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George Liu, D.P.M. Answers Questions On Foot and Ankle Conditions and Treatments

George Liu, D.P.M. Answers Questions On: Foot and Ankle Conditions and Treatments

What’s your approach for diabetic patients who have joint destruction from Charcot arthropathy?

When the arthropathy is in the midfoot, we treat them with casting. These patients have to stay off their feet in order to arrest the inflammatory process. Charcot that occurs at the ankle or hindfoot along the weight-bearing axis is often more unstable and leads to a severe deformity that’s difficult to brace. We operate on these patients to stabilize their limb and correct them in a better position for walking. The surgery is called realignment arthrodesis or osteotomy: realigning the limb through joint fusions or bone cuts. That’s typically done open. We try to use minimal-incision approaches as much as possible.

Calcaneal fracture (broken heel) can be tough to manage. Do you have an innovative approach to helping these patients?

Calcaneal fractures typically happen from high-energy injuries, such as a motor vehicle accidents or falling from a height. These fractures are often complex, involving damage to adjacent joints, which allow the hindfoot bones to move normally. Traditionally, a long extensive hockey-stick incision is used to access and repair the fracture; however, there is an associated 20 percent rate of wound dehiscence in all cases.

We have therefore been performing minimally invasive and percutaneous techniques to reduce and stabilize the fractured heel without these wide incisions. With this surgical approach, we have been able to reduce wound dehiscence rates to less than 5 percent. This approach gives the doctor limited visibility of the fracture, so he or she must be familiar with the anatomy of the fracture.

Why do people get stress fractures, and how do you treat them?

The stress fracture is typically an overuse injury. It is either a normal load on an abnormal bone or an abnormal load on a normal bone. A normal load on an abnormal bone would be osteoporosis, for example, where the bone is thin and does not accept the normal weight of the patient. An example of an abnormal load on a normal bone would a “march fracture” in the military where an 18 year old carries a 70-pound backpack for a 5-to-10-mile hike. Typically stress fractures are treated conservatively – there is usually not a significant amount of deformity associated with them. We use various immobilization devices.

Can flat feet cause problems?

You are either born with flat feet or you can develop them as an adult. Flat feet in children are often no significant concern unless there is pain and limitation of their daily activities. In adults, flat feet can develop from weakening of the posterior tibial tendon, which supports the arch. With overuse, patients can develop microtears along this tendon. Initially, patients will believe it is a sprain that will resolve itself, but with this repetitive microstress to the area on a daily basis, the tendon tear will propagate and cause the arch to collapse. That can lead to a condition called adult acquired flat foot deformity (posterior tibial tendon dysfunction). In the early stages, it is usually treated with rest and appropriate shoe wear and prescription inserts. In the advanced stages, it usually requires tendon and bone work to reconstruct the arch and hindfoot – making a straight and stable foot to accept normal weight-bearing loads. The late stage may require selected joint fusions to realign the foot.

What about people with the opposite problem, high arches?

Patients with high arches tend to bear weight on the outer side of the heel and foot. The arch often feels as if there is no contact to the ground. Some of these patients are more prone to ankle sprains because their heels are in an inverted position when they walk. Basically their ankle wants to rotate outward. That lends them to risk for chronic ankle sprain problems or ankle instability. Those patients need specific types of shoes and prescription orthotics. Sometimes surgery is required.