Patient Experience: Able to Run Again

Dr. Weil,

I was going through some things today and found your card. You performed some "clean up" surgery on my heel in Nov. 2000.

Thanks to you I have been able to run again and am participating in a 10K tomorrow. I am also the mother of two beautiful girls Lowrie (8) and Sara (5 today!)

Thank you for all your help years ago. I remember telling you that my goal was to run again. It didn't take a decade but I wanted to let you know.

Sincerely,

Louise

Shockwave Therapy Effective for Treating Heel Pain

FOOT AND ANKLE
ORTHOPEDICS TODAY July 1, 2010

Shock wave therapy effective for chronic heel pain in randomized, prospective trial
Visual Analog Scale pain scores at 12 months post-treatment dropped 7.5 points from baseline and those patients reported no major adverse events.

Investigators for a multicenter study found that extracorporeal shock wave therapy safely and effectively reduced recalcitrant chronic plantar heel pain, according to findings from their randomized placebo-controlled trial.

“The focused extracorporeal shock wave therapy (ESWT) as applied in this study shows statistically and clinically relevant results with a much better outcome in the active group,” compared to the control group, Ludger Gerdesmeyer, MD, of Kiel, Germany, said at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.

In the ESWT study group, “We have found no relevant side effects,” Gerdesmeyer said. The data he presented have been submitted to the U.S. Food and Drug Administration for possible clearance of the Duolith SD1 (Storz Medical) used in the study for this indication.

The 250-patient study was conducted at European and U.S. centers. Investigators enrolled patients from each center with chronic plantar heel pain of greater than 5 on the Visual Analog Scale (VAS) that did not respond to conservative care.
Focused ESWT

After a wash-out period, patients were randomized to either the active or control group. The active group received 0.25 mJ/mm2 ESWT, 4 Hz frequency, with the device focused on the site of heel pain without the aid of any radiography. Patients in the control group underwent a sham treatment where the ESWT device was deactivated but used identically.

Patients underwent three treatments each. Their results were assessed at 3 months and 12 months following their last treatment using the VAS pain scores as the main outcome measure. Results of the Roles and Maudsley patient self-assessment score and the SF-36 score served as secondary outcomes.

At 3 months, baseline composite VAS scores of 8.3 decreased to 2.7 points after ESWT in the active group and decreased to 5.3 points in the control group. In the ESWT group, VAS scores further decreased after 12 months to 0.8 points.
Less pain

“In the active group we have 69% of the patients [having] more than 60% pain reduction compared to baseline,” Gerdesmeyer said. By comparison, sham treatment was associated with more than 60% pain reduction in 34% of control patients, he said.

Differences between the baseline and follow-up secondary outcomes also favored the active group.

No major adverse events occurred related to ESWT treatment. Some patients treated with ESWT, however, reported device-related events including slight pain or discomfort during and after treatment and minor local swelling or redness.

“It was interesting to see that placebo patients getting just a sham treatment also reported pain during treatment,” Gerdesmeyer added. — by Susan M. Rapp

Reference:

* Gerdesmeyer L, Gollwitzer HW, Saxena A, et al. Focused shock wave therapy in chronic plantar heel pain: A randomized placebo controlled trial. #706. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13, 2010. New Orleans.

Ludger Gerdesmeyer, MD, can be reached in the Department of Orthopedics and Traumatology, Klinikum Recht der Isar, Technical University Munich, Insmaniger Str. 22, Munich, Germany; 49-89-41402271; e-mail: gerdesmeyer@aol.com.

Perspective

Carol C. Frey, MD
Carol C. Frey

Published studies report that more than 2 million patients are treated for plantar fasciitis each year, accounting for approximately 11% to 15% of all foot-related encounters with physicians annually. Plantar fasciitis is a painful inflammatory process that when not treated can evolve into chronic degenerative changes in the fascia. Traditional treatment options, including conservative measures and medication, have shown success rates from 44% to 82%. Surgical intervention with open or endoscopic release of the plantar fascia has unpredictable results, substantial risks and recovery is usually very slow — 1 year. Researchers have been building a strong body of published clinical evidence for ESWT. ESWT has been shown to be safe and effective in several prospective randomized studies including studies by Gerdesmeyer. In cases of failed nonsurgical treatment, ESWT represents an excellent option to surgery and radial ESWT may be a better option than focused ESWT, as anesthesia is not required.

– Carol C. Frey, MD
Foot & Ankle Section Editor
Orthopedics Today

Foot Woes Keeping Him on His Toes

Podiatrist Lowell Weil Sr. had to travel to Papua New Guinea to find people without any foot problems.

"I went there to look at their feet because there'd been a paper written that showed that none of them had bunions. In fact, they have big toes that go out in the other direction," he said, noting the natives never wore shoes. "I had to see it for myself and I did. I took hundreds of pictures of the natives sticking their feet out."

Dr. Lowell Weil Sr. in an office at the Weil Foot and Ankle Institute in Des Plaines. Weil is a long-time Glenview resident and is known as the pioneer of shockwave treatment for heel pain.
(Allison Williams/Staff Photographer)

That solidified for Weil that shoes are a big culprit in aggravating bunions, although not necessarily causing them.

Weil, medical director of the Weil Foot and Ankle Institute in Des Plaines, has seen a lot of bunions, flat feet and other painful conditions below the ankle in 45 years of practice.

His specialty is the front part of the foot, where he designed an operation to shorten a bone causing pain under the ball of the foot that a French orthopedic surgeon named for him.

"I was in France lecturing. Somebody asked me from the audience, 'What do you do for this condition?' and there was a blackboard back in those days and I drew a picture. The next thing I knew, I came back to America and a friend of mine, an orthopedic surgeon, said to me, 'What the hell is this Weil osteotomy?'"

Most recently, he and his son, Lowell Weil Jr. of Lake Forest, who's part of the practice, lectured to a Chicago audience about the results of a nine-year study that showed sonic shockwave therapy has been effective in treating plantar fasciitis, a common form of heel pain.

Weil Sr. is also an expert in the "Refrigerator stepped on me" condition -- a reference to the jokes he heard from teammates of former Chicago Bear William "Refrigerator" Perry during the 25 years he spent as the football team's podiatrist.

Weil grew up in Skokie, where his parents long ran Weil Women's Clothing in downtown Skokie.

He settled with his wife, Nancy, in Glenview 37 years ago, in a house once owned by former Illinois Governor Otto Kerner.

Weil served on the Glenview Village Board from 1986 to 1990. His wife was on the Glenview School District 34 Board from 1980 to 1987.

Now a grandparent of six, Weil balances work with time at their second home in Mexico and travel.

"It's fun to be able to help people and meet the kind of people we meet," he said. "I never thought I'd be able to lecture in 29 countries and travel everywhere. I thought I'd have a nice little practice in Des Plaines, Ill. but it turned into something more than that."

-- Lynne Stiefel

Originally published August 10, 2010 in Glenview Announcements

Study Shows ESWT an Effective Non-Surgical Alternative

The doctors of the Weil Foot & Ankle Institute have studied, published on and utilized Extracorporeal Shock Wave Therapy (ESWT) for years to treat patients with heel pain and other painful conditions of the foot and ankle. The studies commented on below are another confirmation that ESWT can be an effective non-surgical alternative to treating pain. From Orthopedics Today:

Published studies report that more than 2 million patients are treated for plantar fasciitis each year, accounting for approximately 11% to 15% of all foot-related encounters with physicians annually. Plantar fasciitis is a painful inflammatory process that when not treated can evolve into chronic degenerative changes in the fascia. Traditional treatment options, including conservative measures and medication, have shown success rates from 44% to 82%. Surgical intervention with open or endoscopic release of the plantar fascia has unpredictable results, substantial risks and recovery is usually very slow — 1 year. Researchers have been building a strong body of published clinical evidence for ESWT. ESWT has been shown to be safe and effective in several prospective randomized studies including studies by Gerdesmeyer. In cases of failed nonsurgical treatment, ESWT represents an excellent option to surgery and radial ESWT may be a better option than focused ESWT, as anesthesia is not required.

– Carol C. Frey, MD
Foot & Ankle Section Editor
Orthopedics Today

IL Podiatrist Questions Heel Pain Study's Conclusions

Women who habitually wear high heels have shorter muscle fibers in their calves and thicker Achilles' tendons than those who walk in flat shoes, researchers say. The result? The heel lovers’ tendons stiffen and become harder to stretch, which could explain why walking hurts after kicking off the Jimmy Choos, according to a small study published in the Journal of Experimental Biology. The researchers found that wearing heels affected muscle fiber length--the high heel wearers' muscle fibers were 13 percent shorter than those who wore flat shoes. For some women, once the heels come off, the pain starts because the muscles can't stretch enough, the researchers said.

Wearing a variety of different types of shoes and stretching may help alleviate the pain, according to the study authors. But Chicago podiatrist Steve Weinberg, who was not involved with the study, questioned whether it's possible to stretch the Achilles tendon enough to make a clinical difference. "If women are going to wear high heels, they should be prudent—stand or walk in them for a short time,” said Weinberg, a podiatrist at the Weil Foot & Ankle Institute and the longtime chief podiatrist for the Chicago Marathon.

Source: Julie Deardorff, Chicago Tribune [7/16/10]

Patient Experience: Conservative Treatment for Stress Fracture

When stress fractures occur in the foot or foreleg, one course of action is to fit the patient with a walking boot which offloads pressure from the injury. A doctor and colleague of our Dr. Jeff Baker recently experienced this treatment protocol firsthand. Read about her experience with a walking boot here.

Efficacy of Outpatient Bilateral Simultaneous Hallux Valgus Surgery

Abstract

Bilateral simultaneous hallux valgus correction is traditionally performed as an inpatient procedure due to concerns regarding adequate postoperative analgesia and difficulty mobilizing. We prospectively evaluated 40 consecutive patients (80 feet) who underwent outpatient surgical correction of bilateral symptomatic hallux valgus. Patients underwent preoperative radiological and clinical assessment using pain and American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scores. Patients underwent preoperative counseling and were assessed for medical suitability for outpatient surgery. They were instructed to have responsible adult caregivers available for 24 hours postoperatively, easy access to after-hours emergency medical care, and access to a telephone. Procedures were performed under general anesthesia with local anesthetic ankle block.

Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff with an oral analgesia regimen. Cast immobilization was not used. Patients were reviewed at 6 weeks and 3 months postoperatively with repeated clinical and radiological assessment. All patients were discharged home and none required inpatient ward admission. Post-discharge, no patient presented to the emergency department or their general practitioner as a consequence of poor pain control. At final follow-up assessment, mean AOFAS hallux scores had improved from 58.1 (range, 29-80) to 89.0 (range, 47-100) (P<.001). The mean hallux valgus angle improved from 33.2° (range, 15°-53°) to 16.9° (range, 3°-39°) and the intermetatarsal angle had improved from 13.2° (range, 6°-23°) to 8.5° (range, 4°-15°) (P<.001). Eighty-five percent of patients reported that they would recommend outpatient surgery. Bilateral hallux valgus surgery can be performed safely as an outpatient procedure in selected patients with acceptable levels of patient satisfaction.

An increasing number of orthopedic surgeries are now performed as outpatient procedures.^1,2 The clinical and economic benefits of outpatient surgery extend to the patient and the health care provider. Hospital stays are shorter, patients are able to recover in their own home environment, surgery cancellations due to inpatient bed shortages are unlikely, and the risks of hospital-acquired infection are reduced.^1,2

Published results of unilateral hallux valgus correction as an outpatient procedure indicate that it can be undertaken safely with a high degree of patient satisfaction.^3,4 However, hallux valgus has been reported to affect both feet in as many as 84% of cases.^5,6 As such, surgical correction of bilateral, symptomatic hallux valgus normally involves an inpatient admission due to concerns regarding postoperative pain control, or alternatively, 2 separate outpatient procedures. Performing this surgery as an inpatient procedure means that the institution cannot make use of the potential benefits of the outpatient surgery unit. Similarly, performing staged unilateral surgical corrections has social and economic implications for patients, as they must effectively recover from 2 separate surgical procedures.

This article reports the outcomes of bilateral corrective surgery for hallux valgus in a selected patient population.

Materials and Methods

Forty consecutive patients (80 feet) who presented to the outpatient surgery unit at our institution for surgical correction of bilateral hallux valgus were prospectively evaluated. Suitable patients were selected from those attending a specialist foot and ankle service with bilateral symptomatic hallux valgus.

Patient suitability was determined by assessing their medical and social circumstances. Clinical assessment for medical suitability for outpatient surgery was undertaken by a specialist nurse/anesthesiologist. Individuals who were American Society of Anesthesiologists (ASA) grades 1 and 2 were deemed suitable, along with those who were grade 3, providing their disease was well controlled. A body mass index (BMI) of ≤35 was also required. Each patient was counseled about the social and medical implications of having the procedure performed as an outpatient and was provided with an information sheet. In addition to being considered medically suitable for outpatient surgery, patients were instructed that they must have a responsible adult caregiver available for a minimum of 24 hours postoperatively, easy access to after-hours emergency medical care, and immediate access to a private telephone (Table 1).

Patients underwent preoperative clinical scoring using the American Orthopaedic Foot & Ankle Society (AOFAS) hallux assessment scoring system in addition to radiological assessment by dorsoplantar, oblique, and lateral weight-bearing radiographs of the feet (Figure 1). Preoperative pain scores were also recorded.

Figure 1: Preoperative radiographs of a patient with bilateral hallux valgus and varus deformity of the fifth metatarsophalyngeal joints.

All patients were admitted to a dedicated outpatient surgery ward on the day of the intended procedure. All procedures were performed under general anesthesia with local anesthetic ankle block for postoperative analgesia using the maximal individual dose of levobupivicaine (2 mg/kg). Surgeries were performed using pneumatic tourniquets with exsanguination using an Eshmarch bandage. Both feet were draped simultaneously. A number of surgical procedures have been described to correct the deformity of the first ray in hallux valgus, and several authors have published treatment algorithms to simplify the surgical management of this condition.^5,7-15 As such, the surgical procedure depended on a number of factors, including the degree of radiological deformity (hallux valgus and intermetatarsal angles) and the presence or absence of tarsometatarsal joint instability, first metatarsophalyngeal arthritis, and hallux valgus interphalangeus. Patients who required treatment of fixed lesser toe deformities in addition to the bilateral first ray deformity were not considered suitable for bilateral outpatient correction.

Postoperatively, patients were discharged after assessment by medical, nursing, and physiotherapy staff. Each patient was discharged with a standardized oral analgesia regimen (altered if potential drug allergies or interactions were reported), which included diclofenac sodium 50 mg three times daily, acetaminophen 1000 mg 4 times a day, and dihydrocodeine 30 mg to be taken as necessary for 10 days. Each patient was given an information sheet and was advised to contact the orthopedic unit, the after-hours emergency medical service, or the hospital emergency department immediately if any postoperative complications occurred. Patients were reviewed 10 days postoperatively in a nurse-led foot clinic for wound inspection, suture removal, and reduction of dressings. Cast immobilization was not used, and all patients were instructed to bear weight with the heel only for the first 6 weeks postoperatively.

Patients were subsequently reviewed at routine outpatient clinics 6 weeks and 3 months postoperatively. At 3-month follow-up, radiographs were taken as previously described to document the radiological outcome of surgery (Figure 2). Clinical evaluation was repeated using AOFAS hallux scores and pain scores.

Figure 2: Postoperative radiographs after correction with bilateral chevron/akin osteotomies and osteotomies of both fifth metatarsals performed as outpatient procedures.

Statistical analysis was performed using SPSS 13.0 software (SPSS Inc, Chicago, Illinois). Comparison of postoperative outcome scores was performed using the Mann-Whitney test.

Results

All 40 patients (80 feet) successfully underwent bilateral corrective surgery. The mean age of the study population was 45 years (range, 17-69 years; SD ±15.9). Thirty-nine (97.5%) of the 40 patients in the study group were women. The surgical procedures performed and the indications are listed in Table 2.

All patients were discharged home successfully from the outpatient surgery unit, and no patient had to be transferred to the inpatient ward prior to discharge.

One patient (2.5%) presented to her general practitioner in the perioperative period with a superficial wound infection, which was successfully treated with a course of oral antibiotics.

Clinical and radiological outcomes were documented at a mean follow-up of 3.2 months (range, 1.4-4.6 months), and a statistically significant improvement was noted in both of these outcome measures (P<.001; Table 3).

Patients were also surveyed to determine whether they would undergo the procedure again or recommend it to a friend based on their recent experience. Eighty-five percent of patients (34 of 40) reported that they would do so, and 15% (6 of 40) reported that they would in retrospect have preferred the procedure to be undertaken as an inpatient with an overnight stay. Reasons cited for this included postoperative pain (2), difficulties with mobilizing at home (2), and a desire to recover in an inpatient ward-based environment despite adequate analgesia (2).

A number of postoperative complications were recorded, including 1 postoperative superficial infection; 1 case of persisting metatarsalgia; 1 case of persistent pain due to prominent metalwork, which required removal; and 1 deformity recurrence requiring revision surgery. One patient suffered a traumatic fracture of the first metatarsal after tripping while walking after the original osteotomy had successfully healed. No symptoms were reported preinjury, and the fracture healed with conservative management. No further surgery was indicated or performed. All osteotomies and fusions progressed to radiological union.

Discussion

Dedicated outpatient surgery units are more resource efficient and allow a surgical department to release inpatient beds for more major cases.^1,2 Advances in anesthetic techniques have resulted in an increasing number of procedures being offered as outpatient surgeries.¹ Several studies have reported favorable outcomes after unilateral hallux valgus correction as a outpatient procedure.^3,4,6 However, hallux valgus is frequently a bilateral condition, and performing staged unilateral surgical corrections has social and economic implications to patients, as they must recover from 2 separate surgical procedures. A single procedure is associated with increased operating time, increased postoperative pain, and difficulty mobilizing.¹⁶

When a surgical procedure is offered on an outpatient basis, it is essential to ensure that a number of caveats are met. The procedure must be suitable for such a setting, the risk of early postoperative complications (from surgery and anesthetic) should be minimized, and admission to an inpatient ward postoperatively should be unlikely. We have demonstrated that bilateral hallux valgus correction adequately satisfies these criteria. In addition, objective measures of clinical and radiological outcomes were highly satisfactory, and patient satisfaction was similar to that reported for unilateral outpatient hallux valgus surgery.^3,4

To avoid readmission, it is essential that the home circumstances of any patient considered for bilateral outpatient surgery are carefully considered. If a patient does not meet our criteria for domestic support, an inpatient admission is offered. In addition, it is essential that a patient is properly informed of the potential problems that may arise in the early postoperative period and that the patient should be suitably motivated to undergo such surgery.

The provision of adequate postoperative analgesia is also fundamental to the success of this procedure, and the effective use of nerve blocks to achieve this is a key factor in extending the indications of outpatient surgery to bilateral hallux valgus corrective surgery. The safety and efficacy of peripheral nerve blocks in foot and ankle surgery have been well established, and levobupivicaine is a safe, effective local anesthetic agent able to provide analgesia for up to 10 hours postoperatively.^17,18 As such, no patient in this study required increased analgesia above the oral agents prescribed on discharge from the outpatient surgery unit.

Performing bilateral hallux valgus surgery may in theory increase the risk of certain postoperative complications, such as loss of fixation and deep venous thrombosis; however, no such problems were identified in this patient cohort.

Conclusion

Bilateral hallux valgus surgery can be performed safely on an outpatient basis in selected patients with acceptable levels of patient satisfaction. To our knowledge, this has not been previously reported in the literature.

References

1. Department of Health. Day surgery: operational guide: waiting, booking and choice. London, England: Department of Health; August 2002.
2. Aylin P, Williams S, Jarman B, Bottle A. Trends in day surgery rates. BMJ. 2005; 331(7520):803.
3. Bhargava A, Rai P, Shrivastava RK. Adult day case hallux valgus surgery—a safe and viable option. Ambulatory Surgery. 2003; 10(3):151-154.
4. Tibrewal SB, Foss MV. Is day surgery for Wilson’s osteotomy safe? J Bone Joint Surg Br. 1991; 73(2):340.
5. Coughlin MJ, Jones CP. Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 2007; 28(7):759-777.
6. Thomas S, Barrington R. Hallux valgus. Current Orthopaedics. 2003; 17(4):299-307.
7. Barouk LS. Scarf osteotomy for hallux valgus correction. Local anatomy, surgical technique, and combination with other forefoot procedures. Foot Ankle Clin. 2000; 5(3):525-558.
8. Borton DC, Stephens MM. Basal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br. 1994; 76(2):204-209.
9. Coughlin MJ, Saltzman CL, Nunley JA II. Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int. 2002; 23(1):68-74.
10. Coull R, Stephens MM. Operative decision making in hallux valgus. Current Orthopaedics. 2002; 16(3):180-186.
11. Easley ME, Trnka HJ. Current concepts review: hallux valgus part II: operative treatment. Foot Ankle Int. 2007; 28(6):748-758.
12. Johnson KA, Cofield RH, Morrey BF. Chevron osteotomy for hallux valgus. Clin Orthop Relat Res. 1979; (142):44-47.
13. Lapidus PW. The author’s bunion operation from 1931 to 1959. Clin Orthop Relat Res. 1960; (16):119-135.
14. Mitchell CL, Fleming JL, Allen R, Glenney C, Sanford GA. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg Am. 1958; 40(1):41-58.
15. Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005; 87(8):1038-1045.
16. Lin JS, Bustillo J. Surgical treatment of hallux valgus: a review. Curr Opin Orthop. 2007; 18(1):112-117.
17. Dhukaram V, Kumar CS. Nerve blocks in foot and ankle surgery. Foot Ankle Surg. 2004; 10(1):1-3.
18. Gottschalk A, Burmeister MA, Radtke P, et al. Continuous wound infiltration with ropivacaine reduces pain and analgesic requirement after shoulder surgery. Anesth Analg. 2003; 97(4):1086-1091.

Authors

Messrs Murray, Holt, Crombie, and Kumar and Mss McGrory and Kay are from the Department of Orthopedic and Trauma Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom.

Messrs Murray, Holt, Crombie, and Kumar and Mss McGrory and Kay have no relevant financial relationships to disclose.

Correspondence should be addressed to: Graeme Holt, FRCS(Tr&Orth), Department of Orthopedic and Trauma Surgery, Glasgow Royal Infirmary, 84 Castle St, Glasgow, G4 0SF, United Kingdom (graemeholt@btinternet.com).

doi: 10.3928/01477447-20100429-09