DOC » #492 Should a runner have surgery to remove bone fragments?

#492 Should a runner have surgery to remove bone fragments?

Should a runner have surgery to remove bone fragments? Well, that’s a great question and that’s what we’re talking about today on the Doc On The Run podcast.

 

Today’s question actually comes from a telemedicine visit where I was doing a second opinion for a runner and this is actually a pretty common question, and it happens with lots of different conditions. So the question was, should I have a surgery to remove bone fragments?

That’s what she asked me straight off and I said, “Well, let’s talk about what’s going on with you first.” Because anytime that we see something abnormal on an x-ray or an MRI, we often think that it’s pathologic. We think that something’s wrong and that we should go cut you open and fix it.

When I was the chief resident in my surgeon training, I would always, every few months, on this weekly meeting that we had to have with the surgery department where we did lectures and presented interesting cases and stuff like that, I would always take someone who has a really bad-looking MRI or x-ray, and instead of doing what’s normal, which is where you talk about the patient, the patient’s history, what they’re complaining about, what their medical history is, and then talk about imaging. Instead, I would just put up the imaging first.

So what would happen is I would put up the imaging, and then with all these surgical residents sitting there, I would say, “What is that?” and they would say something like, “calcification of the Achilles tendon” or “osteophytes with hallux rigidus” or “a lateral process fracture.” Then I would say, “Okay, what do you need to do?” And they would say, “Well, we should do surgery to remove those fragments, remove that ossicle, remove that calcification, whatever.”

Then I would say, “What if the patient has no pain?” And this is actually what we call an incidental finding, which is where we found it while we were looking for something else, but it’s not even causing a problem. Of course, that would always aggravate the residents, because they’re always looking for something that we can do to cut a patient open and fix it because that’s more fun than just doing something simple.

Bone fragments from Type 3 lateral process fracture – YES

So when you have fracture fragments, it really depends first on what’s going on. An example where you should definitely remove them is if you have a thing called a lateral process fracture. Alateral process fracture is where you have this little pointy piece right here on the talus called the lateral process. You break it, and there are three ways to do it. So you can get a little chip fracture. You can get a piece that’s actually broken where it’s a huge fracture fragment and then you can get a type three lateral process fracture where the entire thing is completely pulverized, and it looks like a whole bunch of gravel sitting in the joint.

Now, in that case, it is indisputable. You need to remove those fracture fragments because otherwise when you walk and move your foot in pronation and supination, and you move the talus on top of the heel bone, it’s going to grind all of that gravel and completely destroy the joint very quickly. If those pieces are really like tiny little bits of gravel, you can’t screw them back together, and it’s not going to heal and be normal, so you just have to take them out. But that’s where you have loose pieces of bone that are definitely in a joint that are going to destroy the joint if you don’t remove them. That one is a slam dunk, yes.

Bone fragments at big toe joint in hallux ridigus – ONLY IF IT HURTS

The second one is when you have problems, like if you have a little bone spur on the top of the big toe joint, and you have a condition called hallux rigidus. Well, you can get little bone spurs, and you can get little osteophytes. You can even have bone spurs that break off and become bone fragments on the top of the joint. But if they’re not causing pain, why would you want to cut your foot open and take them out? You have to remember that every time you do surgery, there’s risk that you can get problems and complications from the surgery itself that cause more problems than this little chip of bone sitting in there.

When you have hallux rigidus, that little chip of bone is actually adhered to the joint capsule. It’s actually sitting in the soft tissue, and it’s attached to the soft tissue. So if we actually make an incision and open that joint, the piece doesn’t fall out on the floor. We actually have to dissect it or cut it away from the soft tissue where it’s adhered to the soft tissue in that joint.

It’s not moving. It’s not going to get stuck in the joint. It’s not going to get crunched in the joint and destroy it in most cases. And in that case, if it’s not causing pain, you probably shouldn’t remove it. If it’s definitely causing pain and you have to wear particular shoes for work that are pushing on the bones spur and moving it around and causing pain, then maybe you should remove it.

Bone fragments in soft tissue near a non-painful joint – NO

In terms of the other case where you definitely should not do it is where you have what looks like bone chips in the soft tissue near a joint. Now this happens lots of times. If you have an injury right next to a bone, sometimes the soft tissue that gets injured can start to get calcification in the soft tissue that looks like bone chips.

For example, when I think I was 18 or 19 years old, but I basically had a motorcycle accident on the street, and I landed on my hip. And so I landed on my right side on my hip bone, and I had a huge bruise, and it also took a lot of the skin off of there. But it was because my hip bone landed and crushed the skin on the asphalt. Now today many, many, many years later, if you feel the skin and actually pinch and roll the skin, it feels like there’s gravel in the skin. And when you do an x-ray of that area, it looks like bone chips, and you would look at it and think that that must be little chips of bone that came from my hip bone and are stuck in the skin. They’re not. It’s calcification that formed in the skin because it was traumatized right next to the bone.

If you have calcification in the perineal tendon or in the interosseous calcaneal ligament or talocalcaneal ligament, when you had a subtalar joint sprain, the terms are not important. The point is that you can have ligaments between bones. You can have joint capsules between bones. You can have tendons that get injured and that develop calcification that looks like bone chips. But if those things are not hurting later, after that injury has healed, you definitely don’t want to go in and start removing those things just to see if you’ll be better. That, in general, is a terrible idea.

So you’ve got to think about the circumstances. Think about whether or not it’s interfering with your activity and if it’s not and you can keep running without having surgery, that is always a better option.