Looking To The Literature For Answers On An Unfamiliar Pathology

Often in the course of treating patients and their pathology, physicians run into questions or situations in which they may not be sure of the "correct" course of treatment. As with anything in medicine, there may not be one "right" answer. When I encounter these situations, I often go back to the basics I learned from school, residency and fellowship. Essentially, I look to the literature for answers.

Whether it is a situation you are encountering for the first time, a question posed by a resident, patient or colleague, or maybe you are looking to change a technique, you can always do a quick PubMed search to see if there is anything in the literature that can help you answer the posed question. I find it surprising that more often than not, there is someone who encountered a similar situation and published on it.

One recent example of this was when a resident of mine asked how much distal fibula length is required to maintain a stable mortise. It was a very good question that I had some thoughts about but found no answer rooted in evidence. She excised a portion of the middle-distal third of a patient’s fibular diaphysis due to osteomyelitis, leaving a distal segment of the lateral malleolus still intact just above the syndesmotic incisura. The patient was currently stable in an external fixation frame while physicians managed the infection but definitive fixation would be required.

Exposing any opportunity to impart some of the lessons I learned through my career, I told the resident to check the literature to see if any studies had explored this topic. Due to my curiosity, I did the same and we did find some published work on the subject. While the search results were limited, there was one article that specifically looked at this question. In this article, the author sequentially cut the fibula from proximal to distal with various forces applied, and evaluated ankle mortise integrity.¹ Briefly, the study author concluded that the entire fibula is essential for stability due not just to distal but interosseous and proximal ligamentous attachments as well. The author recommended syndesmotic fixation, especially when 6 cm or less of fibula remained.

We found an answer. Perhaps it wasn’t the answer to this exact scenario but it is at least something for the resident to go by and reference in her attempting to formulate a surgical treatment plan as if she were the lead surgeon in the case. What I found interesting in reading the article is that the author had the same question too, citing previous reports that stated 4 to 10 cm of residual distal fibular length is required to maintain mortise stability.¹ As no clear-cut guide existed, the author set forth to create one with the study.

I use this simple recent experience to remind us all to spend the few minutes to search out, hopefully find and use the published work of others in treating our own patients when necessary. This exercise also reinforced to the resident the same values I had learned and I hope she passes on the lesson herself one day.
 
Dr. Hood is a fellowship-trained foot and ankle surgeon. Follow him on Twitter at @crhoodjrdpm.

References

1. Uchiyama E. Distal fibular length needed for ankle stability. Foot Ankle Int. 2006; 27(3):185-189.