New techniques available for foot, ankle problems
Surgeons need specific training
Advances in surgical technology have affected all areas of same-day surgery, including podiatric surgery. These advances are beneficial to patients, but require more credentialing diligence from the same-day surgery manager and medical director, say experts interviewed by Same-Day Surgery.
"Although ankle arthroscopy represents only 3% to 6% of all arthroscopies, it requires specific training within a residency program or a hands-on course," says John J. Stienstra, DPM, FACFAS, a podiatric foot and ankle surgeon at the Permanente Medical Group in Union City, CA. "Ankle arthroscopy is more difficult than arthroscopy of the shoulder or knee because of the size and the geometry of the ankle joint with its three bones," he says.
Although the arthroscopic equipment is basically the same for all arthroscopies, with smaller instruments used for ankles, it does require a surgeon who is experienced in foot and ankle surgery, Stienstra adds. For this reason, credentialing requirements for surgeons who perform ankle arthroscopy should include specific training in the procedure, not just training in arthroscopy in general, he suggests. "It is a mistake to assume that the ability to perform shoulder or knee arthroscopy should automatically qualify someone to perform ankle arthroscopy," he adds. (See "Can your ASC meet the credentialing challenge of new tools, techniques?" Same-Day Surgery, June 1999. Previously published stories are available on the web site: www.same-daysurgery.com.)
Used to treat ankle damage caused by injury or arthritis, ankle arthroscopy is beneficial to patients and same-day surgery programs because the technique reduces biologic and financial costs by sparing the patient from injuries that might occur during traditional surgery, Stienstra says.
"Small arthroscopic instruments, along with lasers, enable us to cut and tailor tissues, weld things together, vaporize pathologic tissues, and anchor and repair structures within the ankle joint without dissecting blood vessels that are dissected during traditional surgery," he explains. This procedure means less discomfort and swelling during recovery, Stienstra adds.
Stienstra does not predict an explosive growth in the use of ankle arthroscopy, but describes it as "a slowly expanding envelope." If no surgeon is performing the procedure at a same-day surgery program and there is a qualified surgeon, it does represent an opportunity, he suggests.
Although many same-day surgery procedures often result in shorter recovery times than traditional surgeries, one podiatric surgical technique that requires eight weeks of recovery is actually the better choice for patients suffering from bunions, says Marybeth Crane, DPM, FACFAS, a podiatric surgeon in Grapevine, TX. The best bunion surgery, especially for younger patients, is a procedure that realigns the big-toe joint in order to correct a bunion rather than just shaving the bump, she explains.
"Although patients have to stay nonweight bearing on the foot that undergoes the procedure for up to eight weeks, it is a permanent fix unlike the more commonly requested procedure that shaves the bump," she says. In the procedure, the bone is cut and tendons and ligaments are realigned to prevent the hypermobility of the joint that is the primary cause of bunions, Crane says. Although the simpler removal of the bump means a more immediate return to normal life, the bunion often recurs because the hypermobility of the joint, the cause of the bunion, is still present, she adds.
As with ankle arthroscopy, Crane recommends that credentialing for this procedure require specific training in this procedure since the surgeon must demonstrate an understanding of the internal fixation of the big-toe joint and must be able to graft bone to correct the deformity in some cases, she adds. This is a procedure that is being requested by patients on an increasing basis, Crane says. In addition to seeing patients who have recurring bunions, Crane also sees a growing market in young, athletic people.
Another podiatric procedure that has been very popular since 1996 is endoscopic plantar fascial release to treat heel pain, she says. "It is 85% effective in treating heel pain and is preferred by young, athletic people who don’t want to undergo the more extensive open heel spur resection," she says. The procedure lengthens the tendon, which eliminates the pain, Crane adds. As with other newer procedures, she recommends a hands-on course to establish credentials.
"The good news about each new podiatric technique is that they offer younger people a chance to address foot and ankle problems early, well before arthritis or other damage to the joints require major surgery," Crane says.
Sources
For more information on podiatric techniques, contact:
• Marybeth Crane, DPM, FACFAS, 230 Park Blvd., Suite 106, Grapevine, TX 76051. Telephone: (817) 416-6155. Fax: (817) 329-9434. Web site: www.mcpodiatry.com.
• John J. Stienstra, DPM, FACFAS, Department of Orthopedics, Permanente Medical Group, 3555 Whipple Road, Union City, CA 94587.
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