Multidisciplinary Approach in Foot Reconstruction

The foot, being the complex structure that it is, in which all the connective tissues of the musculoskeletal system come together, has been classically undervalued in the majority of the Orthopaedic Surgery and Traumatology departments of large hospitals; consequently being relegated to a secondary role in comparison with large joints.

Personally, I consider this “Cinderella role” is due to the fact that surgeons do not like to do the dirty work. The treatment of its pathology is complex, requires knowledge of its anatomy, of its biomechanics, and occasionally, after hard work, the results are not those expected. It could be said that the effort is not worthwhile, or at least less compensated for than in other fields of Orthopaedic Surgery.

Something similar used to happen with the hand, where the handling of the complex traumas requires a multidisciplinary approach (Microsurgery, Traumatological Surgery, Plastic Surgery). The correct handling of all the tissues (bone, joint, tendon, nerve, vessel, and skin) was fundamental for obtaining a good result. If anything failed, the result was poor; so it is mandatory to manage all the elements correctly and preferably by the same surgeon, or, if that is not possible, by a team (traumatologist/orthopaedic surgeon + plastic surgeon) who would function as a whole.

The experience shows that this effort is worthwhile. It requires global management at the same stage and as soon as possible. The correct handling of bone, joint and tendinous structures, accompanied by an adequate nerve and vascular repair, and a well-vascularised coverage followed by early rehabilitation, achieved results much superior to those obtained previously. The idea was to repair everything early and well, thus saving secondary surgeries and mobilising the structure fast in order to obtain good functional outcomes.

To such a degree, foot and orthopaedic surgeons have been incorporating techniques from Plastic Surgery to their therapeutic arsenal. Experience has shown how a coverage problem can jeopardize bone work or tendinous repair, and how the attitude of waiting for “divine intervention” to solve the problem did not obtain acceptable success. Sometimes the second intention healing, with time and patience, can lead the surgeon to deal with the soft tissue problem. However, this “wait and see” approach implies that the tissues exposed (tendon, bone, joint) become desiccated losing their function or becoming infected, which affects the outcome of the surgery.

The combined approach of orthopaedic surgeons along with plastic surgeons seeks to avoid these problems, which are, unfortunately, very common in the handling of soft tissue. The early coverage with a well vascularised tissue, allows the preservation of the repaired or exposed osteoarticular and tendinous structures; therefore increasing the possibility of early rehabilitation and considerably reducing risk of amputation.

In view of the good results we have observed, collaboration between foot and plastic surgeons is increasing day by day. The quality of the coverage provided by flaps avoid structure exposure and consequently discharge the foot surgeon from having to manage with complex wounds; in the same way that plastic surgeons resort to traumatologists for the handling of a calcaneous fracture.

Collaboration between specialists is mandatory, so that only through the multidisciplinary handling of a complex problem can an adequate result be obtained; and among the multiple examples that could be listed, Foot and Ankle Surgery is definitely one of them; one where cooperation among plastic surgeons and foot surgeons is as necessary as it is beneficial.