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what exactly should the surgeons tell you before surgery?

Posted by elliott on 9/10/02 at 09:06 (094896)

Would love to hear your opinions, including those of the docs.

Some here have voiced the opinion that the surgeon should tell you of all the risks you might face, e.g.: for PF you risk entrapment of a nerve branch or lateral column pain; for TTS a return of symptoms or RSD. My first surgeon (3 years ago) stated a 90% success rate and a return to running 6 weeks later, with only hand waving to the possibility of scar tissue formation or clot. The result was he gave me problems I never had, possibly ruining my foot due perhaps to inadvertent damage to a tendon. I was far better off before; I could still walk without trouble. People have told me stories of someone they know who even died from minor surgery due to things like a blood clot. I think surgeons tend to make final outcomes look too rosy even in their own minds, to minimize resulting side effects, and to completely exclude the possibility of their own errors. I suspect many here dispute the universally accepted and published PF surgical success rate of close to 90%.

My personal opinion is that a person in pain or severe deficiency is not going to adequately comprehend and appropriately weigh every obscure risk, nor should the doc have to state them all (although if some harmful outcomes are statistically likely, those should be discussed). All I'm asking is that they give an all-encompassing single realistic uninflated success/improvement rate and define what they mean by that term. I think a patient is mature enough to understand that, and in borderline cases at least, weigh carefully whether to opt for surgery.

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Re: what exactly should the surgeons tell you before surgery?

Sharon W on 9/10/02 at 12:33 (094911)

Elliott,

I agree with you on PART of this one. There are many claims out there of incredibly inlated success rates for both PF and TTS surgery, and there are unrealistic assertions being made by doctors sometimes, leading patients to assume they will have rapid and rosy outcomes. A more realistic general expectation should be communicated to the patient considering surgery.

That said, every case is different, every patient has his/her own distinct needs, and statistics don't really apply to individual circumstances. A good, conscientious surgeon should take MANY factors into consideration when giving his patient a general indication of what to expect from surgery, and it IS appropriate that different patients should be told to expect varying recovery times, and warned of different surgical risks, etc.

Patients also vary in their knowledge and background with respect to understanding health issues. I think that if a patient expresses a desire for more information about surgical risks, that information should be provided at a level of technical explanation appropriate to what the patient can understand. It hardly makes sense to throw a bunch of technical medical terms at a patient that he/she cannot understand, and call that 'informed consent'!! I mean, the doctor would effectively be speaking a language that the patient doesn't know.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Janet C on 9/10/02 at 13:16 (094912)

I totally agree with you, Sharon.

Elliott, I would like to see a study done, first, to determine the over-all success/improvement rate from these types of surgeries. I don't know of any official study that's been done yet do you? And I think that to get a clear understanding of the success of these surgeries, they need to follow up with patients... 5 10 yrs post surgery, and ask them how it worked out. I think that most Drs. assume that the patient had a successful outcome to their surgery, if they don't see the patient again. I wonder how many Drs. that I've seen over the years, have written me off as another 'success'?

Once a realistic success rate has been determined, I think that should be made clear to the patient before their surgery, so that they can make an adult, informed decision. Drs. should also advise their patients of certain disorders that could occur in regards to each patient's personal needs. And yes I think Drs. should warn their patients of the possible complications of RSD from TT or CT surgeries, because it seems that RSD is not an uncommon result of these types of surgeries - that is, people with RSD, often have had CT or TT Release surgeries.

So I think that that possibility should be made clear to the patient, but just as importantly, Drs. should be on the lookout for RSD post surgery! So many Drs. don't catch the obvious symptoms of the disease, until it's far past the time when one can have the best results for stopping, and/or reversing the disorder.

~ Janet

Re: what exactly should the surgeons tell you before surgery?

wendyn on 9/10/02 at 13:46 (094915)

Janet, do you think it's possible that some of these RSD patients who have had TTS surgery, actually had RSD _BEFORE_ the surgery (the RSD was misdiagnosed as TTS in the first place).

Wouldn't suprise me if that happened at least sometimes.

Re: I totally agree with myself :-)

elliott on 9/10/02 at 13:55 (094916)

You women keep going about your back-slapping; since I've been here I don't think anyone has ever said, 'Elliott, I totally agree with you.' I could just cry. :-)

When I said 'all-encompassing single realistic uninflated success/improvement rate', I meant for that individual, so no argument there.

The notion of an 'official' study might be a naive one. Different docs of differing abilities do different self- or co-studies of different types of different size, quality, surgical selection criteria, etc. That said, there have been some studies containing sufficient followup. Some results sound fabulously successful. Occasionally there are some with low success rates (one comprehensive TTS study claimed 44% success), sometimes intended to prove the authors' predetermined point that some other treatment should be considered or that surgery shouldn't be done. You get the feeling that everyone has an agenda. And if a surgeon's success rates are too low and he never publishes that, you'll never know and only observe more positively-biased results.

There's a big difference between possibility and probability. As I alluded to in my first post, there is the possibility of death. There may be a LIKELY probability of RSD, in which case one ought to be told. However, if, for example, one has not ever experienced nerve pain or RSD, r even is in much pain now so he/she doesn't care, the warning will be of limited value, unless the likelihood is sufficiently large that the person will think twice about things that might go wrong. Agree they should be on the lookout for things like RSD. I'd go even further and say they should warn their patients post-op to be on the lookout for anything resembling it.

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Re: what exactly should the surgeons tell you before surgery?

Sharon W on 9/10/02 at 14:21 (094918)

Good point, Wendy.

Considering that surgery is usually not a good option for those with RSD, I think it's a reasonable assumption that surgery done even in the early stages of that condition would tend to make RSD worse.

Sharon

Re: I totally agree with myself :-)

Janet C on 9/10/02 at 14:58 (094922)

Elliott - I will give you a pat on the back for making several good points... :-) especially, the fact that most studies have a hidden agenda, depending upon who is paying for it, and so are not a realistic portrayal of the population's true results.

And another question that your post brought to mind, is... who determines the definition of a success?!

You know, no one warned me of developing RSD prior to my TT surgeries... but I do in fact, recall signing a form that said in effect, that I would not sue the Dr. if I died from this surgery... it made me laugh as I signed it... because I thought, _I_ won't sue... but my family just might! ;-)

And I must say, I TOTALLY agree with your last couple of sentences! :-) And wouldn't it be great if Drs. didn't send their patients with RSD away... after telling them it's all in their head... or they're having a mid-life crisis... or they're a drug seeker... or treated with contempt because they didn't heal as the Dr. had expected! I'm not bitter, am I? ;-)

Re: what exactly should the surgeons tell you before surgery?

Pauline on 9/10/02 at 15:02 (094923)

Janet,
I think you hit the nail on the head. Surgery is about need and success rate which is documented by formal studies. I think we should be asking 'Is this surgery necessary and then show me the studies that says it's successful'.

In my mind, far toooo many P.F. surgeries are performed and the final results are nothing to brag about.

How many patients have we seen go from bad to worse following P.F. surgery?
It's happening before our eyes. I've been reading the accounts on the surgery board. I'm waiting for the last batch of patients to remove their post surgical boot and reward us with good news. It hasn't happened yet.

Time we as P.F. sufferers take a long hard look at all the P.F. releases being done today and start asking to see the data.

Re: what exactly should the surgeons tell you before surgery?

Janet C on 9/10/02 at 15:10 (094925)

Sharon, Yes, surgery is to be avoided, if at all possible, for those with RSD. It has been shown to aggravate the condition, causing it to spread more rapidly. And if the surgery, or injury, occurs in a distant place on the body, it can cause the RSD to jump, and spread to that area.

And Wendy, I think that is a possibility. In fact, I had the burning pain after my heel spur surgeries - the year previous to my TT surgeries... so I now realize that I may have developed RSD after the prior surgery, and the latter just made it worse!

~ Janet

Re: what exactly should the surgeons tell you before surgery?

Janet C on 9/10/02 at 16:53 (094934)

Thank you for your thoughts on this issue, Pauline. I couldn't agree with you more.

And from what I've observed - it seems like many patients, post-surgery, initially think that their pain has been reduced... but a year, or even several years later, the pain tends to come back, and often, far worse than before. That's why I think an appropriate study should be done, interviewing patients many years post-op.

Re: Elliott, I ALMOST totally agree with you :o))

Sharon W on 9/10/02 at 18:55 (094948)

Elliott,

This part of your previous post was worthy of repeating:

'I think surgeons tend to make final outcomes look too rosy even in their own minds, to minimize resulting side effects, and to completely exclude the possibility of their own errors. I suspect many here dispute the universally accepted and published PF surgical success rate of close to 90%.'

Surgeons have to keep their confidence up; I mean they really can't afford to start doubting themselves, if they're cutting into human beings! But that means that they may not be all that 'objective' about how successful their own surgeries are, etc. etc.

And as for those 'universally accepted' success rates for PF (or TTS) surgery of about 90% -- phooey! Perhaps there ARE a few good surgeons who only accept 'perfect' cases, that actually achieve those success rates. (Even so, I bet they tend to have rather loose definitions of 'success'!) As far as 90% success being TYPICAL for either of those surgeries -- NO WAY. I just don't believe it. Like Pauline, I've been closely following the reports of surgery results for the past 10 months, and there's no way 90% of our posters with recent surgeries have been happy with their results.

The issue of HOW 'success' is defined, is another biggie that you touched upon. If you define ANY report of improvement as 'success,' then when the patient comes in 2-3 weeks after surgery, perhaps even still taking painkillers, and says s/he feels 'a lot better now,' THAT might be referred to by some as a 'success'! OF COURSE, as a patient begins to heal after surgery they will tend to feel better, because the surgical wound itself is closing and becoming less painful.

And if the patient never returns to the surgeon, after the immediate post-op period, does THAT get written up as a 'success'? (From reading these boards, I would guess it's probably FAR more likely to mean it was a FAILURE -- because if you don't like what the doctor did to you, you probably never go back to him!)

A more valid criterion for 'success' would be, does the patient still say s/he is feeling 'a lot better' after 6 months? After a year? Did the patient develop lateral column syndrome? Nerve entrapment? RSD? Any other complication or condition that may be related to the surgery? As Janet mentioned, I think even a 5-year follow-up would be appropriate for a SERIOUS attempt at determining success/failure rates for these surgeries.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Pauline on 9/10/02 at 20:54 (094960)

Janet,
Your correct. A week after surgery when they are in their boot or cast everything is just great, but come time to kick the boot and apply weight
they report worse pain than before their surgery.

No need to wait a year to see this happen. Just follow the most recent posters who under went a P.F. release. We've seen it toooo much to be coincidental.

I don't think this comes as a surprise to the doctors who post here either. It's just never be in the spotlight before. Well I think it's about time this information comes to light.

Long ago Dr. Z said Pods treat most of the people with foot problems, well then Pods must be the ones doing most of the cutting too.

If their not making lots of income from surgery as we're told, then there certainly is no reason why they can't stop cutting the P.F. tomorrow. I think they need to make this a high priority topic at their next convention. The cutting must stop and the doctors here should be the ones leading the charge.

Re: what exactly should the surgeons tell you before surgery?

Dr. Z on 9/10/02 at 21:00 (094961)

The cutting of the plantar fascia is a major topic that I lecture about. i do this once per week. I show pictures and try to explain why cutting the plantar fascia is a stupid idea.Can you imagine cutting the weight bearing wall in your home . The entire floor and roof will come collapse down. Or imagine remove a basement support steel beam. The entire basement would come crashing down. And we cut the fascia and expect the patient to walk and be painfree. Ok next question

Re: what exactly should the surgeons tell you before surgery?

BGCPed on 9/10/02 at 22:45 (094971)

This may be a bit off the path for some but not many years ago the knee surgeon would remove most of the cartiledgein one of the knee compartments. If you look at some older athletes with the big zipper scar up the knee. Now many of them have severe compatmental osteo arthritis due to of all of the vital shock absorbing material being removed and now it is bone on bone.

At the time it was thought to be the solution.If it grinds, rubs and creates friction then 'remove it'. Now we have some Docs injecting chicken fat into the knee to replace or augment what has worn down.....total different approach. IMHO whether it is a joint or any other body part, God made the best working version. From an orthopedic standpoint there is not many parts like an appendix that you just cut or get rid of and you are better off. It is there for a reason.

The majority of pf release is done on over pronators which to me seems like an even dumber idea since they need the stabilization more than anybody

Re: A lot more than some do now

wendyn on 9/11/02 at 06:57 (094987)

BGCped, The overpronation issue is exactly why my surgeon was against surgery in my case. He told me flat out that the odds were less than 50/50 that it would help me, and that there was a strong possibility I would be worse. This was based on the fact that my MRI did not indicate anything in the tunnel that he could 'fix' or 'remove'.

Re: Ok next question

elliott on 9/11/02 at 07:29 (094989)

Did you do such lecturing before you got the ESWT device?

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Re: what exactly should the surgeons tell you before surgery?

Pauline on 9/11/02 at 07:39 (094990)

Doctors,
Knowing the foot was going to crash, what was happening to patients with P.F. pre ESWT in your practices? Are you saying you all refused to do any P.F. surgeries?

Dr. Z,
Your lectures must be falling on deaf ears, who are you presenting them to every week and where?

Re: Elliott, I ALMOST totally agree with you :o))

Pauline on 9/11/02 at 09:35 (095002)

Elliott,
You touch on probably one of the most highly debatable topics and that is
how 'Success' is defined. I think I might have touched on this before.

I read many medical journal articles and am always amazed by many of the conclusions reached following each study.

To me if patients die as a result of treatment it shouldn't be called a success, yet it happens. That has to make you wonder about the defination of 'Success' as it's being interepted by the doctors doing these various studies. Is treating 10 patients and loosing 1, hospitalizing 1, causing infection in 2 successfull?

Re: what exactly should the surgeons tell you before surgery?

dave r on 9/11/02 at 11:33 (095014)

I had three docs flat out tell me that surgery would only help 50% of the time. They didnt recommend it at all. There is to much room for scare tissue to develope. Once that there you develope other problems. and the fact that surgery changes thes mechanics of your foot. I had one surgeon say that surgery was completely out of the question. And that there wasnt anything that he could do. I also had another surgeon that was willing to do the open fasciotomy. But he also said that for some people they will NEVER get better. He said that 2% of the population will always be in pain.
He claimed to of done hundreds of procedures over 20 years. he also claims that 85% did get better from surgery.

Re: Ok next question

Dr. Zuckerman on 9/11/02 at 11:59 (095017)

didn't lecture I was't on the circuit but I sure talked about it and researched a solution. I found the solution in 1997 It's called ESWT.

Re: what exactly should the surgeons tell you before surgery?

Dr. Z on 9/11/02 at 17:56 (095057)

Before i was doing ESWT I was doing mis partial plantar fascia release. The TTS and Cal-cuboid complicatons were rare but did happen . With ESWT there is none. I would still do a MIS pf release if ESWT failed.

Re: Studies? Heck yes, we need them!

BrianG on 9/11/02 at 19:39 (095061)

I've said it many times in the past myself, I'd really like to see some good studies done, with honest surgical results. The trouble is, who is responsible enough to do these studies, in an unbiased manner ?????

BrianG

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 20:56 (095069)

Personally, I think I do a pretty good job of informing patients of the msot common risks and complications associated with any procedure. There are certain inherent risks irregardless of the procedure (infection, recurrence, delayed healing, pain, prolonged swelling, scar formation). These are a given. However, it is practically impossible to inform a patient of every single risk. What I mean is that there are some complications that can not be predicted. Case in point, I have a buddy who performed ESWT on a young healthy patient of his. About a week after the procedure, the patient began feeling extreme pain in the side of his foot. The patient relates that he had not injured it or traumatized it in any fashion. Physical exam revealed pain along the peroneal tendon sheath on the outside of the ankle. The pain extended onto the bottom of the foot across the midarch area. Just as a precaution, my buddy ordered an MRI. There was a tear in the Peroneus Longus Tendon. What's the chance of that following ESWT? Probably a million to one. Was it because of ESWT? I don't know. Could his heel pain (which is better) been masking this Peroneal Tendon Tear? It could. Why did it show up a week later though?

Personally, when I consent someone for surgery be it a bunionectomy or a major rearfoot procedure, I inform the patient to the point of probably overinforming them. Some quietly tell my nurse that they want to wait. I've had others who have signed the consent and not shown up for surgery. That's ok. 99% of all foot surgery is elective. It is not life threatening for the most part. Therefore, when a patient is ready for surgery, they generally know that they're ready. I had a patient today come in for evaluation of a large bunion deformity. We took xrays, talked about the deformity. It was pretty significant but guess what, it did not hurt. She was more concerned about the 'ugly bump' on the outside of her foot. My comment to her was, I'd wait until it hurt before having it operated on. She seemed pretty bummed but....I don't want to take an asymptomatic foot and make it hurt. That sets you up for a malpractice suit. It's not worth it to me or my family.

Re: Studies? Heck yes, we need them!

Janet C on 9/11/02 at 21:01 (095070)

Who normally is in charge of the scientific studies? The American Medical Association? There has to be some group who performs similar non-biased scientific studies in the U.S., to determine the efficacy of procedures... isn't there?

~ Janet

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 21:04 (095071)

RSD has a classical presentation. Usually most patients with RSD have Pain which is OUT OF PROPORTION. I mean you can't even touch the body part without sending the patient into orbit. I've seen two true cases of RSD. Number two, the foot is usually cool and clammy feeling. It has this mottled appearance. Third, xrays usually will show washing away of the bones. These are patients that are very difficult to treat. I think that both the doctor and the patient get frustrated because the outcome is usually not good.

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 21:10 (095073)

I actually recommended doing a true retrospective study on patients who have undergone open plantar fasciotomies, EPF's etc... I would like to see the longterm follow up of these patients. You need a large sample of patients. An independent evaluator. It would be a hard study to do in that you would have to obtain consent to contact the patients. A board like this would not give you a good sample of patients in that most of the people that post here are not better and are actually worse after surgery. This would be an important part of the study. But to truly get an accurate assessment you would need to contact patient's over that had a plantar fascial procedure over the last 5 years at least.

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 21:17 (095077)

I would say that pre eswt i still only operated on about 2 or 3 recalcitrant cases of plantar fasciitis a year. And this is after me throwing everything in the book at them. 90 to 95% of all people suffering from this get better with conservative care. I'm sure that the other docs here will agree.

Re: Studies? Heck yes, we need them!

Joe S on 9/11/02 at 21:25 (095079)

There are very strict guidelines when performing a study. One easy way of performing a study is to send out a mailer to everyone who has had a plantar fasciotomy and rate their pain pre surgery and post surgery. This could then be sent to an independent statistician for to computate the overall success rate. One thing to keep in mind in research studies is that they have to be reproducible to a certain degree. Also, the journal in which these studies are published hold the researcher to some pretty strict standards. I know that when we were in residecny we tried publishing a study of risk factors in diabetics who went on to amputation. We had a research fellow from Emory University work with us to identify the variables, the consent everything. Well we thought we had a good study. But guess what, the editors at two of our major journals turned us down twice for publication. We put three years into the study. We had over 1000 subjects who had undergone amputations. A very large sample of diabetic patients. Why did it get rejected. According to the editors the study was not specific enough for a certain type of amputation. Anyway, I think their reason was pretty stupid but then again I don't run a Journal.

Re: what exactly should the surgeons tell you before surgery?

Ed Davis, DPM on 9/11/02 at 21:31 (095081)

This is an area of much discussion and debate in the medical community. Medico-legally we strive for something that is called 'informed consent' in which we explain the nature of the surgery, what happens if the surgery is not done, the alternatives to surgery and all REASONABLE risks of the surgery. I knew a surgeon whom, after explaining the risks of cancer surgery to a patient, the patient elected not to go forward with the surgery. The patient got worse and sued the surgeon. The plaintiff attorney argued that the doctor was not forceful enough when explaining what would happen if surgery was not done. Despite our concept of what informed consent should be, it is an area that will probably be litigated for some time to come. One of the challenges for the doctor is to try to place the elements of informed consent into proper perspective, attempting to attach the 'right' amount of weight to each element.
Ed

Re: Studies? Heck yes, we need them!

Janet C on 9/11/02 at 21:44 (095084)

I really appreciate the time that you have been devoting to this message board, Dr. Joe. This discussion has been very interesting, and I appreciate hearing from the Drs' perspective.

Re: I totally agree with myself :-)

Janet C on 9/11/02 at 21:48 (095087)

I think that you might find a higher % rate if studies were done on your patients several years post-op. Because the two Drs. that performed my three sets of foot surgeries, aren't aware of my RSD Dx. I never went back to tell them.

Re: Scott R, another Twilight Zone occurrence

elliott on 9/11/02 at 21:48 (095088)

I think Dr. Ed and I posted at the same time on different boards. The above has my post title but his post.

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Re: oops! wow!

elliott on 9/11/02 at 21:50 (095090)

I typed this on another baord and it got sucked into here!

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Re: what exactly should the surgeons tell you before surgery?

wendyn on 9/11/02 at 23:02 (095102)

Joe, your explanation of RSD sounds very much like where I was at a few years ago. A bedsheet moving across my foot sent me into orbit, and I swore that it hurt when people just looked at my feet.

Re: Studies? Heck yes, we need them!

Sharon W on 9/12/02 at 14:01 (095146)

Dr. Joe,

I see another problem with simply sending out mailers to everyone who has had a plantar fasciotomy and asking them to rate their pain pre- and post- surgery. Sending out a survey relies on patient cooperation, and that could skew the results. I think patients would be MUCH more inclined to cooperate with the surgeon if they were SATISFIED with the results. Many people would probably rule out ANY contact with a surgeon they were unhappy with. No doubt, there would be SOME who wanted their dissatisfaction to be known and recorded, but I think most would already have a NEW foot & ankle specialist and would want no further contact with their former doctor or his office.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/12/02 at 16:29 (095171)

Very well said.

Re: oops! wow!

Scott R on 9/12/02 at 16:44 (095173)

Elliott, it may be the minus signs you use at the end of your posts. The minus sign is used in a way to determine which board posts go.

Re: oops! wow!

Scott R on 9/12/02 at 16:45 (095174)

I noticed Dr Ed also had two minus signs. One minus sign is OK. Two may cause a problem.

Re: I totally agree with myself :-)

Ed Davis, DPM on 9/12/02 at 17:49 (095184)

RSD is related to an incident of trauma. In this situation we are implicating the surgery itself as the trauma which incites RSD. RSD developing several years later would not be related to the surgery.
Ed

Re: what exactly should the surgeons tell you before surgery?

Ed Davis, DPM on 9/12/02 at 17:51 (095185)

Thank you. I guess great minds think alike.
Ed

Re: test--

Ed Davis, DPM on 9/12/02 at 17:53 (095186)

test--

Re: test-

Ed Davis, DPM on 9/12/02 at 17:53 (095187)

test-

Re: test-

Ed Davis, DPM on 9/12/02 at 17:55 (095188)

Trying to see if I can use the minus sign to move messages. Did not work.
I think I'll go with the twilight zone theory.
Ed

Re: I totally agree with myself :-)

Janet C on 9/12/02 at 18:13 (095191)

In my case, the surgery(ies) were the inciting events which caused the RSD. I had all the classical symptoms of it. But it wasn't Dx'ed until two years later. Unfortunately, this doesn't seem to be at all uncommon.

Re: I'll try ending with something else

elliott on 9/13/02 at 09:10 (095225)

Scott R, is it easy for you to program the site to insert a blank line at the end of the body of text (not to mention one at the beginning, which at least responds to a hard return)? As it is, the 'Posted in Category' line looks confusingly like part of the typed text, as does the 'Posted by' line.

[[[[[[[[

Re: Thank you

Tammie on 9/13/02 at 09:46 (095229)

As this has been very imformitive to me! I had a Dr. who never told me WHAT could happen except scar tissue. Not that he was totaly wrong but I have learned so very much thru this conversation here I would like to thank you all!

My Pain Management Dr. also believes I had the RSD before the second surgery the TTS I had even the blue foot , which he described as the nerves being entraped, he also performed NO test before surgery NOT ONE he said some blood work but it turned out to be A PG test that was it.

As I have said I have followed this and I have learned things I wish my mind had been more open to hearing before that second surgery ,But Pain was talking for me, with no intervention of pain relief for several nights and days I had no mind of my own it was pain that talked . Thanks for the interesting posts.

Re: I'll try ending with something else

scott r on 9/13/02 at 11:01 (095237)

I purposefully take out ending blank lines because sometimes many blank lines are added. I also try to scrunch things close so that everyone has fewer pages to scroll down. I wonder if periods will work or maybe it removes duplicate ending periods.

....

Re: test-

scott r on 9/13/02 at 11:02 (095239)

No, the double minus sign stuff is 'context sensitive'. Sometimes it will and sometimes it won't. So it really is voodoo.

Re: Scott R, any other options?

elliott on 9/13/02 at 13:13 (095254)

Can you swing it so that the 'Posted by' line above the text gets underlined and the 'Posted in Category' line below it gets overlined? Or something like that. That should delineate the text body from the rest, avoid the blank lines problem and satisfy the scrunch test.

[[[[[[[[[[]]]]]]]]]]]]

Re: I totally agree with myself :-)

Joe S on 9/14/02 at 00:44 (095304)

I've seen one true post op RSD patient and thankfully she was not mine. She was a post op neuroma excision. Her case turned into a malpractice case and I was asked for a 2nd opinion and to review her records. The patient had a true RSD. Cool, clammy, mottled foot. Pain out of proportion. Type A personality. Washing away of the bones. Anyway, the only thing really not on the sugeons informed consent was chronic pain syndrome or RSD. The chance of developing this is so low that most surgeons do not list it. Her charge is lack of informed consent. Well they got him there. Technically the surgery healed fine. Path report confirmed a Morton's Neuroma. I've not heard anything else from the case. I told the patient that RSD can occur from anything. Tying your shoes too tight. You can't predict who will develop this disabling condition. This is not what she wanted to hear I guess. I've not seen her back so we'll see. It was good for me to see this though. I've made it customary to include this possible complication on every procedure I do. They initial each complication and possible risk in order to say that we at least talked about it. I am curious however, would it be appropriate to video tape the informed consent. I got this idea when I was signing all of the papers for car a few months back. It makes good sense medicolegally. It may take a little extra time but would it be worth it in the end? Probably. If you adequately inform the patient about the nature of the procedure as well as the possible risks and complications with explanation of the risks and complications would that hold up in a court of law? I don't know.

Re: Joe S: videotaped informed consent

Sharon W on 9/14/02 at 13:01 (095326)

My podiatrist's practice does that. Actually, ALL of the patient rooms, for all of the podiatrists in the practice, are equipped with surveillance cameras, and they are always on. The podiatrists and their staff make no secret of it.

At first, I was dubious about the idea. I believe in being honest with my doctors -- I figure if you can't tell your doctor the truth about things your health concerns within his/her area of expertise, then you need to find another doctor. The camera made me a bit nervous. But as I thought about it, and about what its purpose was, I realized that it would only be a problem for me if I were considering a lawsuit or confessing to illegal activities. Since I have no interest in lawsuits and I'm a law-abiding citizen, the camera is no threat to me and I figure it might help to reduce some of the paranoia that goes on.

Yes, I know that the 'paranoia' I'm complaining about is a necessary response to the very real risk of malpractice suits. It's quite understandable. That's WHY I accept the presence of the camera.

But if I've noticed something going on with my foot and ankle that worries me, do I tell my podiatrist what I'm thinking, or do I keep my concerns to myself because I think it might send up a yellow flag? It's frustrating for a patient who has NO interest in malpractice suits and wants to 'play it straight'. I know my podiatrist took a chance on me, doing the surgery -- she doesn't usually DO TTS releases -- and I appreciate that. I don't want her to regret it. But I also don't want to to have to worry about triggering a fear of malpractice suits when I describe some new symptom I've noticed, or when I simply ask her a question.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Sharon W on 9/10/02 at 12:33 (094911)

Elliott,

I agree with you on PART of this one. There are many claims out there of incredibly inlated success rates for both PF and TTS surgery, and there are unrealistic assertions being made by doctors sometimes, leading patients to assume they will have rapid and rosy outcomes. A more realistic general expectation should be communicated to the patient considering surgery.

That said, every case is different, every patient has his/her own distinct needs, and statistics don't really apply to individual circumstances. A good, conscientious surgeon should take MANY factors into consideration when giving his patient a general indication of what to expect from surgery, and it IS appropriate that different patients should be told to expect varying recovery times, and warned of different surgical risks, etc.

Patients also vary in their knowledge and background with respect to understanding health issues. I think that if a patient expresses a desire for more information about surgical risks, that information should be provided at a level of technical explanation appropriate to what the patient can understand. It hardly makes sense to throw a bunch of technical medical terms at a patient that he/she cannot understand, and call that 'informed consent'!! I mean, the doctor would effectively be speaking a language that the patient doesn't know.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Janet C on 9/10/02 at 13:16 (094912)

I totally agree with you, Sharon.

Elliott, I would like to see a study done, first, to determine the over-all success/improvement rate from these types of surgeries. I don't know of any official study that's been done yet do you? And I think that to get a clear understanding of the success of these surgeries, they need to follow up with patients... 5 10 yrs post surgery, and ask them how it worked out. I think that most Drs. assume that the patient had a successful outcome to their surgery, if they don't see the patient again. I wonder how many Drs. that I've seen over the years, have written me off as another 'success'?

Once a realistic success rate has been determined, I think that should be made clear to the patient before their surgery, so that they can make an adult, informed decision. Drs. should also advise their patients of certain disorders that could occur in regards to each patient's personal needs. And yes I think Drs. should warn their patients of the possible complications of RSD from TT or CT surgeries, because it seems that RSD is not an uncommon result of these types of surgeries - that is, people with RSD, often have had CT or TT Release surgeries.

So I think that that possibility should be made clear to the patient, but just as importantly, Drs. should be on the lookout for RSD post surgery! So many Drs. don't catch the obvious symptoms of the disease, until it's far past the time when one can have the best results for stopping, and/or reversing the disorder.

~ Janet

Re: what exactly should the surgeons tell you before surgery?

wendyn on 9/10/02 at 13:46 (094915)

Janet, do you think it's possible that some of these RSD patients who have had TTS surgery, actually had RSD _BEFORE_ the surgery (the RSD was misdiagnosed as TTS in the first place).

Wouldn't suprise me if that happened at least sometimes.

Re: I totally agree with myself :-)

elliott on 9/10/02 at 13:55 (094916)

You women keep going about your back-slapping; since I've been here I don't think anyone has ever said, 'Elliott, I totally agree with you.' I could just cry. :-)

When I said 'all-encompassing single realistic uninflated success/improvement rate', I meant for that individual, so no argument there.

The notion of an 'official' study might be a naive one. Different docs of differing abilities do different self- or co-studies of different types of different size, quality, surgical selection criteria, etc. That said, there have been some studies containing sufficient followup. Some results sound fabulously successful. Occasionally there are some with low success rates (one comprehensive TTS study claimed 44% success), sometimes intended to prove the authors' predetermined point that some other treatment should be considered or that surgery shouldn't be done. You get the feeling that everyone has an agenda. And if a surgeon's success rates are too low and he never publishes that, you'll never know and only observe more positively-biased results.

There's a big difference between possibility and probability. As I alluded to in my first post, there is the possibility of death. There may be a LIKELY probability of RSD, in which case one ought to be told. However, if, for example, one has not ever experienced nerve pain or RSD, r even is in much pain now so he/she doesn't care, the warning will be of limited value, unless the likelihood is sufficiently large that the person will think twice about things that might go wrong. Agree they should be on the lookout for things like RSD. I'd go even further and say they should warn their patients post-op to be on the lookout for anything resembling it.

----

Re: what exactly should the surgeons tell you before surgery?

Sharon W on 9/10/02 at 14:21 (094918)

Good point, Wendy.

Considering that surgery is usually not a good option for those with RSD, I think it's a reasonable assumption that surgery done even in the early stages of that condition would tend to make RSD worse.

Sharon

Re: I totally agree with myself :-)

Janet C on 9/10/02 at 14:58 (094922)

Elliott - I will give you a pat on the back for making several good points... :-) especially, the fact that most studies have a hidden agenda, depending upon who is paying for it, and so are not a realistic portrayal of the population's true results.

And another question that your post brought to mind, is... who determines the definition of a success?!

You know, no one warned me of developing RSD prior to my TT surgeries... but I do in fact, recall signing a form that said in effect, that I would not sue the Dr. if I died from this surgery... it made me laugh as I signed it... because I thought, _I_ won't sue... but my family just might! ;-)

And I must say, I TOTALLY agree with your last couple of sentences! :-) And wouldn't it be great if Drs. didn't send their patients with RSD away... after telling them it's all in their head... or they're having a mid-life crisis... or they're a drug seeker... or treated with contempt because they didn't heal as the Dr. had expected! I'm not bitter, am I? ;-)

Re: what exactly should the surgeons tell you before surgery?

Pauline on 9/10/02 at 15:02 (094923)

Janet,
I think you hit the nail on the head. Surgery is about need and success rate which is documented by formal studies. I think we should be asking 'Is this surgery necessary and then show me the studies that says it's successful'.

In my mind, far toooo many P.F. surgeries are performed and the final results are nothing to brag about.

How many patients have we seen go from bad to worse following P.F. surgery?
It's happening before our eyes. I've been reading the accounts on the surgery board. I'm waiting for the last batch of patients to remove their post surgical boot and reward us with good news. It hasn't happened yet.

Time we as P.F. sufferers take a long hard look at all the P.F. releases being done today and start asking to see the data.

Re: what exactly should the surgeons tell you before surgery?

Janet C on 9/10/02 at 15:10 (094925)

Sharon, Yes, surgery is to be avoided, if at all possible, for those with RSD. It has been shown to aggravate the condition, causing it to spread more rapidly. And if the surgery, or injury, occurs in a distant place on the body, it can cause the RSD to jump, and spread to that area.

And Wendy, I think that is a possibility. In fact, I had the burning pain after my heel spur surgeries - the year previous to my TT surgeries... so I now realize that I may have developed RSD after the prior surgery, and the latter just made it worse!

~ Janet

Re: what exactly should the surgeons tell you before surgery?

Janet C on 9/10/02 at 16:53 (094934)

Thank you for your thoughts on this issue, Pauline. I couldn't agree with you more.

And from what I've observed - it seems like many patients, post-surgery, initially think that their pain has been reduced... but a year, or even several years later, the pain tends to come back, and often, far worse than before. That's why I think an appropriate study should be done, interviewing patients many years post-op.

Re: Elliott, I ALMOST totally agree with you :o))

Sharon W on 9/10/02 at 18:55 (094948)

Elliott,

This part of your previous post was worthy of repeating:

'I think surgeons tend to make final outcomes look too rosy even in their own minds, to minimize resulting side effects, and to completely exclude the possibility of their own errors. I suspect many here dispute the universally accepted and published PF surgical success rate of close to 90%.'

Surgeons have to keep their confidence up; I mean they really can't afford to start doubting themselves, if they're cutting into human beings! But that means that they may not be all that 'objective' about how successful their own surgeries are, etc. etc.

And as for those 'universally accepted' success rates for PF (or TTS) surgery of about 90% -- phooey! Perhaps there ARE a few good surgeons who only accept 'perfect' cases, that actually achieve those success rates. (Even so, I bet they tend to have rather loose definitions of 'success'!) As far as 90% success being TYPICAL for either of those surgeries -- NO WAY. I just don't believe it. Like Pauline, I've been closely following the reports of surgery results for the past 10 months, and there's no way 90% of our posters with recent surgeries have been happy with their results.

The issue of HOW 'success' is defined, is another biggie that you touched upon. If you define ANY report of improvement as 'success,' then when the patient comes in 2-3 weeks after surgery, perhaps even still taking painkillers, and says s/he feels 'a lot better now,' THAT might be referred to by some as a 'success'! OF COURSE, as a patient begins to heal after surgery they will tend to feel better, because the surgical wound itself is closing and becoming less painful.

And if the patient never returns to the surgeon, after the immediate post-op period, does THAT get written up as a 'success'? (From reading these boards, I would guess it's probably FAR more likely to mean it was a FAILURE -- because if you don't like what the doctor did to you, you probably never go back to him!)

A more valid criterion for 'success' would be, does the patient still say s/he is feeling 'a lot better' after 6 months? After a year? Did the patient develop lateral column syndrome? Nerve entrapment? RSD? Any other complication or condition that may be related to the surgery? As Janet mentioned, I think even a 5-year follow-up would be appropriate for a SERIOUS attempt at determining success/failure rates for these surgeries.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Pauline on 9/10/02 at 20:54 (094960)

Janet,
Your correct. A week after surgery when they are in their boot or cast everything is just great, but come time to kick the boot and apply weight
they report worse pain than before their surgery.

No need to wait a year to see this happen. Just follow the most recent posters who under went a P.F. release. We've seen it toooo much to be coincidental.

I don't think this comes as a surprise to the doctors who post here either. It's just never be in the spotlight before. Well I think it's about time this information comes to light.

Long ago Dr. Z said Pods treat most of the people with foot problems, well then Pods must be the ones doing most of the cutting too.

If their not making lots of income from surgery as we're told, then there certainly is no reason why they can't stop cutting the P.F. tomorrow. I think they need to make this a high priority topic at their next convention. The cutting must stop and the doctors here should be the ones leading the charge.

Re: what exactly should the surgeons tell you before surgery?

Dr. Z on 9/10/02 at 21:00 (094961)

The cutting of the plantar fascia is a major topic that I lecture about. i do this once per week. I show pictures and try to explain why cutting the plantar fascia is a stupid idea.Can you imagine cutting the weight bearing wall in your home . The entire floor and roof will come collapse down. Or imagine remove a basement support steel beam. The entire basement would come crashing down. And we cut the fascia and expect the patient to walk and be painfree. Ok next question

Re: what exactly should the surgeons tell you before surgery?

BGCPed on 9/10/02 at 22:45 (094971)

This may be a bit off the path for some but not many years ago the knee surgeon would remove most of the cartiledgein one of the knee compartments. If you look at some older athletes with the big zipper scar up the knee. Now many of them have severe compatmental osteo arthritis due to of all of the vital shock absorbing material being removed and now it is bone on bone.

At the time it was thought to be the solution.If it grinds, rubs and creates friction then 'remove it'. Now we have some Docs injecting chicken fat into the knee to replace or augment what has worn down.....total different approach. IMHO whether it is a joint or any other body part, God made the best working version. From an orthopedic standpoint there is not many parts like an appendix that you just cut or get rid of and you are better off. It is there for a reason.

The majority of pf release is done on over pronators which to me seems like an even dumber idea since they need the stabilization more than anybody

Re: A lot more than some do now

wendyn on 9/11/02 at 06:57 (094987)

BGCped, The overpronation issue is exactly why my surgeon was against surgery in my case. He told me flat out that the odds were less than 50/50 that it would help me, and that there was a strong possibility I would be worse. This was based on the fact that my MRI did not indicate anything in the tunnel that he could 'fix' or 'remove'.

Re: Ok next question

elliott on 9/11/02 at 07:29 (094989)

Did you do such lecturing before you got the ESWT device?

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Re: what exactly should the surgeons tell you before surgery?

Pauline on 9/11/02 at 07:39 (094990)

Doctors,
Knowing the foot was going to crash, what was happening to patients with P.F. pre ESWT in your practices? Are you saying you all refused to do any P.F. surgeries?

Dr. Z,
Your lectures must be falling on deaf ears, who are you presenting them to every week and where?

Re: Elliott, I ALMOST totally agree with you :o))

Pauline on 9/11/02 at 09:35 (095002)

Elliott,
You touch on probably one of the most highly debatable topics and that is
how 'Success' is defined. I think I might have touched on this before.

I read many medical journal articles and am always amazed by many of the conclusions reached following each study.

To me if patients die as a result of treatment it shouldn't be called a success, yet it happens. That has to make you wonder about the defination of 'Success' as it's being interepted by the doctors doing these various studies. Is treating 10 patients and loosing 1, hospitalizing 1, causing infection in 2 successfull?

Re: what exactly should the surgeons tell you before surgery?

dave r on 9/11/02 at 11:33 (095014)

I had three docs flat out tell me that surgery would only help 50% of the time. They didnt recommend it at all. There is to much room for scare tissue to develope. Once that there you develope other problems. and the fact that surgery changes thes mechanics of your foot. I had one surgeon say that surgery was completely out of the question. And that there wasnt anything that he could do. I also had another surgeon that was willing to do the open fasciotomy. But he also said that for some people they will NEVER get better. He said that 2% of the population will always be in pain.
He claimed to of done hundreds of procedures over 20 years. he also claims that 85% did get better from surgery.

Re: Ok next question

Dr. Zuckerman on 9/11/02 at 11:59 (095017)

didn't lecture I was't on the circuit but I sure talked about it and researched a solution. I found the solution in 1997 It's called ESWT.

Re: what exactly should the surgeons tell you before surgery?

Dr. Z on 9/11/02 at 17:56 (095057)

Before i was doing ESWT I was doing mis partial plantar fascia release. The TTS and Cal-cuboid complicatons were rare but did happen . With ESWT there is none. I would still do a MIS pf release if ESWT failed.

Re: Studies? Heck yes, we need them!

BrianG on 9/11/02 at 19:39 (095061)

I've said it many times in the past myself, I'd really like to see some good studies done, with honest surgical results. The trouble is, who is responsible enough to do these studies, in an unbiased manner ?????

BrianG

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 20:56 (095069)

Personally, I think I do a pretty good job of informing patients of the msot common risks and complications associated with any procedure. There are certain inherent risks irregardless of the procedure (infection, recurrence, delayed healing, pain, prolonged swelling, scar formation). These are a given. However, it is practically impossible to inform a patient of every single risk. What I mean is that there are some complications that can not be predicted. Case in point, I have a buddy who performed ESWT on a young healthy patient of his. About a week after the procedure, the patient began feeling extreme pain in the side of his foot. The patient relates that he had not injured it or traumatized it in any fashion. Physical exam revealed pain along the peroneal tendon sheath on the outside of the ankle. The pain extended onto the bottom of the foot across the midarch area. Just as a precaution, my buddy ordered an MRI. There was a tear in the Peroneus Longus Tendon. What's the chance of that following ESWT? Probably a million to one. Was it because of ESWT? I don't know. Could his heel pain (which is better) been masking this Peroneal Tendon Tear? It could. Why did it show up a week later though?

Personally, when I consent someone for surgery be it a bunionectomy or a major rearfoot procedure, I inform the patient to the point of probably overinforming them. Some quietly tell my nurse that they want to wait. I've had others who have signed the consent and not shown up for surgery. That's ok. 99% of all foot surgery is elective. It is not life threatening for the most part. Therefore, when a patient is ready for surgery, they generally know that they're ready. I had a patient today come in for evaluation of a large bunion deformity. We took xrays, talked about the deformity. It was pretty significant but guess what, it did not hurt. She was more concerned about the 'ugly bump' on the outside of her foot. My comment to her was, I'd wait until it hurt before having it operated on. She seemed pretty bummed but....I don't want to take an asymptomatic foot and make it hurt. That sets you up for a malpractice suit. It's not worth it to me or my family.

Re: Studies? Heck yes, we need them!

Janet C on 9/11/02 at 21:01 (095070)

Who normally is in charge of the scientific studies? The American Medical Association? There has to be some group who performs similar non-biased scientific studies in the U.S., to determine the efficacy of procedures... isn't there?

~ Janet

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 21:04 (095071)

RSD has a classical presentation. Usually most patients with RSD have Pain which is OUT OF PROPORTION. I mean you can't even touch the body part without sending the patient into orbit. I've seen two true cases of RSD. Number two, the foot is usually cool and clammy feeling. It has this mottled appearance. Third, xrays usually will show washing away of the bones. These are patients that are very difficult to treat. I think that both the doctor and the patient get frustrated because the outcome is usually not good.

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 21:10 (095073)

I actually recommended doing a true retrospective study on patients who have undergone open plantar fasciotomies, EPF's etc... I would like to see the longterm follow up of these patients. You need a large sample of patients. An independent evaluator. It would be a hard study to do in that you would have to obtain consent to contact the patients. A board like this would not give you a good sample of patients in that most of the people that post here are not better and are actually worse after surgery. This would be an important part of the study. But to truly get an accurate assessment you would need to contact patient's over that had a plantar fascial procedure over the last 5 years at least.

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/11/02 at 21:17 (095077)

I would say that pre eswt i still only operated on about 2 or 3 recalcitrant cases of plantar fasciitis a year. And this is after me throwing everything in the book at them. 90 to 95% of all people suffering from this get better with conservative care. I'm sure that the other docs here will agree.

Re: Studies? Heck yes, we need them!

Joe S on 9/11/02 at 21:25 (095079)

There are very strict guidelines when performing a study. One easy way of performing a study is to send out a mailer to everyone who has had a plantar fasciotomy and rate their pain pre surgery and post surgery. This could then be sent to an independent statistician for to computate the overall success rate. One thing to keep in mind in research studies is that they have to be reproducible to a certain degree. Also, the journal in which these studies are published hold the researcher to some pretty strict standards. I know that when we were in residecny we tried publishing a study of risk factors in diabetics who went on to amputation. We had a research fellow from Emory University work with us to identify the variables, the consent everything. Well we thought we had a good study. But guess what, the editors at two of our major journals turned us down twice for publication. We put three years into the study. We had over 1000 subjects who had undergone amputations. A very large sample of diabetic patients. Why did it get rejected. According to the editors the study was not specific enough for a certain type of amputation. Anyway, I think their reason was pretty stupid but then again I don't run a Journal.

Re: what exactly should the surgeons tell you before surgery?

Ed Davis, DPM on 9/11/02 at 21:31 (095081)

This is an area of much discussion and debate in the medical community. Medico-legally we strive for something that is called 'informed consent' in which we explain the nature of the surgery, what happens if the surgery is not done, the alternatives to surgery and all REASONABLE risks of the surgery. I knew a surgeon whom, after explaining the risks of cancer surgery to a patient, the patient elected not to go forward with the surgery. The patient got worse and sued the surgeon. The plaintiff attorney argued that the doctor was not forceful enough when explaining what would happen if surgery was not done. Despite our concept of what informed consent should be, it is an area that will probably be litigated for some time to come. One of the challenges for the doctor is to try to place the elements of informed consent into proper perspective, attempting to attach the 'right' amount of weight to each element.
Ed

Re: Studies? Heck yes, we need them!

Janet C on 9/11/02 at 21:44 (095084)

I really appreciate the time that you have been devoting to this message board, Dr. Joe. This discussion has been very interesting, and I appreciate hearing from the Drs' perspective.

Re: I totally agree with myself :-)

Janet C on 9/11/02 at 21:48 (095087)

I think that you might find a higher % rate if studies were done on your patients several years post-op. Because the two Drs. that performed my three sets of foot surgeries, aren't aware of my RSD Dx. I never went back to tell them.

Re: Scott R, another Twilight Zone occurrence

elliott on 9/11/02 at 21:48 (095088)

I think Dr. Ed and I posted at the same time on different boards. The above has my post title but his post.

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Re: oops! wow!

elliott on 9/11/02 at 21:50 (095090)

I typed this on another baord and it got sucked into here!

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Re: what exactly should the surgeons tell you before surgery?

wendyn on 9/11/02 at 23:02 (095102)

Joe, your explanation of RSD sounds very much like where I was at a few years ago. A bedsheet moving across my foot sent me into orbit, and I swore that it hurt when people just looked at my feet.

Re: Studies? Heck yes, we need them!

Sharon W on 9/12/02 at 14:01 (095146)

Dr. Joe,

I see another problem with simply sending out mailers to everyone who has had a plantar fasciotomy and asking them to rate their pain pre- and post- surgery. Sending out a survey relies on patient cooperation, and that could skew the results. I think patients would be MUCH more inclined to cooperate with the surgeon if they were SATISFIED with the results. Many people would probably rule out ANY contact with a surgeon they were unhappy with. No doubt, there would be SOME who wanted their dissatisfaction to be known and recorded, but I think most would already have a NEW foot & ankle specialist and would want no further contact with their former doctor or his office.

Sharon

Re: what exactly should the surgeons tell you before surgery?

Joe S on 9/12/02 at 16:29 (095171)

Very well said.

Re: oops! wow!

Scott R on 9/12/02 at 16:44 (095173)

Elliott, it may be the minus signs you use at the end of your posts. The minus sign is used in a way to determine which board posts go.

Re: oops! wow!

Scott R on 9/12/02 at 16:45 (095174)

I noticed Dr Ed also had two minus signs. One minus sign is OK. Two may cause a problem.

Re: I totally agree with myself :-)

Ed Davis, DPM on 9/12/02 at 17:49 (095184)

RSD is related to an incident of trauma. In this situation we are implicating the surgery itself as the trauma which incites RSD. RSD developing several years later would not be related to the surgery.
Ed

Re: what exactly should the surgeons tell you before surgery?

Ed Davis, DPM on 9/12/02 at 17:51 (095185)

Thank you. I guess great minds think alike.
Ed

Re: test--

Ed Davis, DPM on 9/12/02 at 17:53 (095186)

test--

Re: test-

Ed Davis, DPM on 9/12/02 at 17:53 (095187)

test-

Re: test-

Ed Davis, DPM on 9/12/02 at 17:55 (095188)

Trying to see if I can use the minus sign to move messages. Did not work.
I think I'll go with the twilight zone theory.
Ed

Re: I totally agree with myself :-)

Janet C on 9/12/02 at 18:13 (095191)

In my case, the surgery(ies) were the inciting events which caused the RSD. I had all the classical symptoms of it. But it wasn't Dx'ed until two years later. Unfortunately, this doesn't seem to be at all uncommon.

Re: I'll try ending with something else

elliott on 9/13/02 at 09:10 (095225)

Scott R, is it easy for you to program the site to insert a blank line at the end of the body of text (not to mention one at the beginning, which at least responds to a hard return)? As it is, the 'Posted in Category' line looks confusingly like part of the typed text, as does the 'Posted by' line.

[[[[[[[[

Re: Thank you

Tammie on 9/13/02 at 09:46 (095229)

As this has been very imformitive to me! I had a Dr. who never told me WHAT could happen except scar tissue. Not that he was totaly wrong but I have learned so very much thru this conversation here I would like to thank you all!

My Pain Management Dr. also believes I had the RSD before the second surgery the TTS I had even the blue foot , which he described as the nerves being entraped, he also performed NO test before surgery NOT ONE he said some blood work but it turned out to be A PG test that was it.

As I have said I have followed this and I have learned things I wish my mind had been more open to hearing before that second surgery ,But Pain was talking for me, with no intervention of pain relief for several nights and days I had no mind of my own it was pain that talked . Thanks for the interesting posts.

Re: I'll try ending with something else

scott r on 9/13/02 at 11:01 (095237)

I purposefully take out ending blank lines because sometimes many blank lines are added. I also try to scrunch things close so that everyone has fewer pages to scroll down. I wonder if periods will work or maybe it removes duplicate ending periods.

....

Re: test-

scott r on 9/13/02 at 11:02 (095239)

No, the double minus sign stuff is 'context sensitive'. Sometimes it will and sometimes it won't. So it really is voodoo.

Re: Scott R, any other options?

elliott on 9/13/02 at 13:13 (095254)

Can you swing it so that the 'Posted by' line above the text gets underlined and the 'Posted in Category' line below it gets overlined? Or something like that. That should delineate the text body from the rest, avoid the blank lines problem and satisfy the scrunch test.

[[[[[[[[[[]]]]]]]]]]]]

Re: I totally agree with myself :-)

Joe S on 9/14/02 at 00:44 (095304)

I've seen one true post op RSD patient and thankfully she was not mine. She was a post op neuroma excision. Her case turned into a malpractice case and I was asked for a 2nd opinion and to review her records. The patient had a true RSD. Cool, clammy, mottled foot. Pain out of proportion. Type A personality. Washing away of the bones. Anyway, the only thing really not on the sugeons informed consent was chronic pain syndrome or RSD. The chance of developing this is so low that most surgeons do not list it. Her charge is lack of informed consent. Well they got him there. Technically the surgery healed fine. Path report confirmed a Morton's Neuroma. I've not heard anything else from the case. I told the patient that RSD can occur from anything. Tying your shoes too tight. You can't predict who will develop this disabling condition. This is not what she wanted to hear I guess. I've not seen her back so we'll see. It was good for me to see this though. I've made it customary to include this possible complication on every procedure I do. They initial each complication and possible risk in order to say that we at least talked about it. I am curious however, would it be appropriate to video tape the informed consent. I got this idea when I was signing all of the papers for car a few months back. It makes good sense medicolegally. It may take a little extra time but would it be worth it in the end? Probably. If you adequately inform the patient about the nature of the procedure as well as the possible risks and complications with explanation of the risks and complications would that hold up in a court of law? I don't know.

Re: Joe S: videotaped informed consent

Sharon W on 9/14/02 at 13:01 (095326)

My podiatrist's practice does that. Actually, ALL of the patient rooms, for all of the podiatrists in the practice, are equipped with surveillance cameras, and they are always on. The podiatrists and their staff make no secret of it.

At first, I was dubious about the idea. I believe in being honest with my doctors -- I figure if you can't tell your doctor the truth about things your health concerns within his/her area of expertise, then you need to find another doctor. The camera made me a bit nervous. But as I thought about it, and about what its purpose was, I realized that it would only be a problem for me if I were considering a lawsuit or confessing to illegal activities. Since I have no interest in lawsuits and I'm a law-abiding citizen, the camera is no threat to me and I figure it might help to reduce some of the paranoia that goes on.

Yes, I know that the 'paranoia' I'm complaining about is a necessary response to the very real risk of malpractice suits. It's quite understandable. That's WHY I accept the presence of the camera.

But if I've noticed something going on with my foot and ankle that worries me, do I tell my podiatrist what I'm thinking, or do I keep my concerns to myself because I think it might send up a yellow flag? It's frustrating for a patient who has NO interest in malpractice suits and wants to 'play it straight'. I know my podiatrist took a chance on me, doing the surgery -- she doesn't usually DO TTS releases -- and I appreciate that. I don't want her to regret it. But I also don't want to to have to worry about triggering a fear of malpractice suits when I describe some new symptom I've noticed, or when I simply ask her a question.

Sharon