General thoughts on surgery....Posted by Ed Davis, dPM on 5/29/04 at 13:09 (151552)
Many have seen me discourage surgery here at times. My thought process revolves around success rates of various procedures and comparative efficacies.
There are times that I will promote surgery fairly aggressively. There are entities in which I feel that surgery has a lcear advantage. For example, Morton's neuroma. It is a fairly simple surgery with a modest recovery period and high success rate. As such, I question whether months of 'conservative' care actually prolongs pain and suffering. I also question 'alternate' techniques when the downside to removing a neuroma is relatively small and the success rate fairly high.
Another area is AICT (a spur in back of the heel). I realize that ESWT may be a viable option here although if the area has a large protrusion and the attachment of the achilles is problematic, the heel cord tight; I find that surgery, sooner than later, if executed properly is the way to go without undue delay.
Surgeries I don't like include plantar fascial release surgery. It is tempting to do that as it is an incredibly easy procedure to perform. I have to chuckle when arguments arise over the issue of 'skill' here since it just does not take a high levle of skill to do this -- I have seen general surgeons do this as well as specialists. The problem is that the success rate is very unpredictable and that ESWT really is far superior in terms of percentage of cure. Additionally, cutting the plantar fascia removes a vital strut supporting the foot; it is potentially destructive to foot function. Another surgery I lack enthusiasm for it TTS surgery. It, too, is relatively simple, if performed in the classic manner. The success rate is not very high. Dellon has a modified technique that, based on his published work, appears to push the success rate up. Unfortunately, alternatives to tarsal tunnel surgery are more limited. If a obvious growth in the tarsal tunnel including varicose veins is the culprit placing pressure on the nerve, I will embrace the surgery with enthusiasm. If it is an issue of scar tissue being released, the success rate goes down and I think aggressive aftercare to suppress formation of new scar tissue is needed.
Re: General thoughts on surgery....Dr. Z on 5/29/04 at 15:58 (151570)
I agree with your approach 100%, except for the not excluding Achilles. If there is classic insertional pain with or without spur formation and there is no shoe gear wearing problem, then ESWT is the way to go. On another note lower energy seens to be the way to go. I am finding that a one session of 0,29mj2/mm2 is a very effective approach for the chronic insertional achilles tendinosis. I use a total of 1300mj/mm2 for total energy. Some are using 0.21mj/mm2 and reporting good results.
Re: General thoughts on surgery....chrisb on 5/31/04 at 09:09 (151615)
Dr Ed: re your TTS surgery comment: 'I think aggressive aftercare to suppress formation of new scar tissue is needed'
Can you describe that aftercare in detail?