Transcription:
Complex Foot and Ankle Reconstruction

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're examining complex foot and ankle reconstruction. Joining me is Dr. Anish Kadakia. He's a professor in the Department of Orthopedic Surgery at Northwestern Medicine.

Dr. Kadakia, it's a pleasure to have you join us today. As we get into complex foot and ankle reconstruction, before we do that, tell us a little bit about your background and what type of surgery are you known for.

Dr Anish Kadakia: Well, thank you very much, Melanie, for having me today. My background is that I am an orthopedic surgeon who has done a fellowship in foot and ankle for a year with Dr. Meyerson out in Baltimore. And over the last 16 years, my practice has developed to work on more severe deformities, revision work, which is what we kind of term complex foot and ankle. And so that's what I'm known for. I'm known for doing things and working on patients that others either find too difficult or have already operated on it and there may not be a solution. So that's kind of where my practice has focused on in the last few years.

Melanie Cole (Host): Well, thank you for sharing that with us. So tell us what makes a surgical case complex.

Dr Anish Kadakia: That's a great question. Sometimes it's either the patient themselves with regards to the severity of the deformity. So if the foot is shaped abnormally enough such that the difficulty of fixing the foot requires both bony, soft tissue work, and sometimes even multiple surgery. Sometimes it's because they've already had surgery and undoing or redoing what has been done just requires a lot of either a skill, implants, biologics that may not be either capable or possible for some other physicians to do. And a lot of what we do is either prior infections that when surgeries-- you know, unfortunately, no surgery is perfect and surgeries go wrong and you get a complication. And so sometimes surgeons need somebody to send that to, to try to help when things don't always go correct. And so that's really what defines complex. And the fourth thing is the patient themselves. Sometimes either they're very sick, they have maybe some other issues that make not just the surgery difficult, but the entire situation difficult. And that's really what we try to deal with.

Melanie Cole (Host): So that would include comorbid conditions, things like that, that just make this a more complex situation overall, yes?

Dr Anish Kadakia: That's absolutely correct.

Melanie Cole (Host): So now tell us about non-union of fusions. I understand you do quite a few of these.

Dr Anish Kadakia: Yes, I do. So when you look at fusions, a fusion, just to know what that is, is where you take two bones and you remove the cartilage and you try to make them grow together with either screws or plates or some metallic construct. And unfortunately, that doesn't always work. And so we fuse the ankle sometimes, the back of the foot, the middle of the foot, or the big toe, trying to minimize somebody's pain and you lose motion with that, but you're trying to get them more functional.

The problem is that doesn't work and it can happen about 5% to 10% of the time. And then redoing the fusion is much more difficult because the biology is a problem. There is some loss of bone, and that's probably the most complicated part because when we do a fusion, we take down cartilage and some bone. And if that doesn't heal, now you have a gap between the two bones. And so trying to get those to heal can be a big deal. In some cases, people come to us because they are being told they need an amputation and no one can help them. So we've developed techniques using your stem cells from your pelvis. We've used bone graft of wedges to reconstruct the bone itself. I don't use a tourniquet, so we try to minimize the amount of blood flow restriction that occurs during surgery. And with that technique, and sometimes we have to have help from plastics to help do these surgeries, but we've developed techniques that have been published to try to salvage legs where others would say you need an amputation.

Melanie Cole (Host): It's amazing. What an exciting time to be doing what you do, Dr. Kadakia. So one of the things that I found in healthcare around the board, and this is for other clinicians and other providers, is how you work with other types of surgeons for the best outcomes. Tell us about the multidisciplinary approach for these patients. What does that team look like?

Dr Anish Kadakia: Absolutely. So, you know, it's interesting. In the United States, a lot of surgeons really operate alone. And when I travel around the world, it's a much more team-focused approach where in many cases, two surgeons are usually present during the case. And so I've kind of brought that concept back here at Northwestern. So what we do is we work very closely with the plastic surgeon for any nerve work that needs to be done, any wound care that needs to be done.

So if I see a patient that needs revision work and sometimes even a primary work and we notice a problem, we send them to our plastic surgery colleagues, we'll get vascular involved if we need to before we come up with the surgical plans that we have the best option for them. If it's a hard case or it requires a lot of time and effort, my partner, Dr. Patel and I sometimes will do parts of the cases together, not because we're not capable of doing the case, but as we always say, two eyes are better than one or two sets of eyes are better than one. And that's bringing the concept that a lot of the world does where you have multiple surgeons trying to help these hard cases to give them the best chance of doing well. And it's really something that we can provide at Northwestern, which a lot of private practices and community can't do, just because it's not a financially viable scenario. We do it because it's better for the patient, not for any other reason.

Melanie Cole (Host): Such an important point that you made. So now, I'd like you to talk about biologic augmentation and surgical techniques that are used for complex foot and ankle reconstruction.

Dr Anish Kadakia: So one of the things that I think the evolution is, and we can see that now with medicine is not just relying on plates and screws, which is what orthopedic surgery has been for a hundred years probably. What we now are trying to do is maximize the biology, so trying to make the body heal itself or doing of that nature that augment our metallic fixation. So for example, in the clinic, we use something called PRP, platelet rich plasma, where we try to inject that into the tendons and the joints to avoid surgery.

At the time of surgery, we're very heavily dependent for these complex cases on using either we call it mesenchymal signaling cells, which is the colloquial term is stem cells. We use things called BMP, which is a protein that's designed to make the body heal. And again, we understand the biology of bone healing, and we know that when you restrict the blood flow, you get heat and that can kill the cells. So we really try to avoid that. And then post-operatively, we know the mechanics and the biology of how long things take to heal, so we keep people off for a certain amount of time to try to maximize the bone healing before we get you going.

Melanie Cole (Host): Such an interesting field. And I find that biologic augmentation fascinating. Have any techniques shown to be superior in terms of outcome?

Dr Anish Kadakia: Yes, they have. And that's something that we consistently look at too. So one of the things that I've done since I started at Northwestern was have patient-reported outcomes and radiographic outcomes looked at for most of our surgeries. And so one of the things that we were dealing with were these fusions of the ankle, where somebody has a significant amount of bone loss, an inch to two inches of missing bone, sometimes even more. And many of these patients either require an amputation or a surgery that's called a bone block fusion, where we take somebody else's hip bone and stick it in there and try to reconstruct their leg. The problem is historically that had a 50% nonunion rate or one out of two would fail. So we try to improve that. And what we just got published in Foot & Ankle International was able to show that we had a 90% fusion rate. So instead of half-healing, we were able to get nine out of ten heal for these surgeries where most people would say you need an amputation. So yes, the biology, the techniques, are now showing that we can do a better job. And we're looking at that in the back of the foot, in the middle of the foot as well.

Melanie Cole (Host): Before we wrap up, doctor, what advice do you have for other orthopedic surgeons looking to improve their outcomes in complex foot and ankle reconstruction, and any research that you're working on that other providers might not know about that might impact the future of complex limb reconstruction?

Dr Anish Kadakia: That's a very interesting question. One of the things that I think that other providers can look at, and this is what I lecture about a lot, if you look at kind of complex foot and ankle in general is, one, you need a good plastic surgeon to help you in many cases. Don't try to do what you're not capable of doing or your facility doesn't have the resources to do. Because I've tried that too, where you try to be a hero and do everything yourself. The problem is these patients need a little bit more help sometimes.

So you need to believe in adding biology, whether that's stem cells or protein called BMP, avoid heat necrosis, which is going to be a future study that we're trying to look at. It's very hard to look at that, but there's some data showing that avoiding necrosis of the bone with heat when you drill is very important. And I think, in these difficult cases, adding a plastic surgeon to improve the soft tissue, especially where there's an infection or you need the bone to really heal is going to be something in the future that we're going to be able to see as important for the patients.

Melanie Cole (Host): And do you have any final thoughts you'd like to leave us with, key takeaways from this episode today?

Dr Anish Kadakia: I think for the physicians and patients, is that complex surgery or any surgery doesn't always work and that's really the advice I give to the patients. So if you're going to undergo surgery or you're going to perform surgery, you should be aware that there's a 5% to 10% chance that the surgery does not end up the way you want it. And you need to be sure that the function you have now is bad enough that you are willing to undergo the risk of surgery, because I don't think that's explained enough both from the physician or understood by the patient. And that's why I have the practice I have.

Melanie Cole (Host): What great advice on counseling their patients about complex foot and ankle reconstruction. Thank you so much, doctor, for joining us today.

And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ortho to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.