10/20/2016    Robert D. Phillips, DPM

How are you applying podiatric biomechanics to advanced surgical procedures such as ankle fusions? (Harold Vogler, DPM)

I am a little bit disturbed by the answer by
Dr. Vogler as printed in PMNews, in response to
Dr. Ribotsky's question, "How are you applying
podiatric biomechanics to advanced surgical
procedures such as ankle fusions?"
Unfortunately Dr. Vogler did not really address
any of the changes in the biomechanics of the
lower extremity when one does an ankle fusion,
and instead made a very generalized statement
about ankle fusion changing the biomechanics of
the lower extremity, referred to nondescript
changes in orthotic technology, and finally
recommended that an orthotist be consulted. If
this is the best answer that such a renowned
surgeon as Dr. Vogler can give, it is indeed a
sad commentary on the low state of knowledge of
kinesiology, kinematics and kinetics of the
lower extremity that is sweeping our
profession. It is very important that
podiatrists not only fully understand how any
surgery changes the kinesiology, the kinematics
and the kinetics of gait, but that podiatrists
understand how to fix or ameliorate the
consequences of those changes. If we do not
understand such, then there is a serious
question about whether the world even needs the
podiatric profession as there are others that
can do just surgery. Do we explain to our
patients the changes in biomechanical function
of their foot as well as their entire lower
extremity before we fuse a joint or do an
amputation? Do we explain how we propose to fix
the changes of doing the proposed procedure? If
we do not, how can any patient truly make an
informed decision and sign an informed consent?
It's rather interesting that all current books
on doing surgery of the foot and the ankle are
basically technician books, i.e. they present
minimal indications for any procedure, give
details on the technique and explain what to do
up until the skin, tendon and bone heals. I see
nothing being written about the changes in
function that occur after any surgical
procedure. Let's hope that the future authors
of surgical books are much more detailed in the
pre-op biomechanical indications and the post-
op biomechanical consequences. We have seen an
increasing move toward shoving the results of
our surgical procedures onto orthotists,
prosthetists and pedorthists. I certainly have
great respect for these people as I work with
them on a daily basis, and they do much
valuable work, however I find them only to be
extenders of my services and knowledge -- they
still function under my supervision, and I am
still ultimately responsible for everything
that they do. Let's hope that Dr. Vogler is
actually prescribing and supervising the work
that the orthotist does for him. As a mentor of
mine said, "It's good to do the right thing,
but it's even better to do the right thing for
the right reason." Biomechanics is a science --
it's not just making shoes, orthotics and
braces. Everything we do, from the simplest to
the most complex, has an effect on the
biomechanics of the foot, and the entire body.
I trust that Dr. Vogler will write a complete
article in the near future on the biomechanics
of doing an ankle fusion and how to address the
biomechanical changes that must be dealt with
after the surgery heals.

Robert D. Phillips, DPM, Orlando VAMC

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