By Joel D. Stewart, MD:
Complex, traumatic injuries to the foot and ankle can present some of the greatest challenges to an orthopaedic surgeon. Due to their unique weight bearing role, feet and/or ankles that sustain crush injuries/open fracture traumas may never regain normal functional strength and motion.
As a surgeon, I understand my patients’ desire to have a somewhat normal looking and semi-functioning foot, even after a mangling injury. I also understand their aversion to even the mention of amputation, even though it may be the best treatment option. If feasible, limb salvage becomes my primary goal; the return of limb function is secondary, and the cosmetic issues are tertiary. If we are successful in achieving our short-term goals, we then progress to the treatment of chronic, lifelong foot and ankle problems.
Long term care of these patients almost always ensures that I will treat them for post-traumatic arthritis, tendon or ligamentous issues, non-union or all of the above, even when their acute medical care was handled expeditiously and appropriately. Pain reduction is vital, while stabilizing bones and joints, restoring functionality, and arresting further deformities.
My team often works closely with Infectious Disease and Plastic Surgery to manage these complex injuries. If there is nerve damage, we may need to work with Neurology or Physical Medicine and Rehabilitation/Pain specialists to diagnose which nerves are damaged and determine options for management. If there was vessel damage, the patient may need bypass surgery or other vascular procedures.
The determination of nerve damage, alignment and infection are crucial to treatment option selection. Often, custom bracing can accommodate deformity and help with pain, but if there are wound healing issues or nerve damage, these can be difficult to manage. Skilled prosthetists and orthotists are key to make these non-operative options successful.
If non-surgical options fail, limb realignment or tendon transfers should be considered. Arthrodesis remains the standard of care for treating post-traumatic arthritis, especially with soft tissue damage. It is important to accurately pinpoint the painful bony or joint abnormalities through diagnostic studies and selective anesthetic blocks to prevent fusion of non-symptomatic bones/joints. We have options for possible joint replacement for the ankle, but this is very dependent on soft tissue integrity and balancing of the limb and joint.
If all other options are exhausted, amputation can provide the patient a better quality of life. The level of amputation, pre-injury activity level, and other co-morbidities can change how we manage prosthetics, sockets, and suspension systems. Managing patient expectations of what an amputation can and can’t do is critical. We see young military veterans doing amazing things on prosthetics, but an older, overweight, smoking diabetic may not get the same results. Finally, these are often work-related injuries and legal, economic and psychological issues can also play a role.
In summary, the management of severe extremity trauma is a team effort. The orthopaedist, patient, family and multiple specialists must work cooperatively to return the patient to a relatively normal life and employment.
Dr. Joel Stewart is a fellowship trained foot and ankle specialist with an emphasis in Sports Medicine at Orthopaedic & Spine Center (OSC). osc-ortho.com
