Preventative Surgery: Is There Such a Thing??

Is there such a thing as preventative surgery? We usually think of surgery as something that we need to fix a problem that is currently present. That makes perfect sense! Why would we ever need to have surgery when there is no current need for it? To the average healthy person, preventative surgery seems like too much of a risk. Why fix something that doesn't hurt? Every surgeon would agree that in most cases this is correct assumption. Lets think outside the box for a minute. I will give an example to make it easier: I have been seeing a diabetic patient for several months who has a callus on the tip of his toe. His toes bend and don't straighten well. They are stuck in that position (we call those hammertoes). This is why he gets the callus. No biggie right? Shave the callus and all is well right? Say this patient has very little feeling in their foot(they have diabetic neuropathy) and cannot tell if the callus is getting irritated and they do maybe a little more than usual that day. By days end, they may end up with swelling and redness to that toe! Now that is a problem! Shave the callus this time to find a wound under it! If all is working in the patient's favor, we treat the wound and, over time it gets better. Eventually though, a callus forms over the healed skin because nothing in the patient's lifestyle has changed. Over and over this is the cycle. Callus, wound, heals. Callus, wound, heals. That is the best it gets. It heals at least. Here is the sacrifice. Every time the wound heals, scar tissue is left. Scar tissue is not as flexible or forgiving as regular skin. It forms callus more quickly because it is less resistant to friction. Some times it doesn't matter that they are in the best shoes and inserts,(and seeing the best podiatrist here at FAANT!),the skin is just too vulnerable. The worst case is that eventually, and this happens more times than you can imagine, the wound gets infected and the infection gets into the bone! That could lead to an amputation!! Who wants to risk that? Surgery in this case is a feasible option! Even if there is no wound, surgery is a viable consideration. What if we could do a surgery to straighten the toe (while they have no active wound), so that there is less pressure at the tip? We may be able to halt that vicious cycle and make visits to our office much more pleasant! Much needs to be considered health wise to make the best choice for this patient as there are risks with any surgery, especially in a patient with health problems. Is there more risk having this surgery or to continue cycling with a wound that keeps popping up, increasing the risk of infection every time it does? Next time you visit, keep an open mind about this possibility. If preventative surgery is an option for you, we will do all we can to make sure it is done under the best of circumstances!

Diabetes and Foot Surgery

One remark I hear frequently from my diabetic patients is that they have the belief that since they are diabetic, they cannot and should not have foot surgery. Is this true?

Let me answer this question by giving an example of a patient I saw in my office recently. She was referred by her primary care doctor for evaluation of sores on the ends of the third toes of both feet. When I first saw her, it was instantly evident that she had some serious problems. Not only were sores (ulcers) present on the ends of the third toes on both feet, but those same toes were red and swollen - classic signs of infection. I also noticed that she had severe contractures of the second, third and fourth toes of both feet. This caused her to put excessive pressure on the ends of the toes. It was this pressure that ultimately caused the ulcers to form, and became a hindrance in the healing of her ulcers. Further testing showed that not only did she have infected ulcers on both feet, but that the infection had progressed to the bone. After a lengthy discussion with her, we decided that it was best to remove the infected portions of the toes. For a podiatrist, this is not the kind of surgery that we want to perform, but sadly at times must be done.

Since her surgery, she has gone on to heal well, and what is left of the third toes on both feet is healthy and shows no signs of problems. However, she has since developed an ulcer on the fourth toe of the right foot. Again, because of the severe contracture of the toe (also known as a hammertoe), excessive pressure on the end of the toe has caused the skin to break down and ulcerate. So, we are back to fighting the battle to save her toe.

I gave this example to illustrate why surgery in diabetics is sometimes not only permissible, but can turn out to be a way to prevent more drastic complications at a later date. In the case of this patient, my plan now is to perform surgery on the remainder of her hammertoes in order to straighten them. This is not so that her feet will look better (although they undoubtedly will will better), but rather to remove deformities that are causing excessive pressure and make her prone to ulceration, infection, and potential amputation.

So, when can and should a patient with diabetes have surgery? In my mind, diabetes in and of itself does not mean that surgery is not possible. Rather, I look at the patient as a whole and determine if he/she is healthy enough to withstand the surgery, and heal properly afterwards. Things that your podiatrist will look for when contemplating foot surgery include the status of the circulation to your feet. This may involve not only an examination, but also non-invasive testing as discussed by Dr. Wishne in a prior post on this blog. In addition, your podiatrist will want to know how healthy you are in general. How is your heart functioning? How are your kidney's functioning? How well is your diabetes controlled? These and many other factors will be considered before surgery is contemplated.

Your podiatrist has had the advantage of seeing many patients who have developed diabetic foot ulcerations, and he knows the types of feet that are prone to develop such ulcerations. If your podiatrist feels that you are at an increased risk for developing a foot ulcer because of your foot deformity (including hammertoes, bunions, bone spurs, ingrown toenails, etc.), he will be doing you a big favor in recommending procedures that can prevent later complications. Every procedure in medicine has potential risks and benefits. The trick is to determine if the risk of surgery is less than the potential benefits that the surgery will offer. For most patients, pain is a major motivating factor to proceed with surgery. In a diabetic patient who may have neuropathy, prevention of future complications rather than the presence of pain is the main reason to proceed in many instances. This is a decision to be made jointly by you and your podiatrist.