Foot and Ankle Specialty Continues to Evolve: Q&A with Daniel E. Murawski, M.D.

March 17, 2014

Topic: Foot and Ankle

orthopaedic, foot and ankle surgeon, Dr. Dan Murawski, Andrews Institute, Foot & Ankle Center

A foot has 26 bones, 33 joints and more than 100 tendons, muscles and ligaments. Most people will take thousands of steps daily with certain activities and subject their feet to forces of two to three times their body weight. Taking that into consideration, injuries are probable.

Ankles are equally vulnerable. During the past three decades, a more active older population has led to a marked increase in broken ankles. Some health care systems report having treated 1.2 million people for ankle problems in one year alone.

Foot and ankle specialists are industry leaders for diagnosing and treating foot and ankle injuries. Using their highly specific knowledge base, they work alongside nurses, physical therapists, pedorthists (to address orthotic needs) and other physicians to keep patients healthy, strong and on their feet.

To help shed some light on this important specialty, Daniel E. Murawski, M.D., fellowship-trained orthopaedic surgeon at the Andrews Institute Orthopaedic Foot & Ankle Center, took some time with us to answer a few questions.

Q: Why did you decide to specialize in the foot and ankle?
Daniel Murawski: I wanted to choose something that I was passionate about, something that I could study in depth and help develop. During my residency rotations I learned about all aspects of orthopaedic surgery, and foot and ankle was one of the few specialty areas where you treat a broader spectrum of patients from childhood disorders to advanced arthritis in older adults. You care for neuromuscular conditions and trauma, perform leading-edge arthroscopic techniques and many types of reconstructive surgery. I get to use the breadth of my knowledge and skills. I also find the anatomy and physiology to be complicated, yet very intriguing. It allows me to use my strengths in serving patients: attention to detail and a focused approach.
Q: Are there foot and ankle injuries that can cause permanent damage if misdiagnosed or not promptly treated?
DM: Absolutely. A few conditions come to mind. One is significant high ankle sprains. These injuries are more severe than the standard lateral ankle sprain, and if treated inadequately can cause persistent disability. A second injury that gets a lot of attention in the media when it comes to professional sports is Lisfranc injury. This injury is a mid-foot sprain through the bony arch, and also can occur with recreational sports such as flag football. It’s often misdiagnosed and if not treated sufficiently, can lead to irreversible damage.
Q: Can you give me some examples of long-term problems?
DM: With Lisfranc injury, you can get a progressive collapse of the arch, progressive deformity, pain and arthritis. Improperly treated high ankle sprains such as this can lead to arthritis of the ankle, which can also be painful during weight-bearing activities. In fact, the most common cause of ankle arthritis is trauma.
Q: So when a person sprains his/her ankle, what symptoms indicate the injury may be something more than a regular sprain that warrants immediate medical attention?
DM: The first sign would be the inability to bear weight. In simple, low-grade sprains, a person should be able to walk immediately after the injury occurs. If it’s so painful that you can’t put any weight on it, or if it feels unstable, that would be a significant warning sign that you need professional evaluation including X-rays. Excessive swelling and bruising, especially if it extends above the ankle or to the inside area of the ankle also are warning signs.
Q: Besides injury, what are the most common causes of foot and ankle pain?
DM: Arthritis, which commonly affects the ankle, mid-part of the foot (the arch) or the great toe. Another common cause is acquired flat foot deformity, which is a progressive collapse of the arch accompanied by pain and swelling that occurs most commonly in the female population older than 40 to 45.
Q: Why is that?
DM: We don’t really know the specific causes, but there likely is a genetic predisposition that makes a person susceptible to repetitive microtrauma over time. Influences could be anything from improper footwear to hormonal changes.
Q: You mentioned arthritis a few times, and said that one of the most frequent causes of arthritis is trauma, but what are other causes of this condition? And how common is it overall?
DM: That’s a tough question because many people think of the foot and ankle as one entity, but they actually are two regions. If include the two together, there are 28 bones in the combined region. The various forms of arthritis affect each region differently. By far, the most common cause for arthritis of the ankle is trauma, followed by rheumatoid arthritis and age-related primary osteoarthritis. In comparison, the most common cause of hip and knee arthritis is age-related primary osteoarthritis. In general, knee and hip arthritis is about three times more common than ankle arthritis. In cadaveric dissections of people older than 70, 15 to 20 percent of ankle specimens show advanced osteoarthritis while more than 60 percent of knee specimens show advanced osteoarthritis.

Today, age-related osteoarthritis affecting the mid-foot is very common. It tends to be, more in line with the arthritis that affects the hip or the knee. People also can get arthritis of their big toe. Interestingly, this can start very early. We see it in people in their 30s and 40s. In fact, statistics show that about 3 percent of people older than 40, which is a pretty decent number, will get arthritis of their big toe.
Q: What are the most non-traumatic causes?
DM: Osteoarthritis is one of the most common causes of arthritis anywhere in the body - hip, knee, spine, wrist, elbow, shoulder, ankle and foot. The next large category includes inflammatory arthritis, such as rheumatoid arthritis. Traumatic arthritis, osteoarthritis and rheumatoid arthritis can affect the foot and ankle.
Q: What about genetic factors?
DM: That’s a good question. We are not aware of specific genes that make a person more likely than another to develop ankle arthritis, but there is a difference in the composition of cartilage between the ankle and other major weight-bearing joints. This difference helps account for the differences in the rates of age-related osteoarthritis. As individuals get older, the cartilage in the hip and knee starts to be significantly less resistant to tensile stress while ankle cartilage stays relatively strong. So genetic factors in ankle cartilage make it more resistant to age-related osteoarthritis, but certain biomechanical factors make the ankle more likely to be injured and hence develop traumatic arthritis.

Although we haven’t identified a genetic predisposition for ankle arthritis, we have found a strong genetic predisposition for arthritis of the big toe. If your parents have forefoot arthritis - particularly of the big toe - you have a much higher risk.
Q: What about treatment options? I’m guessing there are many...
DM: Yes there are. For foot and ankle arthritis, the classic surgical solution is fusion - which is technically called arthrodesis and consists of removing the bad cartilage and fusing the two bones together, eliminating the joint and motion. The other option is joint replacement.
Recently, there has been more attention to ankle replacement surgery because there has been an improvement in technology, particular biomaterials and techniques. Back in the 70s and 80s, when hip and knee replacements were gaining popularity because of high success rates, surgeons also were doing ankle replacements, but success rates were much lower than hip and knee surgery. The mechanics of the ankle were found to be quite complicated, not easily substituted with an artificial device, and failure rates were unacceptably high. Ankle replacement surgery was essentially abandoned and fusion became the gold standard. More recently, second- and third-generation replacements have become available and more and more surgeons are doing those, though not nearly as frequently as hip and knee replacements.
Q: When would you recommend that a person undergoes bunion surgery?
DM: Recommendations from the American Academy of Orthopaedic Surgeons suggest that surgery should be considered only after failure of reasonable conservative treatment methods. If the bunion isn’t painful, and the person can enjoy everyday recreational activities, I don’t recommend surgery. If they have a painful bunion, I recommend wearing reasonable, wide-toe box shoes with a lower heel and an occasional anti-inflammatory either oral or topical. They also can try a toe spacer. If they are into high foot stress activities like running, I recommend cross training with some less stressful exercises such as swimming and bicycling. If these methods don’t eliminate the pain and the person is can no longer enjoy reasonable activities, that’s when I recommend considering surgery.
Q: Some people believe bunion surgery is very painful, and is not always successful. Why is that?
DM: I always have an in-depth conversation with patients when it comes to bunion surgery. It’s really important to understand that a bunion is an angular deformity of the main toe joint that may progress with time and disrupt the normal weight-bearing mechanics of the forefoot. So there is more to it than just appearance. It’s actually very complicated, and I think a lot of mistrust comes from not having enough information about it.
It’s important for patients to talk to their doctors and get their questions answered. I remind patients that even if they know someone who has had bunion surgery, it doesn’t mean that he or she will have the same surgery. Depending on the magnitude of the deformity and other factors, one surgery can be a completely different from another. There really are hundreds of ways of correcting bunions, and most of them involve either cutting the bone and/or rearranging the soft tissue around the joint to realign the big toe.
"So patients need to sit down with their doctor, ask them hard questions: How many surgeries have they done? What techniques do they use? What is their rate of complications?"
Complications from bunion surgery are numerous and include, among others, recurrence of deformity, nerve injury, loss of blood supply to the joint, poor bone healing, overcorrection, pain and stiffness. Patients need to know this if they are going to go through with the surgery. It is very important that patients trust their doctor’s experience in terms of number of surgeries performed and the ability to tailor the surgery to the specific characteristics of their patients.
Q: What is the best specialist to see about bunions?
DM: That’s a tough question, and I may be biased since I’m an orthopaedic surgeon fellowship trained in foot and ankle surgery. The other field that deals with foot pain would be podiatry. I’m inclined to say that orthopaedic surgeons have an edge in terms of standardized training and surgical experience, but patients really have to do their own research.
Orthopaedic surgeons who are fellowship trained in foot and ankle surgery are highly regulated and receive uniform education regarding quantity and quality of time learning surgery. They are medical doctors (MDs) or doctors of osteopathy (DOs) and training is the same across the board:  four years studying general medicine in medical school, a five-year residency in orthopaedic surgery including all aspects of the musculoskeletal system including the spine, upper and lower extremities, and a one-year fellowship devoted to advanced study of the foot and ankle. The culmination of their training is board certification by the American Academy of Orthopaedic Surgery under the American Board of Medical Specialties. In contrast, podiatrists are doctors of podiatric medicine (DPMs) and have varied levels of post-graduate training that may differ based on state regulations; the time spent in a surgical residency is not standardized and may range from zero to three years. Podiatrists are not regulated by the American Board of Medical Specialties like orthopaedic surgeons and all other physicians (MDs and DOs).
So patients should do their research and make sure that the surgeon has done extra training. If you choose to see a podiatrist, make sure he or she has done a full three-year residency and is certified by the podiatric board. If it’s an orthopaedic surgeon, make sure he or she did a fellowship in foot and ankle surgery and is board-certified by the American Academy of Orthopaedic Surgery.
Q: Aside from bunions, what types of conditions are better treated by a foot and ankle surgeon as opposed to a podiatrist?
DM: First of all, patients should do their own research and make decisions based on their own personal needs, preferences and expectations. As mentioned earlier, a fellowship-trained orthopaedic surgeon by definition has extensive surgical experience and therefore is well-suited to provide the breadth of surgical care ranging from bunion surgery all the way through ankle replacement surgery. Some surgeries require exposure of the whole leg or bone graft harvest from the pelvic bone, and while these surgeries are done routinely by orthopaedic surgeons, they fall outside the scope of podiatrists.
Orthopaedic surgeons are not generally trained in routine care of dermatologic conditions of the foot such as corns, calluses, toe nail disorders, warts and fungal infections. For these conditions and routine diabetic foot care, I generally refer patients to podiatrists. Unlike most podiatrists, orthopaedic surgeons also do not generally fabricate foot orthotics. Of course, some podiatrists have extra interest and training in surgery.
Q: What has been the most revolutionary development in foot and ankle orthopaedics in the last few years?
DM: No. 1 is better ankle replacement surgery with better patient outcomes. No. 2 is the new biologic agents for chronic conditions such as tendonitis in which we retrieve and concentrate growth factors and cells from the patient’s own blood or aspirated bone marrow. We then inject these factors into areas of sluggish healing. Chronic Achilles tendonitis would be a condition amenable to these new agents.
No. 3 is imaging. The foot has 26 bones (as opposed to three in the knee or two in the hip). So it’s quite complicated, and you need high-resolution imaging to show you what you need to see. Until recently, the technology wasn’t as good. For example, an MRI of the knee was much more reliable than that of foot and ankle. At the Andrews Institute, we have a very powerful MRI, a 3-Tesla, and we have radiologists trained in reading these higher-resolution images. It’s extremely helpful and helps us make diagnoses we couldn’t make before. At the Andrews Institute Foot & Ankle Center, we also have a weight-bearing CT scanner, one of only a few such devices in the country. We can image both feet and ankles at the same time and see them in ways that we couldn’t before. We have several research projects in the works right now based on evaluating conditions with this device. I think it will revolutionize how we treat patients.

Thank you for your time.

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