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questions regarding lisfranc hardware removal

Discussion in 'Ask your questions here' started by bogglor, Jun 28, 2010.

  1. bogglor

    bogglor New Member

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    Before I get to my questions, here is my history:

    I am 34 years old.

    On March 11 2008, I suffered a lisfranc fracture/dislocation of my left foot while playing basketball. I fractured the 1st, 2nd, and 5th metatarsals. I had ORIF surgery done by a foot/ankle specialist on March 12 and 6 screws and 2 plates were inserted, as well as 1 pin with a K wire for the pinky toe. I was probably NWB for 2 months or so, followed by a walking boot for another 2 months. I resumed normal walking shortly thereafter that. After a long and slow rehab procedure to regain the strength in my leg/calf, I returned to basketball in February of 2009. I was playing 4 times a week for 1.5 hours prior to the injury and I slowly worked myself back to this same level of activity probably somewhere around November of 2009. Pain level decreased as the months wore on and I was able to do more and more of the things that I was able to do before the injury. Somewhere around March or April of 2010, I started to feel really like my old self again without any pain really when I played and a marked increase in mobility. Being a right handed player, I drive off of my left foot a lot, and I didn't really have the confidence or capability to do that until March/April 2010.

    So, I would have to say that my first surgery, after about 2 years of healing and rehab, was a successful outcome.

    Last Thursday, I felt sharp tingling pain at the top of my foot while playing and I knew something was wrong. The pain was excrutiating when pressure was applied to the region of the injury, but otherwise I was able to walk normally. I removed my shoe and could clearly feel a loose body of some kind underneath the skin. I reasoned that it was probably a broken screw head or bone chip of some kind. I think I was probably stepped on a couple of weeks ago as the area had a bit of swelling the week prior but that subsided and I had no pain.

    I got in for an x-ray and my fears were confirmed -- I have two broken screw heads and one of the plates is dislodged. Only one of the broken screws is bothersome and I thought that they might perhaps just scoop it out, since it is really just below the skin, but they said they couldn't do that and that all of the hardware had to come out.

    I was never told that this hardware could come out when I had the surgery. I always thought that the options were hardware forever or bone fusion. So, I was a little taken aback when I was told that I should have outpatient surgery to remove the hardware (it's happening Wednesday).

    I have some questions regarding this that I asked of my doctor, but honestly, their practice churns through patients so quickly that I never feel like I'm able to get all of my questions answered in any detail.

    So, here goes.

    1) Is there a reason why they can't just take the screwhead out and leave the rest of the hardware? Is it because they are worried that the rest of it is going to fail evenutally now that the structural integrity of the site is compromised?

    2) They said that they would remove the old screws the same way they put them in - with a screw gun. How does this work for the screws that are broken? Will they just leave those in? I would imagine trying to remove a headless screw is going to cause major trauma to the bone in the surrounding area, but I'm not a doctor...

    3) This is an outpatient procedure where I'll receive a standard nerve block and sedation. They don't seem to be treating it very seriously despite the fact that my first injury was very bad. They did say that the foot has healed completely, but I am worried that removing the hardware is going to compromise the structural integrity of the foot, particularly for someone as active as I am. Is this a valid concern going forward? Is it reason enough to not have the surgery?

    4) What is the typical timetable of recovery for hardware removal in a lisfranc fracture given the severity of the above? I have read countless stories on these forums and others (and yes, I am aware of the outcome bias inherent in them -- you hear 90% bad stories and 10% good) where people have said the timetable is longer than what the doctors told me. They said that I would be NWB for only a week and then return to a boot and then full regular walking in a month, and back to basketball in two months. This seems awfully optimistic / accelerated to me given what I have read before.

    5) I had a ton of swelling that took months to subside. I imagine that a lot of it was resultant moreso from the injury trauma than from the surgery itself, but I don't know what to expect in the event of just surgery w/o trauma.

    In a nutshell, I am scared. I consider myself to be one of the lucky few able to beat this injury and resume the same level of activity that I had before. With each additional surgery, no matter how minor the doctors seem to be treating it, it's another compromise to an already compromised area, and I feel like it worsens my chances of being back to 100%. I also feel like I might be getting sold on a recovery timetable that is not realistic.

    Any advice is welcomed.
  2. FootDoc

    FootDoc New Member

    My advice is clear, succinct and non-negotiable. I would recommend the following:

    1. that one never, never, never considers undergoing surgery in the hands of a doctor who "churns through patients so quickly that all his/her (the patient's) questions are not answered in sufficient detail."

    2. that one never, never, never relies on Internet forum responders to substitute for his/her doctor and answer case-dependent questions which only the attending doctor can answer with accuracy.
  3. bogglor

    bogglor New Member

    It isn't a case so much that I don't trust the doctor or his care, as he is one of the top foot/ankle specialists (though I am sure patients get told this all the time as a matter of course) -- but the orthopedics clinic where he sees patients (along with other doctors) is a zoo. As is the case I suspect with most busy teaching hospitals, you spend 5 minutes with the actual doctor doing the surgery and the rest of the time with medical students, nurses and other attending physicians. I've come to expect this as the norm these days.

    I realize that every case is unique and you are right to deflect many case-dependent questions. But there are some more general questions, such as the nature and procedure of screw removal that (I would guess) do not appear to be as case-dependent. Perhaps you could at least address those?

    And in no way am I "relying" on Internet forum advice - I plan to ask all of these questions tomorrow of my doctor's nurse / attending tomorrow, but it is always nice to have multiple sources of information.
  4. Unregistered

    Unregistered Guest

    Good luck to you "bogglor", and prepare yourself for an all-out assault when Foot Doc replies. I fear you've just stepped into the forum trap and will be told how ridiculous it is to seek additional OPINIONS to enable you to ask good questions and make informed decisions about your condition and treatment plan.

    Take the original advice as it's as good as it gets. Take a thorough list of questions to your doctor tomorrow. Again, good luck to you.
  5. FootDoc

    FootDoc New Member

    Well, why DO you trust the doctor and his care? He's too busy or doesn't care to give you more than 5 minutes of his time, He doesn't answer your questions. All signs would seem to me to point to the fact that he really doesn't care. So what is there to trust other than being "told" that he's one of the top foot/ankle specialists? I don't know anyone who claims to be less than terrific. It is sad that you and so many others have come to expect such treatment as you depict as the norm, and frankly, you don't really even know if HIS hands ever performed surgery on you. Perhaps he's too busy for THAT too, and maybe a resident or an intern or a medical student actually does the hands-on work and he just gives a wink and a blessing to it. I suppose I really can't blame you for being scared.

    All that being said, screws are employed in Lisfranc surgeries for two basic reasons:

    1. as internal fixation for fractures

    2. for immobilization of reduced joints to facilitate the healing of ligaments

    Screws employed for reason 1 are generally left in place, unless they are creating problems. Once the fracture site has healed, they no longer serve a structural function. Screws employed for reason 2 are frequently routinely removed at a generally predetermined time after surgery, as motion is desired at those joints and failure of the hardware is a definite possibility due to this motion. I don't know which screws you are talking about, but I would suspect that if they fractured, they were probably place there for reason 2. I think it is ridiculous to assert that a screw with a broken head can be removed in the same manner in which it was placed in the bone. I can't judge what sort of post-operative swelling and pain you might be expected to experience from a procedure employed to remove a screw without a head. It would depend on its difficulty. But that assessment would be one which your own doctor should discuss with you . . if you can ever stop him long enough to ask him.

    Finally, when challenged, just about everyone will assert that they are not going to rely on Internet advice. But then, what is the object in asking? Of what benefit could an opinion that one does not rely upon be?

    Forums are no place to obtain case-dependent information and even though you now couch your request as a solicitation for general information, we both know that you are looking to applying any opinion which you might trust to your own case. I think it an insult to you to relegate your questions to the doctor's nurse . . or is that nurse performing your surgery? Why don't you ask your doctor who is getting paid for your surgery?
    Last edited: Jun 29, 2010
  6. bogglor

    bogglor New Member

    I don't know how you generally arrive at your decisions, but there's a marked difference between soliciting someone's opinion and relying on that information exclusively and simply adding that person's opinion to your collected information and factoring it in to one's decision making process, if necessary. When you shop for a television on the Internet and go to read some reviews, are you necessarily "relying" on those opinions to make your decision or are you trying to do due diligence (as I am here) and collect as much information as possible before acting? If you are saying a question where the response can't be exclusively relied upon is a worthless question, then I heartily disagree.

    It's condescending and even mildly insulting for you to insinuate that my questions are anything BUT a solicitation for general information. One can read through a handful of posts on this forum and quickly deduce that you are no nonsense and quick to exhort the poster to refer their case-specific questions back to the doctor with full knowledge of the patient. My sense is that people come here to get information and opinions from a source with no stake in the patient who (hopefully) will provide unbiased general answers to add to their collected information.

    All I was looking for is to potentially hear other people's stories about their hardware removal and if I was lucky, get a qualified orthopedist to perhaps answer some of my more general questions. I thank you for answering the questions about the screws.

    On the whole though, the Unregistered user in this thread was right. Your motives for even answering questions here at all are a mystery to me, given the level of irritation many posts seem to cause you.
  7. Unregistered

    Unregistered Guest

    While I cannot offer you (Bogglor) any advice, as my hardware is still in place and hopefully forever will be (to avoid surgery again)....I thank you for your well-spoken words regarding Footdoc's approach to this forum--I echo your sentiments (and empathize with your care situation).

    On the brightside, the 'no-nonsense', or just plain condescending and mean replies he has for many of us here, well...are pretty hilarious.

    I get a chuckle knowing there's someone crankier than me out there, and I can't walk.

    Good luck!!
  8. FootDoc

    FootDoc New Member

    A medical opinion from a medical professional is not analogous to someone's opinion of a TV or a refrigerator or a restaurant. Medical opinion are diagnoses which are expected to be founded in good medicine. They are not the whimsical personal likes and dislikes of objects or services. Accordingly, when one asks a doctor for his professional opinion, one should not expect to be given a personal opinion of likes and dislikes, but a judgment which is founded in science and medicine. Whether one goes to his own doctor or posts to a forum, the expectation for both the doctor and the patient is that the response will be worthy of being accepted and that the patient is willing to give it serious consideration. If, as a poster who is asking case-specific questions (which I think is totally inadvisable), he is signaling that he will accept those answers and probably act upon them. That is how I consider that my responses will be taken, and I am quite careful to not overstep the bound which that trust engenders. Accordingly, I offer very few, if any, definitive responses to case-specific problems, as only the attending has the specific knowledge of the case and can and should do that.

    You had offered a detailed history of your personal situation and have asked questions as to how your situation could and should be treated. If that is a solicitation for GENERAL information, then you simply don't understand what general information is. If you feel that I was either condescending or insulting to you by pointing that out, then you need to re-read your own words of your question.

    So, realizing this in advance, why would you think that I would be able to tell you how your broken screws would or should be dealt with when that answer would require specific knowledge of your situation beyond that which you could relate?

    Why people come here and the often unrealistic expectations they have in asking a question is not my problem. Nor is it my problem if and when a few become irked when I tell them so.

    When you come to a site where only people with problems come, then you get a very skewed idea of how things generally go and what represents nominal treatment. Disgruntled patients are the very worst source of information as they see things only by their singular unfortunate experiences.

    Now THAT would have been the proper and gentlemanly entire response. It is simply not necessary for someone who has be give something of value and for nothing to then pick at the issues with which he was not satisfied. Talk about insulting.

    If you recall, my first response to you was clear, succinct and non-negotiable. It was YOU who pushed this past the point of which I clearly stated that I wanted to go. Did that irritate me . . You bet it did. But you chose not to be satisfied with my clear and succinct answer which I forewarned you was not negotiable. To then claim that I was inappropriately irritated by your subsequent attack and rant is rather odd. But, on the other hand, you have a doctor who I am certain is earning good money to treat you, and part of that treatment should be to answer your questions to your complete satisfaction. The fact that he is "too busy" to do so should certainly be perceive by you as more of an insult than anything that I have posted herein. The fact that you expect and accept that sort of treatment is curious, especially in light of the disdain you have shown for me . . . someone who owes you nothing and to whom you will give nothing. So you are going to pay your doctor, probably thank him graciously and no-doubt will shut your mouth about his lack of attention to your needs. How comes THAT??
    Last edited: Jun 30, 2010
  9. Liz

    Liz Guest

    Right on, Foot Doc. Loved your reply. I don't know why you even try to help ungrateful people like this who take what you give them for no charge and then whine that you didn't walk on eggs and treat them with more concern and tact than the doctors they are paying. They act like spoiled brats. Thanks in general for all the good information and keep up the good work.
  10. bogglor

    bogglor New Member

    LOL, nice job responding with a guest account to make it look like you have an ally. That's pathetic. Deny it all you want; it's too hard to hide your unique pacing and diction, not to mention your fondness for clever turns of phrase like "walk on eggs".

    I'm about an hour out before I go in to surgery, so this will be my final post. You can have the last word. After all -- this is your kingdom. But review the tone of my first two posts, and then review yours. In my second post, you perceive my asking for the answer to what I think anyone would ascertain as a very basic question (re: screws) as an attack or rant. I was polite, and indeed "proper and gentlemanly" as I always am when asking for something. It's too bad you chose to devolve the entire discourse into a tirade about the nature of Internet questions, the current state of doctor/patient relationships in a managed care world, etc.

    Why do you even do this? Why do you choose to provide "something of value" (a dubious claim in many responses) to us, the unwashed Internet masses? It can't be out of some inner kindness or willingness to help others -- because let's face it: you're a prick. You know this and you delight in it, taking every opportunity to make a snarky comment or light someone up whenever possible. No, it must be something else. Proper and professional responses I would think are the norm in your field, but you feel the need to jazz it up? Is it to stroke your ego?

    I have no idea what your motives are, but if you're taking time out of your practice to belittle people who visit this forum and even occasionally participate in flame wars with anonymous patients, then I fear for any flesh and blood patient who comes to you seeking care.
  11. Liz

    Liz Guest

    Bogglor, you're an idiot. I don't think Foot Doc needs an ally, but I guess it would never occur to a dunce like you that there are people who read this site who actually have some sense and can write a sentence or two. I guess that's all new to you. I take it as a compliment that you think I use clever phrases, but I just googled "walk on eggs" and it brought up 17 million 900 thousand references. So Foot Doc and I can't be too exclusive in using it. LOL
    Again, you're an idiot and I don't think the Foot Doctor needs my help.
  12. FootDoc

    FootDoc New Member

    Though I appreciate your support, Liz, the only thing comments like yours do is incite an idiot as you have called him into greater idiocy. Let 'em be and they just fade away back into the woodwork from whence they came.

    p.s. I though I was the only one who knew the expression, "walk on eggs."

    p.p.s. Please don't reply. It will only invoke more of the same.
    Last edited: Jun 30, 2010
  13. Unregistered

    Unregistered Guest

    I've read several posts on this forum about lisfranc. It helps me understand what questions to ask my doctor....its part of educating myself about my lisfranc injury.

    On every post where I see "FootDoc", he is repeatedly condescending about the use of the forum. FootDoc, if you are so against people inquiring about their injuries here, why do you even bother to participate. Why are you on this forum? You don't help people, you just make them more frustrated.
  14. mlm_ smiles

    mlm_ smiles Guest

    You two spent entirely too much time going back and forth. From one Lisfranc patient to another, ALL of the hardware can be removed if you are stable. They will remove the plates and screws thru the incisions made, any broken scree parts they'll remove thru the longer incision on the top of the foot, although an x-ray will be needed to guide them when looking for the pieces . There you have it.

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