The Ugly Brother, Conservative Care |
As part of our retrospective New Docs series, I decided to look back on the other face of podiatric care. We spent the last few issues discussing surgery; now let's take a look at surgery's "ugly brother," conservative care, which we had originally discussed in Residency Rap #23. I describe this as the ugly brother because nonsurgical care has, in my opinion, received very little attention in comparison with surgery. If you don't agree, just think how many of you residents sit around discussing the best bunion pads. Very few, I'd imagine.
When I originally wrote the editorial I received an interesting argument against the word "conservative," with which I agree. "Conservative" implies that surgical treatment is radical. We know this is not always the case. Which is more radical: incision and drainage for a deep space abscess or IV antibiotics alone? So, from now on I'm going to use "nonsurgical" instead of "conservative."
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Jarrod Shapiro, DPM
PRESENT New Docs Editor
Joined Mountain View
Medical & Surgical Associates
of Madras, Oregon July 2008 |
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I have to applaud Levy and Hetheringon's text Principles and Practice of Podiatric Medicine for focusing some attention on nonsurgical care. Most of us spend much more time treating patients nonsurgically, and a broader discussion and focus on this is important for the practicing podiatrist.
So, let's talk a bit about nonsurgical care. Here are just some of the advantages:
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1. It often works!
2. It gives you time to know your patients, establishing trust on both ends of the exam chair.
3. It's often nonpermanent. For example, you can remove or change an orthotic if it doesn't work, while surgery permanently alters structure. On the other hand alcohol sclerosing solution also permanently alters structure – hence my inserting "often."
4. Often multiple method options to treat one pathology. Think of the number of options to treat verruca. |
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What about the disadvantages? Here are a few: |
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1. If often fails.
2. It's often nonpermanent. Sometimes, for instance, changing shoes will reduce plantar fascial symptoms, but once you remove the shoes the symptoms return.
3. Often multiple methods to treat one pathology. Think of the number of options to treat verruca. If there were one successful treatment we wouldn't have so many. |
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I always find it interesting that the advantages and disadvantages can be the same depending on how you look at it!
In my practice well over 90% of my patients are treated nonsurgically at some point in their care. In our next installment I'll review my nonsurgical care of some representative pathologies. I'll state here at the outset that these will be MY treatments – I am not doing a scientific metanalysis of nonsurgical care – so I don't expect anyone to read the editorial as the gospel. It's just how one doctor treats patients.
This topic is as important as any surgical discussion—so I'd urge you residents who think you're going to graduate into a full practice with only surgical patients to spend some time talking with your attendings and colleagues about nonsurgical algorithms. I look forward to an informative discussion on nonsurgical treatment.
RETRACTION: We would like to apologize for and clarify an error printed in last week's issue, New Docs 128 - Letters to the Editor: A Retrospective.
The following letter, from esteemed colleague, Jeff Kass, and my Editor's response, should have read as follows: |
In your last "blog" you commented that you do partial head resections versus the Weil as per someone who trained you. Can you expound on exactly what you are doing. Did you say you do this in cases of plantar plate ruptures?
You also commented that you do modified Lapidus procedures – in what way is the procedure you do modified?
—Jeff Kass, DPM
[email protected]
Editor's Response:
...I'm never dogmatic about the procedures I choose. So, when I discuss a procedure I'm talking in generalities. I'll always determine the etiology of the problem and any associated factors and consider the entire pathology and patient. Having said that, I still do the Weil osteotomy just less often and on younger or more athletically active patients. In the case of a clear plantar plate rupture I'll generally repair it primarily and do a flexor tendon transfer through the same incision (assuming a flexible deformity).
As far as the Lapidus, this is actually a small technical point. The modified Lapidus is the procedure most of us discuss and currently perform, namely fusion of the 1st met-medial cuneiform joint. Any change in technique from Paul Lapidus' would be "modified." The original procedure did not use any fixation, so simply using screws would be a modification. We'll all know what you're talking about if you say you do a Lapidus arthrodesis as opposed to using the word "modified."
—Jarrod Shapiro, DPM |
Letters to the Editor—Surgical Retrospective (your feedback):
Your New Doc comments are great. All new practitioners should be required to read. Your partial met resection comments were great. Too often we abandon procedures that work well for what is popular now, with no thought for is this the best procedure and of course can have a screw inserted.
—Bill Martin
[email protected]
I also enjoy your column. Having been a residency director for 30 years, it is always interesting and worthwhile to listen or read the comments of young podiatrists. As with anything in life, I have found after 34 years of practice and 30 years of training residents that "what works in your hands" is the best way to go. Only being in practice and using the various techniques you were exposed to during training can tell you what is best to do. I agree, not everything that is "textbook" is right for everyone. Keep exploring and reporting on what is working for you and the feedback is great. By the way, the percutaneous TAL is becoming a standard of care for treating forefoot diabetic wounds and does it impress those MD's at the wound center when the wound they've been treating for months suddenly disappears 2 weeks after the procedure.
—Louis R. Lapow, DPM, FACFAS
[email protected]
Former Director, St Joseph Regional Medical Center
Podiatric Residency Program Milwaukee, Wisconsin
(2 time winner of the PRESENT Residency Challenge)
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Thanks again for your interest and your interesting responses. For those of you who have questions or comments, please write in. I like my own opinion, but the real fun and usefulness of this editorial is your thoughts and concerns. Write in and be part of the community! Best wishes...
Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]
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