Foot and ankle surgery

Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. The typical training of an orthopedic foot and ankle surgeon consist of four years of college, four years of medical school, one year surgical internship, 5–6 years of orthopedic training and a 1 year fellowship in foot and ankle surgery. Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school and 2-4 years of a surgical residency. One can also make the distinction between a podiatric and orthopedic foot and ankle surgeon: an orthopedic surgeon has an allopathic medical degree and training that encompasses both orthopedic residency and a 6-month to one year of fellowship training specific in techniques of foot and ankle surgery, while the training of a podiatrist consist of a 4 year podiatric medical degree and mandatory two to four year residency training specific to foot and ankle medicine and surgery, with a possibility of an additional 1 year fellowship.

Clinical scope

Foot and ankle surgeons are trained to treat all disorders of the foot and ankle, both surgical and non-surgical. One is also trained to understand the rather complex connections between disorders and deformalities of the foot and ankle and the knee and hip and in return, the spine. Therefore, the surgeon will typically see cases that vary from trauma (such as malleolar fractures, tibial pilon fractures, calcaneus fractures, navicular and midfoot injuries and metatarsal and phalangeal fractures.) Arthritis care (primarily surgical) of the ankle joint and the joints of the hindfoot (tarsals), midfoot (metatarsals) and forefoot (phalanges)also plays a rather significant role. Congentital and acquired deformalities include adult acquired flatfoot, non-neuromuscular foot deformity, diabetic foot disorders, hallux valgus and several common pediatric foot and ankle conditions ( such as clubfoot, flat feet, tarsal coalitions...etc.) Patients may also be referred to a foot and ankle surgeon for proper diagnosis and treatment of heel pain (such as a consequence from plantar heel facitis), nerve disorders (such as tarsal tunnel syndrome) and tumors of the foot and ankle. Amputation and ankle arthroscopy (the use of a laproscope in foot and ankle surgical procedures) have emerged as prominent tools in foot and ankle care. A patient may also be referred to a foot and ankle surgeon for the surgical care of nail problems and phalangeal deformalities (such as bunions and buniettes.)

Non-surgical treatments

The vast majority of foot and ankle conditions do not require surgical intervention. For example, several phalangeal conditions may be traced to the type of foot box used in a shoe, and a change of a shoe or shoe box may be sufficient to treat the condition. For flammatory processes such as rhuematoid arthritis, non-steroidal anti-inflammatories (NSAIDs) and Disease Modifying antirheumatic drugs (DMARDS) may be used to manage or slow down the process. Orthotics, or an externally applied devie used to modify the structural or functional characteristics of the neuromusculoskeletal system specifically for the foot and ankle may be used as inserts into shoes to displace regions of the foot for more balanced, comfortable or theraputic placements of the foot. Physical therapy may also be used to alleviate symptoms, strengthening muscles such as the gastrocnemius (which in return will pull on the achillies heel which will then pull on the plantar fascia thus changing the structure and shape of the foot).

Surgical treatments

Surgery is considered to be a last option when more conservative fails to alleviate symptoms (such as the above techniques outlined in the section above.) Such as bunionectomies may be used to surgically remove bunions and other foot and ankle deformalities, arthrodesis (or fusion of joint spaces) for inflammatory processes, and surgical reconstruction (i.e. invasive measures of manipulating neuromusculoskeletal structures) to treat other deformalities. One should note that orthotics, physical therapy, NSAIDs, DMARDs and a change of shoe will act in compliments to surgical intervention, and in most cases will be required for optimal recovery.

Open heart surgery

This is a surgery in which the patient's heart is opened and surgery is performed on the internal structures of the heart.

It was soon discovered by Dr. Wilfred G. Bigelow of the University of Toronto that the repair of intracardiac pathologies was better done with a bloodless and motionless environment, which means that the heart should be stopped and drained of blood. The first successful intracardiac correction of a congenital heart defect using hypothermia was performed by Dr. C. Walton Lillehei and Dr. F. John Lewis at the University of Minnesota on September 2, 1952. The following year, Soviet surgeon Aleksandr Aleksandrovich Vishnevskiy conducted the first cardiac surgery under local anesthesia.

Surgeons realized the limitations of hypothermia - complex intracardiac repairs take more time and the patient needs blood flow to the body (and particularly the brain); the patient needs the function of the heart and lungs provided by an artificial method, hence the term cardiopulmonary bypass. Dr. John Heysham Gibbon at Jefferson Medical School in Philadelphia reported in 1953 the first successful use of extracorporeal circulation by means of an oxygenator, but he abandoned the method, disappointed by subsequent failures. In 1954 Dr. Lillehei realized a successful series of operations with the controlled cross-circulation technique in which the patient's mother or father was used as a 'heart-lung machine'. Dr. John W. Kirklin at the Mayo Clinic in Rochester, Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations, and was soon followed by surgeons in various parts of the world.

Dr. Nazih Zuhdi worked for four years under Drs. Clarence Dennis, Karl Karlson, and Charles Fries, who built an early pump-oxygenator. Zuhdi and Fries worked on several designs and re-designs of Dennis' earlier model from 1952–1956 at the Brooklyn Center. Zuhdi then went to work with Dr. C. Walton Lillehei at the University of Minnesota. Lillehei had designed his own version of a cross-circulation machine, which came to become known as the DeWall-Lillehei heart-lung machine. Zuhdi worked on perfusion and blood flow trying to solve the problem of air bubbles while bypassing the heart so the heart could be stopped for the operation. Zuhdi moved to Oklahoma City, OK, in 1957, and began working at the Oklahoma University College. Zuhdi, the heart surgeon, teamed up with Dr. Allen Greer, a lung surgeon and Dr. John Carey, forming a three man open heart surgery team. With the advent of Dr. Zuhdi's heart-lung machine which was modified in size, being much smaller than the DeWall-Lillehei heart-lung machine, and with other modifications, reduced the need for blood down to a minimal amount, and the cost of the equipment down to $500.00 and also reduced the prep time from two hours to 20 minutes. Dr. Zuhdi performed the first Total Intentional Hemodilution open heart surgery on Terry Gene Nix, age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a success; however, Nix died three years later in 1963. In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age 3½, using the Total Intentional Hemodilution machine, with success. That patient is still alive.

In 1985 Dr. Zuhdi performed Oklahoma's first successful heart transplant on Nancy Rogers at Baptist Hospital. The transplant was successful, but Rogers, a cancer sufferer, died from an infection 54 days after surgery.