungal infection, as the injury provides a portal for the fungus to invade. Elderly, diabetics and men seem to have a greater predilection for onychomycosis, but it is not exclusive to them and can be seen in anyone, including children. Individuals susceptible to athlete’s foot and those who have previously been infected with toenail fungus also seem to have a greater chance of suffering.
To better decrease your chances of developing fungal toenail infections avoid re-wearing socks and do your best to keep feet clean and dry, especially after times when the foot has perspired. Do not apply moisturizers to the nails mistaking the fungus as dry skin and do not apply toenail polish in attempt to hide the color change. Both of those “treatments” tend to trap moisture into the nail and lead to an increase in growth of the fungus! It might also be helpful to carry an extra clean, dry pair of socks with you and to wear “shower-shoes” when using public showers, creating a barrier between your feet and the shower floor.
Treatment of onychomycosis can be tricky! Over the counter topicals generally are not successful, thus it is best to see your Podiatrist for treatment. Various treatment options include oral medications such as Lamisil and nail lacquers such as Penlac. Depending on the severity of infection it may be recommended that you combine a nail lacquer with an oral medication to attack the fungus systemically and topically, increasing chances of successful treatment. Other treatment options have been suggested including laser therapy, UV light therapy and several topicals that are all undergoing FDA trials. The effectiveness of these treatment methods has yet to be determined, but they do suggest promising evidence for success.
Onychomycosis is extremely difficult to treat and even after successful clearing of infection, reoccurrence rates are high. Be patient while your podiatrist works with you on an effective course of treatment!
Monday, February 1, 2010
HbA1c and Me: How does my HbA1C Level Reflect upon my overall Diabetic Glucose Control?
The Hemoglobin A1c (HbA1c) blood test measures glycosylated hemoglobin, indicating your average blood glucose levels over a 90-day period. Hemoglobin carries oxygen through your body using your Red Blood Cells (RBC’s) as its vehicle. As your blood glucose levels rise above normal, sugar combines with the hemoglobin molecules and your blood cells become “glycosylated.”
The average life span of an RBC is 90 days, at which time they are shed from the body via the spleen and new RBC’s are formed. Once the hemoglobin has become glycosylated, it will remain that way for the entirety of its Red Blood Cells life span. Therefore, when your blood is drawn and an HbA1c level is tested for, it will show the average amount of glycosylation in your blood via the hemoglobin molecules. Essentially indicating your average blood glucose level and how well you have been doing in controlling your diabetes over a 3-month period (90 days).
In patients without diabetes, the normal HbA1c level is between 4% and 6%, with an average daily glucose level of 90mg/dL. For the diabetic patient remember: “7 and below is the way to go!” Your Podiatrist and your Primary Care Physician are looking for your A1c level to be below 7%, as that indicates that over a 90-day period your average daily blood glucose level has been around 170 mg/dL. HbA1c testing is a foolproof way for your doctor to gain an accurate picture of your sugar control over a longer period of time than just on the day they see you in their office. Thus, fasting or eating healthier and controlling your sugar levels the day or two before heading to the doctors for your blood test, will not be effective in lowering your HbA1c level. It is a more accurate way of gauging your glucose control and overall control of your diabetes.
The chart below outlines the average blood glucose levels that correspond to your Hemoglobin A1c level. As you climb the chart in your A1c percentage, it shows that your average blood glucose levels are increased over a 90-day period and the risk of complications from diabetes become greatly increased.
HBbA1c Average Blood Glucose Level
12% 345
11% 310
10% 275
9.0% 240
8.0% 205
7.0% 170
6.0% 135
5.0% 100
4.0% 65
The higher your A1c, the more glycosylated your RBC’s become, the more uncontrolled your diabetes has been, and the higher your risk of complications stemming from the disease becomes. Some of those complications include diabetic neuropathy, retinopathy, kidney complications and decreased blood flow to the hands and feet! Control of your blood glucose level is the best tool as a diabetic patient that you have in decreasing your risk of long-term complications, and it is something that once you pay close attention to long enough, maintaining your levels will become second nature. Over the next 3 months I challenge you to control your glucose levels so that on your next HbA1c testing, your “day- of” glucose level will match that of your 90 day average!
As an aside, it is important to remember that Hemoglobin A1c levels are not to be confused with standard blood hemoglobin levels, which indicate your body’s ability to transfer oxygen from the lungs to the tissues, and carbon dioxide from the tissues back to the lungs for expiration.
The average life span of an RBC is 90 days, at which time they are shed from the body via the spleen and new RBC’s are formed. Once the hemoglobin has become glycosylated, it will remain that way for the entirety of its Red Blood Cells life span. Therefore, when your blood is drawn and an HbA1c level is tested for, it will show the average amount of glycosylation in your blood via the hemoglobin molecules. Essentially indicating your average blood glucose level and how well you have been doing in controlling your diabetes over a 3-month period (90 days).
In patients without diabetes, the normal HbA1c level is between 4% and 6%, with an average daily glucose level of 90mg/dL. For the diabetic patient remember: “7 and below is the way to go!” Your Podiatrist and your Primary Care Physician are looking for your A1c level to be below 7%, as that indicates that over a 90-day period your average daily blood glucose level has been around 170 mg/dL. HbA1c testing is a foolproof way for your doctor to gain an accurate picture of your sugar control over a longer period of time than just on the day they see you in their office. Thus, fasting or eating healthier and controlling your sugar levels the day or two before heading to the doctors for your blood test, will not be effective in lowering your HbA1c level. It is a more accurate way of gauging your glucose control and overall control of your diabetes.
The chart below outlines the average blood glucose levels that correspond to your Hemoglobin A1c level. As you climb the chart in your A1c percentage, it shows that your average blood glucose levels are increased over a 90-day period and the risk of complications from diabetes become greatly increased.
HBbA1c Average Blood Glucose Level
12% 345
11% 310
10% 275
9.0% 240
8.0% 205
7.0% 170
6.0% 135
5.0% 100
4.0% 65
The higher your A1c, the more glycosylated your RBC’s become, the more uncontrolled your diabetes has been, and the higher your risk of complications stemming from the disease becomes. Some of those complications include diabetic neuropathy, retinopathy, kidney complications and decreased blood flow to the hands and feet! Control of your blood glucose level is the best tool as a diabetic patient that you have in decreasing your risk of long-term complications, and it is something that once you pay close attention to long enough, maintaining your levels will become second nature. Over the next 3 months I challenge you to control your glucose levels so that on your next HbA1c testing, your “day- of” glucose level will match that of your 90 day average!
As an aside, it is important to remember that Hemoglobin A1c levels are not to be confused with standard blood hemoglobin levels, which indicate your body’s ability to transfer oxygen from the lungs to the tissues, and carbon dioxide from the tissues back to the lungs for expiration.
Hammering Out Your Hammer Toe!
Last week we discussed 3 types of digital deformities: Hammer toes, Mallet toes and Claw toes. They are very similar and treatment for each is much the same, but they can be distinguished from one another by the involved joints. The most common complaint with these deformities relates to areas of increased pressure and formation of a corn with resultant pain. Eliminating pressures on the top of the toe is usually the goal of treatment and there are various ways in which to have success. Conservative treatments can include periodic trimming down of the corns, padding of the toes and strapping the affected digit to a “neighboring” toe in attempt to straighten out the deformity. Wearing shoes with a roomier toe box can also be effective making hammer toes easier to manage and live with. When conservative treatment fails or is not an option, surgical options are available.
Much the same as surgical correction for bunion deformities, hammer toe surgical correction involves a choice between a soft tissue, boney or fusion procedure. The selection of one procedure over the other is a decision that your Podiatrist will make based on their clinical judgment and your level of discomfort. Each procedure aims to bring the joints involved in the deformity back into correct alignment resulting in straightening of the toe and reduction of pain.
Soft Tissue Procedure: A soft tissue procedure used for surgical correction of a hammer toe attempts to release the capsule surrounding the joint as well as release the tendons entering the toe so that the bones are free to straighten out into their correct position. Often times the digit contracts due to muscular imbalance, thus releasing the tendons of the involved digit essentially eliminates the imbalance. It is common practice during these procedures to have the corn, located on the top of the toe, removed decreasing pressure and reducing pain. Soft tissue procedures are used alone in the presence of mild deformity where the patient complains of pain without significant boney involvement. However, when a more aggressive boney or fusion procedure is used for surgical correction, as described below, a soft tissue procedure is also performed.
Bone Procedure: A boney procedure is one that requires cutting the bone and eliminating a portion of the bone involved in the deformity. Depending on the joint affected (whether you’re dealing with a hammer, mallet or claw toe), one or two of the three bones within the toe will be cut and a portion of that bone removed. In the classic hammer toe where the middle joint is affected, a portion of the bone closest to the body of the foot will be removed, decompressing the joint and allowing the toe to straighten. A pin will be placed into the toe for 4 to 6 weeks holding the corrected position until the surrounding soft tissues have healed. Keep in mind that because a portion of the bone within the toe is being removed, the toe will end up a little shorter than it started out.
Fusion Procedure: A fusion procedure is used when there are multiple joints (remember there are 3 joints within each toe) involved in the deformity and when the hammer toe is considered to be rigid, or non-flexible. A fusion removes any material within the joint space that is destroyed and allows the bones within the toe to be straightened out and brought together by pin fixation over 6 to 8 weeks. Fusions eliminate motion at the joints within the toe, so it is important to remember that after the procedure you will no longer have a contracted digit, but you will also no longer be able to bend the toe as you were prior to the surgery.
The risks and benefits of surgery must be weighed and discussed with your Podiatrist prior to consenting for a procedure, and it’s always wise to attempt treating your hammer toe conservatively first. If you decide to move forward with surgical intervention your period of recovery will range anywhere from 2 to 8 weeks with the ultimate goal being reduction of pain and straightening of the toe to prevent excessive pressures.
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