Patients often come in to my office requesting a second opinion for foot surgery after they have seen another podiatrist in New York City. I always welcome my patients to seek second opinions as well.
Many times I agree with the other doctors’ recommendations for surgery. Also, many times I disagree with their recommendations. Often, I disagree because I feel they have chosen the wrong procedure for bunion surgery or hammertoe surgery.
In regards to bunion surgery, many doctors perform distal osteotomies for large bunions that require a more proximal osteotomy. I will explain distal versus proximal osteotomies in a moment, but first let me explained why this happens. Many podiatrists are not trained or experienced in performing more difficult surgical procedures such as proximal osteotomy bunionectomies. Proximal osteotomies are much more challenging, and require much more skill than the distal osteotomies. If you have browsed this blog, you will have seen examples of large bunions that require more proximal osteotomies. This is one of my favorite topics to write about.
Small bunions can be fixed with distal osteotomies. An osteotomy is simply a medical term for a cut in a bone. A distal osteotomy is performed at the far end of the metatarsal bone just behind the toes. Most podiatrists are very experience performing this kind of osteotomy.
Larger bunions require a more proximal osteotomy. Proximal osteotomies are performed at the base of the metatarsal, further back in the foot. There are a few types of these proximal osteotomies. The most common ones are a ‘closing base wedge osteotomy’, an ‘opening base wedge osteotomy’, and a ‘scarf osteotomy’. In previous blog posts I have discussed each of these. Proximal osteotomies are much more difficult than distal osteotomies. The surgeon must be experienced and knowledgeable in order to remove the proper amount of bone, add the appropriate amount of bone graft, fixate the bone cuts properly with screws and plates, and align the bones in three dimensions.
Getting back to second opinions for surgery, I often advised patients to ask their previous doctor about their experience with these more difficult surgeries. It is not my intention to take patients away from their original doctor, but rather to inform them of my opinion on the proper surgical procedures of choice.
When it comes to second opinion for hammertoe surgery, I often advised patients to have the small joints of the toes to be fused called an arthrodesis, rather than just remove part of the bone, called an arthroplasty. I perform many arthroplasty procedures but many times a joint fusion is necessary to get a better cosmetic and more permanent correction of hammertoes.
The way I fuse hammertoes is also superior in my opinion to the older methods of joint fusions. Most podiatrists use a wire that sticks out from the end of the toe in order to hold the bones together while they heal, and fuse. I prefer to use a screw that is totally within the toe and does not stick out. There are many advantages to this method. The most important in my opinion, is that the screw creates compression between the 2 bones pushing them together and achieves the goal of fusing the 2 bones together almost all the time. Using a pin in the toes simply holds the bones in one direction and does not push them together. The bones are free to move longitudinally in the direction of the pin as well as rotate on the pin. The screw prevents this. Additionally, the screw is buried within the toe does not stick out which allows the patient to get the foot wet in the shower after just 12 days, rather than keeping it dry for 4 weeks while the pin sticks out from the end of the toe.
I have tried many of the new implants that have been designed for hammertoe fusion. These are very extensive pieces of metal that go inside the toe in order to avoid the need for the pin to stick out from the end of the toe for 4 weeks. Unfortunately, I have not been satisfied with any of them. They all fail to have one importance quality that the screw has. Only the screw pushes the two bones together called compression. These new implants hold the bone in 2 directions. They stopped the bones from rotating and moving up and down, but all fail to push the bones together in that third longitudinal direction that I think is necessary in order to increase the chances that the bone will heal together.
A Story about Second Opinion for Foot Surgery
Now that I have discussed second opinions for bunion surgery and second opinion for hammertoe surgery, let me tell you a story about second opinions for surgery.
Unfortunately, there are some unethical doctors that consider monetary gain as a reason to do surgery on patients. In the past few weeks, I have seen three patients that came to me for second opinions for foot surgery that I told not to have surgery. It is unfortunate and disturbing that these doctors recommended surgery when it was not necessary or recommended the wrong procedure.
Interestingly, two of the patients came from the same unethical doctor. This doctor recommended surgery for a 15-year-old patient with plantar fasciitis without performing any conservative care. First of all, the patient was only 15 years old and not done growing completely. Secondly, I would estimate 98% of patients with plantar fasciitis do not need surgery, and get better with conservative treatment. There are many treatments for plantar fasciitis that do not involve invasive surgery. In fact, there are at least 10 different treatments that are regularly done before surgery is recommended. This doctor only recommended one treatment, custom molded orthotics. I speculate that this treatment was recommended because orthotics can be profitable for the doctor. Orthotics alone are not the recommended treatment for plantar fasciitis. They are a good long-term solution to prevent it from returning as well as helping other acute treatments. I told this 15-year-old patient and his parents that he should not have surgery until all conservative measures are exhausted.
The next patient that came to me for a second opinion for surgery from the same unethical doctor that they saw previously had a soft tissue mass on the top of her foot. The mass had been there for only a few weeks. The patient had no associated pain and it was very small, and not a cosmetic concern. The previous doctor did an ultrasound in his office on the first visit and told the patient that he did not like the looks of the lesion and scared her that it may be cancerous. He recommended surgery as soon as possible to remove the soft tissue mass. She came to me for a second opinion for foot surgery to remove the soft tissue mass. I also did an ultrasound in my office that showed the mass was a simple fluid-filled ganglion along one of the tendons. Treatment for a ganglion involves aspiration of the fluid out of it and injection of steroid to prevent it from coming back. I would only recommend surgery if, and only if, this treatment failed two to three times to get rid of it, and it was also symptomatic/painful or a major cosmetic concern. Additionally, if I had suspected anything more than a simple benign lesion I would order an MRI to evaluate it prior to surgery.
The next patient that came to me for a second opinion involved her toenails. Her doctor had removed 9 of her toenails in order to treat nail fungus. When the nails grew back exactly the same as they were, he recommended repeating the procedure. She came to me for a second opinion on nail removal. When I examined her I concluded that the discoloration and thickening of her toenails was not due to fungus. It was due to repetitive trauma from tight shoes that damaged the nail roots. To be sure, I sent a sample of the nail to the laboratory for biopsy for a pathologist to look under the microscope for fungal elements. As I suspected, the biopsy came back negative. Had the biopsy been positive, treatment would still not have been surgical removal of the nails. Fungal nails are much better treated with laser or oral medication, as removal of the nails rarely works. It is sometimes painful and can sometimes cause damage to the nails that is permanent. When there is damage to the nail root surgical removal of the nail rarely works also to resolve the discoloration and thickening. Most of the time, the nail grows back exactly the same or can be worse. Sometimes I will remove nails but I informed patient that there is a greater chance that they will grow back the same. If it is one or two nails, I am more likely to perform this procedure than when many more are affected.
Besides these unethical behaviors most patients come in for second opinions when surgery is indicated. I give my honest opinion as to what procedures I recommend and inform the patient of risks, complications and postoperative expectations. I do not ask the patient who the previous doctor was until the end of the visit and reserve any judgment about the doctor as that is ethical behavior.