Infections and Horrible Mistakes

A recent news story tells of a woman whose "minor gynecological procedure" was botched, resulting in her having both legs amputated. According to the link, her colon was perforated. This caused an infection, and she ultimately had gangrene spreading to her feet. Once gangrene sets in, the tissue is for all practical purposes dead. It is a medical emergency. All dead tissue must be removed in order to minimize the damage, and, unfortunately, this patient lost her legs below her knees.

It might seem odd that you could get an infection in a hospital. Generally speaking, hospitals will try to be as sterile as possible where patients will be exposed. However, by making efforts to sterilize the environment, it ensures that only the toughest bacteria can survive. Though a rare occurrence, being infected by these aggressive, antibiotic resistant bacteria is a very serious matter.

The more pressing question on your mind is probably, "Who's to blame?" The answer to that question will be determined in a court of law. Patient privacy prevents us from knowing the full details of how her infection progressed. Perhaps it was due to negligence on the part of the surgeon or hospital.

On the other hand, she might be one of the unlucky one-in-a-million medical catastrophes. While medical science has advanced by leaps and bounds over the years, we still don't know everything. There are no guaranteed successes in medicine. All surgeries carry the risk of infection. While the story above is an extreme case, patients need to realize that surgeries occasionally do not go as planned. Doctors, including podiatrists, make efforts to prevent these kinds of disasters, but the bottom line is that we are still searching for the fountain of youth. Until then, bad things will happen, and it might not be anyone's fault.

Calluses—What You Might Not Know

We all know what calluses are, and we all have them to some extent. They are the thick areas of skin that appear on the bottom of your feet in places where there is a high amount of friction. Of course, you can find them on your hands as well, depending on your hobbies and occupation. They are basically harmless, since they are your body's way of protecting you from the stresses you are exerting on it.

Your podiatrist's role in treatment of calluses is to get to the root causes. Yes, we can sand them or trim them away (what we call debridement). Another option is to offload the area by applying protective pads. However, it may be fruitful to ask the question, "Why is the callus appearing in the first place?" Perhaps you are walking abnormally, or maybe you have an irregularly shaped foot. Don't be embarrassed if this is the case—nobody's perfect, and that's true of feet too!

Calluses should raise a red flag for people with diabetes. Remember that a callus is the body's response to friction. However, people with diabetes are prone to developing ulcers where the callus began. This is due to a couple of things. First, some people with diabetes lose sensation in their feet, so they don't know if they're inflicting harm on them. Secondly, poor circulation is another side effect of diabetes.

Dueling Surgical Groups

Today's topic is more relevant to podiatrists than it is to patients, although it may affect patients in the future. I recently was chatting with one of my colleagues in the M.D. program at my university, and we were engaging in a little interprofessional trash talk. After I made light of the fact that the American Medical Association has less than 20% of doctors as members, she retorted that we podiatrists have "dueling surgical groups." This refers the rift between the American Podiatric Medical Association (APMA) and the American College of Foot and Ankle Surgeons (ACFAS).

Without going into too much detail, ACFAS was formerly under the umbrella of the APMA, before they decided to assert their independence and secede from the APMA. Not to be outdone, the APMA believed they needed a surgical group under their auspices and created the American Society of Podiatric Surgeons (ASPS). So now, we have two podiatric surgical societies. While I have described this conflict in cavalier terms, it should be noted that there are good arguments on each side, and I am not endorsing one over the other.

Nonetheless, this is a disaster. For decades, the APMA has lobbied on behalf of the profession to give podiatrists the clinical privileges we enjoy today. In return, podiatrists have united behind the APMA. At the same time, ACFAS has been the premier surgical group for decades. No, this will not result in a civil war. However, as the years go by, this divide could result in podiatrists going in different directions. Because podiatrists have been able to unite in the past, we enjoy tremendous recognition as medical professionals. I hope that despite these differences, we continue to be able to rally behind our common cause.

A Pregnant Woman’s Feet

Pregnancy causes many changes throughout a woman's body, and the feet are no exception. Fortunately, these changes are relatively benign and can be addressed without extraordinary effort.

The complex process of creating a new life requires that a woman carry extra weight around with her at all times. As with people who are overweight, this causes the mother to alter her stance and pronate, which flattens out her feet, stretching out and irritating her plantar fascia. If left untreated, it may result in pain along the bottom of the heel. However, this can be addressed with orthotics. Your podiatrist will be able provide guidance as to what is the best orthotic for your condition.

Another change has to do with circulation. When our blood circulates through the foot and leg, our veins are designed to carry it back up to the heart using a system of valves and muscles not unlike the locks in the Panama Canal. Under normal circumstances, some of the serum (the watery component of blood) will leak out and accumulate in the feet. It is not uncommon, however, for the drainage mechanism in expectant mothers to not function as efficiently. Consequently, more fluid leaks and accumulates in the feet, resulting in swelling, also known as edema. (See the link for treatment options.) You should not be surprised if you need to buy larger shoes to fit your feet!

One thing you should not change is your exercise routine. In other words, if you're doing it, great, keep it up, but if not, now is not the proper time to start a vigorous regimen. Exercising is associated with shorter and easier labors. However, your body will warn you if you're overdoing it—bleeding, nausea, faintness, and shortness of breath are all signs that you need to cut back. Both your podiatrist and your OBGYN will be able to help you determine an appropriate level of activity.

Ultrasound in Podiatry

If you have children, you are probably familiar with ultrasounds. After all, it's what the OBGYN uses to take pictures of your baby while he or she is still developing. However, ultrasonography is useful in many areas of medicine to show pictures of body parts below the skin, including podiatry.

"Ultrasound" means that the machine is producing sound at a pitch much higher than what the human ear can detect. The doctor will place a transducer up against your foot, producing sound waves, and the machine detects the echoes that bounce back. Using these echoes, the machine is able to put together a picture of the different tissues in your foot in the same way that dolphins and submarines use sonar to detect other objects and hazards in the water.

So what is it good for? Since ultrasound depicts soft tissue problems, it is useful to diagnose plantar fasciitis and various tendonitis, though the list is longer. Other advantages:

• No radiation, unlike X-ray and CT
  
• Live Action—you don't have to wait for the image to develop because it's on the screen instantly
  
• The doctor can direct injections by watching where the needle is going on the screen
  

Another advantage to ultrasonography is the cost. An in office ultrasound ($100-$160) is significantly cheaper than an MRI which can cost 5 times as much. An MRI is a much more detailed image than an ultrasound, but in many cases they are not necessary. A common misconception amongst patients is that more medicine equals better medicine. While you might like to have the best diagnostic test out there, in the back of your podiatrist's mind is the question: is it worth it? Should we spend more money to get a more accurate diagnosis? Or can we get a good level of accuracy using low-tech methods? Podiatrists will disagree about the answer to these questions, since there are good arguments either way.

Luke McCown, ACL injuries, and Podiatry

This past weekend, the Jacksonville Jaguars lost their quarterback for the season due to a torn right ACL. The ACL refers to the anterior cruciate ligament, found in the knee, and tearing it is a relatively common injury in football. (Anterior means front or forward, and cruciate simply means it runs diagonally instead of straight up and down.) So why would a foot doctor be interested in a knee injury? As I discussed here, podiatrists are more than just foot doctors. We study the entire lower extremity. While knee surgery is technically outside of our legal scope of practice, many of our patients are athletes and will suffer this injury. Besides, anatomically speaking, the knee is one of the coolest joints in the body.

The knee is marvelously complex. Unlike other joints, it is held together entirely by soft tissue—ligaments, cartilage, and muscles. The ACL is one of these ligaments, and its job is to prevent the lower leg from sliding forward on the thigh by connecting the top of the shin bone (the Tibia) to the bottom of the thigh bone (the Femur). In fact, one of the ways to test for an ACL rupture is for the doctor to pull on the shin of a person lying back to see if it slides forward.

Surgical repair is often necessary for an ACL rupture, since it will not heal on its own. This is where the podiatrist needs to pass the patient on to the orthopedic knee specialist. The repair is performed arthroscopically, meaning a tiny camera is inserted into the joint, minimizing the invasiveness of the procedure. Despite that the procedure is minimally invasive, the patient will still have many months before returning to 100%, and this is why Mr. McCown will spend his season on injured reserve.

One of the clichés of our profession is that podiatrists and orthopedists have an adversarial relationship, fighting over which group is the final authority over which region of the body. However, the truth is that we can work together to our mutual benefit. The podiatrist refers out the patients with knee injuries to the orthopedist, and the orthopedist refers out to the podiatrist patients with the foot and ankle issues. While this is an idealized picture, this sort of multi-specialty cooperation results in much better patient care.

Ingrown Toenail

After some unanticipated technical difficulties, we here at On Your Feet are back online and proud to resume blogging! We herald our return by discussing one of the more common sights to any podiatrist: the ingrown toenail, also known as onychocryptosis. If you feel pain around the sides of your toenail, or if they appear red, the nail has probably grown into the side of the foot and is digging in. Furthermore, redness is a sign of infection, and your podiatrist will prescribe antibiotics.

Ingrown toenails arise in various ways. Sometimes you cut your nail too short, changing the way it grows. Other times, you might bump your foot, and that is the cause. And then, you might just be born with it.

You can attempt to deal with an ingrown nail on your own by soaking it and wearing shoes with a wider toe box. Your podiatrist can also treat an ingrown toenail surgically. However, to call it a surgery is a bit of an overstatement, since you will be wide awake and perfectly capable of walking out of the office under your own power. The podiatrist will simply numb up your toe, and trim away the portion of the nail causing irritation. He or she might also apply chemicals to ensure that no further nail grows back.