surgical consideration

Surgical consideration to decide if foot surgery is right for you.

The purpose of this page is to discuss my opinion on when is the right time to have a foot problem surgically corrected. This question is asked of me on a regular basis. Generally people have chronic foot pain but because most foot surgery is of an elective nature many people just keep putting it off because there is always some other thing going on and people cannot find the time necessary to devote to the foot surgery and the necessary recuperation period.

It is should be noted that there are certain instances such as in the case of severe infections particularly in the compromised patient, or osteomyelitis (bone infections), or gangrene where surgical intervention is no longer of the elective nature. Suspected malignancies are not elective procedures. These problems if not treated in a timely manner can be limb threatening and in certain cases even life threatening.

The standard of care in any medical condition is to first try the simplest and most conservative measures; if they do not alleviate the problem then more aggressive measures are indicated.

For the elective procedures that we as foot specialists perform there is rarely an urgency to have the given procedure performed. Yes, pain can be of varying degrees to different patients and patient pain thresh-holds can vary from person to person.

So, assuming conservative measures either have failed to alleviate a given foot problem or perhaps have reduced the pain somewhat, once again, the question asked of me (and probably every other doctor) is when is it time to finally have a foot deformity corrected?

As I discuss with my patients, there are various considerations to take into account. If you have a problem that you noticed has been getting worse over time (in spite of medical treatment), then you probably want to have the procedure sooner rather than later, for two reasons. One, the condition is only worsening and depending on the problem it may be harder to surgically correct a problem when it gets too bad rather than the point at which it presents itself presently. Bunions, for example, in most people are a condition that get progressively worse and the worse they get the more involved is the procedure necessary to correct them which translates into a longer recuperation process. Secondly, as you keep putting off having a surgical procedure done you run the risk of developing some other kind of medical condition that may prevent you from ever having the foot surgery. This is probably true of older individuals in their late 60’s and 70’s. One may develop diabetes, which in itself is not a reason not to have foot surgery, but if this individual’s blood sugars are too high and cannot be controlled then they no longer are candidates for foot surgery. Diminished circulation over time in the foot would be another reason to no longer be a candidate for elective foot surgery.

The length of time that you have been suffering from a foot problem should also be taken into account. There are no hard-fast rules but it is safe to say that a lot of musculo-skeletal pain may simply subside by itself if given enough time. “Tincture of time” is a medical treatment that can be very effective. As a general rule, if you have been experiencing foot pain for at least a couple of months, with no overall improvement in spite of all treatment therapies, then surgical correction should be on your mind.

So, how much pain does one have to have in order for a foot or ankle problem to be severe enough to consent to surgery? My philosophy here is very simple: when your foot or ankle pain gets in the way of living your life then you need to seriously consider having the condition corrected. An example would be the situation where a friend invites you to their summer home in the mountains. You would love to go but you know that a visit there will require a lot of hiking and other activities and your foot pain just will not stand up to that sort of rigor, so you decline the invitation. Now your foot pain is dictating your life, it is time to do something about it.

A simpler example would be one where you want to start a walking program to lose weight, but you cannot walk any real distance because your foot hurts. Again, your foot is dictating your life.

Once you have made up your mind to have surgery make sure you choose a doctor you have faith in. Choose someone that treats you like human being; spends all the time necessary to explain the procedure and answer any of your questions. Keep in mind, no question is too foolish. Human nature being what it is, I find that most patients basically end up asking the same questions, so I try to incorporate the most commonly asked questions in my preoperative discussions.

Do not be railroaded into consenting to surgery. Even in medicine, there are a lot of “used car salesmen”. If you are uncomfortable in any way with what your doctor has told you, get a second opinion. If your doctor is a legitimate, confident, well trained surgeon, he will welcome the suggestion because he is comfortable in what he has proposed to you and will be able to explain any discrepancies from the second surgeon's opinion. Keep in mind that many proposed procedures look better on paper then they do in actual practice and no matter how good a job your doctor may end up doing, we as surgeons cannot put things back together as well as mother nature and there is a price to be paid for that.

Consenting to surgery is about risk vs. reward. No matter how pretty a picture a surgeon paints about having surgery, how quickly you are going to heal, how much better your foot is going to feel, there are risks involved. The type of risks vary depending on the various condition and procedure but common to all of them is the risk of infection and the real risk of surgical failure whereby you are no better off after surgery than you were before the procedure. That is why you have to look at the potential reward. If you are in a lot of pain and this pain has been keeping you from doing the things that you want, then the risk reward ratio is in your favor. (Resolution of pain is the reward, which far outweighs the risk). If on the other hand you have minor pain, which is more a nuisance than any thing else, or you do not like some “bump” sticking out of your foot, then the risk reward ratio is not in your favor. You are taking on a lot of risk for very little potential reward.

While we are on the subject of surgical considerations a new area of foot surgery has developed and this is cosmetic foot surgery. The basic premise is to allow, primarily women, to wear the stylish shoes they desire by undergoing surgical procedures to allow their feet to more readily fit into shoes that feet were not designed to fit into in the first place. The other reason for cosmetic foot surgery is make a person's foot "prettier". This whole concept goes against my feeling that the only reason to have foot surgery is to eliminate pain. Having said that the point I would like to make for those contemplating foot surgery strictly for cosmetic reasons is that even with cosmetic surgery there are surgical failures and you do run the risk of ending up with feet that look and feel worse than what you started out with. Be careful when having this conversation with your surgeon and he or she shows you all the "before and after" pictures of other patients. Keep in mind you are only seeing the successful surgeries. It is actually possible to end up with a better looking foot that actually hurts more then the original foot.

The American College of Foot and Ankle Surgeons (ACFAS) has stated in part, "Surgery performed solely for the purpose of improving the appearance or size of the foot or ankle carries risks without medical benefit, and therefore should not be undertaken."

The American Orthopaedic Foot and Ankle Society has stated "...that surgery not be performed simply to improve the appearance of the foot. Surgery should never be performed in the absence of pain, functional limitation or reduced quality of life."

In conclusion if you have come to this site looking for answers to proposed surgical procedures (and I do get a lot of emails asking about various procedures), I obviously cannot comment on specifics without actually seeing the foot, but hopefully this essay has given you some insight into making a sound decision.

If your decision is to go ahead with the proposed surgery.....good luck.

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