Selecting a surgeon


Brendan on http://achillesblog.com/brendan
I think he did the right thing by not getting pressured into surgery by the first surgeon and going with a different surgeon who he felt more comfortable with.

Wednesday Feb 27th - decided to see PCP first, got an appt in the morning. I didn’t really have to do this with my insurance, but figured the least he could do was give me a good recommendation for a specialist. He performed the Thompson Test, which was positive and got me into see a doc at our ortho clinic in town that afternoon. In between appointments, I started to research the docs at the clinic, and found that a few of them specialized just in foot and ankle problems, unfortunately my appt was not with one of them, but figured it was good that I at least got an appt and the ball was rolling. In the meantime, I had read that if you go the surgery route, 7-14 days is fine in between injury and repair, but not to extend it too much longer than that. As luck would have it, I was able to see one of the foot specialists that afternoon, and he confirmed a torn achilles. He gave me stats for the options: 18% re-rupture with casting method, 2-3% re-rupture with surgery, 18% chance of infection with surgery. I asked if further testing would be helpful in deciding, and he said an MRI could help, so I scheduled that for the following day.

Thursday February 28th - MRI in the morning, follow up appt with doc scheduled for next day. MRI was loud and annoying, but not uncomfortable at all. Late that afternoon, my wife and I both start getting phone calls from various nurses saying they need to talk to me ASAP. I finally get a call from a surgery center, prompting me to be there the following morning at 6:00 AM. I haven’t even talked to a doc yet about the results of the MRI. This is a bit nervewracking…and I finally get in touch with the doc to discuss. Turns out he is heading out of town, and if I want him to do the surgery, it has to be the next day. It’s really high pressure salesman style…and I don’t like it. I call the ortho center and get an appt with the other foot/ankle specialist after some hounding. I cancel the surgery with the first doc for now.

Friday Feb 29 - Meet with the other specialist, his stats are a little different, 10-11% re-rupture with casting method, 1-2% re-rupture with surgery, 1-2% infection risk with surgery. He talks to me for 30 minutes and is completely open to either route, although 99% of his treatments have been surgeries. He does 1-2 repairs per month, and I feel good about him, so I schedule the surgery for the following Monday (6 days after injury).

Lesson learned here, don’t be pressured into something you don’t want to do. If it feels funny to you, get a second opinion. I wasn’t questioning the first docs diagnosis, but I was questioning his method of communication and it didn’t jive with mine.

7 Responses to “Selecting a surgeon”

  1. I ruptured my tendon on a Sat, called my PCP but did not go to the ER, and then made calls to get an appointment with a orthopedist on Mon. I think I got lucky finding my orthopedic surgeon, though not without some effort.

    On Mon, my PCP’s receptionist/nurse (who is also his wife) referred me to the California Pacific Orthopedic and Sports Medicine (I have a Blue Shield HMO plan). However, I was uncomfortable with seeing a random orthopedist when surgery was a likely outcome.

    In 2002, I had seen a Dr. G after separating my shoulder falling off my bike. An orthopedist friend had recommended Dr. G, and though I ended up not needing surgery, he seemed like a good doctor. So I called Dr. G, but he was going on vacation and they did not want to potentially schedule surgery just before. I told the the nurse/receptionist that my PCP had recommended the CPO&SM and could she recommend a doctor there? She said no. I felt like I was stuck, but didn’t give up, and explained that I didn’t want to just see anyone, and wanted to get a recommendation. I let the silence go for many seconds and then she recommended a Dr. H, who was covered by my insurance, but was not in the CPO&SM.

    I called Dr. H, but he too was going on vacation and cannot fit me in. I pleaded for a recommendation, and got a pair in the same office, including Dr. Kevin Louis, who I ended up going with.

    In a strange coincidence, Dr. G. turns out not only to be a 3rd doctor in this office, but Dr. Louis taught Dr. G. as his resident. Still, because I am really thorough, and anxious about surgery, I ask him for a resume or other background info since “I want to make sure I have the right guy to do this”. He looks at me funny, and gets me an 11 page CV. It has pages of presentations given at orthopedic conferences, and he just happens to be an associate professor at UCSF. I feel a little sheepish, but very lucky.

    The surgery was a week ago (May 1), and I have had only 24 hours of significant pain, and am already able to walk with one crutch while wearing an orthopedic boot. Dr. Louis used internal dissolving stitches and then adhesive closures covering the entire incision, to try to minimize scarring, since I tend to form (keloid/hypertrophic) scars.

    So, don’t give up asking politely and if necessary persistently for anything you need to make decisions. Better sheepish than sorry. :-p

  2. Both of the estimates of re-rupture rates above from “casting” — i.e., from non-surgical treatment of a complete ATR — are way out to lunch, according to all four of the only studies that have ever randomly assigned ATR patients to surgery or non-surgery. In fact ALL FOUR of those studies (linked from my blog page) found statistically IDENTICAL re-rupture rates from surgery and non-surgery! (They also found statistically IDENTICAL flexibility ["ROM"] and strength!)

    I’ve discussed elsewhere how so many intelligent well-meaning health professionals could have gotten this question so thoroughly wrong for so long. Briefly, “jocks” were talked into surgery, while “crocks” (and everybody who was too weak or sick to be a good surgical risk) got slapped in a cast. The jocks healed way better, and that was taken as proof that the surgery made them heal way better.

    Not until 2007(!) did a group of careful doctors finally publish the results of a randomized trial that put this hoary old assumption to the test, and they found it WRONG!! And since then THREE other randomized studies have come to the same conclusion! The rate of infections and other surgical complications really is higher if you have surgery (though it shouldn’t be anything like 18%, I hope!), but the other results were indistinguishable, with only one minor exception in one of the four studies (in favor of the NON-surgical patients!).

    Check out my own blog for details about the evidence and the studies.

    In my own case, I got a very good orthopedic surgeon to repair my first ATR, in late 2001. But when I tore the second one (other side) in late 2009, I was lucky enough to find a GREAT orthopedic surgeon, who told me that he had heard the authors of the latest study present their findings at a conference, had asked them some questions about it, and has STOPPED doing surgical ATR repairs, because the study proved that the surgery was of no benefit!

    Instead, he recommended that I follow the NON-surgical protocol used in that same study, which is what I started 6 months ago, and I’m delighted with it! The protocol is linked in a comment on my blog, below the discussion of the studies. If you have trouble finding it, ask me and I’ll post the link here. (I’m still hanging around here WAY too often — GREAT website!)

    BTW, at least two other bloggers here (mike753 and gunner) have made the same decision as I did and followed the same non-surgical protocol, with excellent results so far. And one or two others have said that they wish they had seen the evidence before they got their surgery, because they would have skipped it! (GerryR for one.)

    The re-rupture rates in the 4 studies averaged around 2%, with or without surgery, and is probably dominated by patients who fell hard or did something similarly violent to their still-vulnerable AT. (It’s not easy — what we’ve all gone through or are still going through — and there are lots of chances to mess up!)

    So, “Selecting a surgeon?” Try to find one who’s read the scientific studies since 2007, and has stopped operating on torn Achilles Tendons!! I did. I admit that Toronto is more advanced medically than lots of other places — and my surgeon is the chief surgeon of the local pro football team and a young smart keener — but there’s no reason you can’t follow the same study-tested protocol wherever you are. And the future ATR patients of your surgeon will thank you for doing that — or at least they should!

  3. I ruptured mine a week ago. I am sceduled for surgery tomorrow. I just read your blog and wonder if i shuld just get a good boot and let it heal. It has already began to heal in the 7 days since the rupture. I dont know if its a 100% rupture, i can walk on me heal and move my foot around. There is a void where the once tight achilles was. perhaps it is 80 to 90 % torn. I met a sergeon last monday and he said “oh yes this must be repaired” It did feel like a quick sale, but i guess when you go to a sergeon, he will want to do sergury, right?

    I would like to read mor of the recent study results, and i need to do it now.

  4. Carl, we’re trying NOT to turn this wonderful site into an op-vs-non-op debate site, at the owner’s request. You can see my opinion in the post above, and that opinion — and the short version of the current evidence — is summarized on my own second-newest page, called something like “The case for skipping ATR surgery”.

    The studies — including the four new ones, two of which show really identical results either way with FULL ruptures, except for complications — are endnotes 4-7 in the Wikipedia article on ATR, which is short-linked at bit.ly/Wiki-ATR . As I recall, 4 & 7 are clear and persuasive on this question, while 5 & 6 did more “tricks” and are less persuasive, IMHO.

    Several of us have skipped “the knife”, some of us at the last minute. So far, I think all of us who’ve done that here are happy with our choice. (Touch wood, since there are no guarantees either way!) It’s a really personal and controversial choice, but there IS a choice, it should be yours, and it should be informed.

    A good fast modern protocol always helps, and I believe it’s clinically even more important non-op than op. I’ve recommended that patients confront their Docs with one printout in each hand — bit.ly/UWOStudyPub in one and bit.ly/UWOProtocol in the other. The study (= Wiki #7)shows their great results with and without surgery, and the protocol (in your other hand) is what they followed (and so did I).

    This is NOT “your father’s conservative casting”, though the first 2 weeks is total immobilization in a gentle “equinus” position (2cm firm heel wedges) withOUT weight-bearing (so I’d quit the walking and standing now, for another week). Cast vs. boot doesn’t matter for the first two weeks, then it does.

    Others whose blogs might be interesting (maybe especially at the very start) include johanna’s (aka “firstdayofsummer”, @ achillesblog.com/johanna/ ), mikek753’s ( achillesblog.com/mikek753/ ), and gunner’s. They all went non-op, as have a number of more recent folks, like bronny and northrancher etc. The personal experiences may help round out the statistics from the studies.

    Both ways work well for most people, despite my clear preference. A small minority have problems either way, which is one of the things the studies counted.

    Good luck, and good healing!!

  5. Medical procedures vary from country to country so here is my observations for selecting a surgeon here in Australia.

    I went to emergency after tearing the achillies. They popped me in plaster said I need to see a specialist surgeon. They recommended Dr A as they know of him. One of the doctors at emergency knew of Dr A because his brother was 10 weeks post op on a Achillies repair. He said he was conservative but seemed very good.

    I went to see Dr A the next day and he removed the cast and fitted me with a Vaco boot, confirmed the complete achilles rupture and booked me in for surgery 2 days later. I have private health care so I thought all would be covered. Upon leaving the clinic the secretary presented me with a bill for $550 - $200 for the consultation and $350 for the boot. I could not claim this back on private health care. She also presented me with a quote for $3000 for the operation which covered the surgeon and anethastist. Private Health Insurance would only cover $500 of the $3000. (Aussie Dollar is about the same as the US dollar right now)

    For the next 2 days I tried to get my head around the private health care system. In the end I discovered that there were certain surgeons that would do operations for the price the health insurance would cover. I also checked out Dr A’s credenials. He is an ankle specialist and is listed on all the appropriate websites, unfortunately I couldn’t find any customer comments.

    In the end I made contact with a surgeon, Dr B, who would do it for the health insurance price and also had some good reviews online. He was a general orthopedic surgeon not specialising in ankles. I decided to go with Dr B for cost reasons and he could fit me in for surgery 7 days after Dr A. I phoned Dr A to cancel but he agreed to do it for the health insurance price.

    So in the end I got a good price and 7 days earlier. I guess it pays to shop around and negotiate with your surgeon.

  6. Hello, am thankful to find you all!!! I am contemplating surgery for Haglund’s Deformity which is causing tears in my achilles. Kinda scared. What is the difference between choosing a Podiatrist or Ortho Surgeon to do surgery? Is it technique, skill or new equipment? I have not made committment yet, but pain and imobilization is driving me there.
    LadyDeb

  7. I’m 5 days post OP for Haglund’s Deformity. From what I’ve read- podiatrists specialize in feet from the get go. Ortho’s are general and then decide to specialize in an area, say feet. I went with a highly recommended podiatrist in my area. I saw him a year and a half after seeing an ortho surgeon who kept doing ineffective procedures and told me he wouldn’t operate on me because I could still walk. It took me a long time to decide to have the surgery and I had doubts about whether or not it was the right decision even minutes before the surgery. Feel free to ask me any questions you have

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