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JP Driver-Jowitt is an orthopaedic surgeon with wide experience across the entire field of orthopaedics. He spent much of his professional career in vertebral management, and now has a special interest in the foot and ankle.
He is registered in many countries, which include the United Kingdom, Ireland, Malta and Zimbabwe and has decades of experience acquired in five continents. These include the National Health Services of United Kingdom, Canada, New Zealand and others. He has been a Professor of orthopaedic surgery and has held posts as a teaching hospital consultant as well as with the armed forces, and a dedicated private practice. He has worked extensively in underdeveloped countries, with wide experience of battlefield and other trauma.
Comments or enquiries are welcomed: large volumes of requests are received which means that questions which have earlier been addressed will not necessarily receive a response.
Hello, what are your views on the Mini TightRope procedure for bunions which seems to be gaining popularity in the United States? Is it being performed anywhere in Europe, in countries such as Malta? Thank you for any information you can give me.
It is difficult to do your question justice in a short note, as this is a complex entity. I have therefore written a post instead. However even that does not come close to addressing all aspect of this entity.
I found out about your website, just a few days ago. I was on a desperate Internet search, using Google.com, to find out why the skin above a 8 screw metal implant, placed on the front of my broken right leg, below my knee, some 8 years ago, was not healing. I do not know the medical name, for that part of my leg, below the knee, and at the front part of my leg, with almost no muscle tissue between the bone fracture and the skin. There is a hole, about a centimeter in diameter, in my skin, right above the metal implant location. That skin opening never heals or closes, or causes me any pain. Health personnel who put bandages on my leg, can see the metal of the plate, right beneath the skin opening. Those health personnel can also touch the metal of the plate, when they clean the wound. I can feel those personnel touch that plate. Over and over, when doctors look at that skin opening, they say that plate has an "infection colony", on it, established when the plate was implanted, over 8 years ago. But, in 8 years, that "infection colony" has never changed in size, even with taking tremendous amounts of antibiotic pills. Those doctors say my right leg, might need to be amputated, at any time. My right leg at this time, looks very healthy, except for the skin opening. What is the cause of that leg skin opening, and should I get that 8 screw metal implant, below that skin opening, removed? I am definitely considering that surgery option. Thanks for any help you can give me.
The ulcer is almost certainly the result of low grade infection. The problem with a persisting breach like this is that it acts as a portal for other, perhaps more destructive infections, which will have an "easy passage" along and below the plate. Antibiotics are unlikely to have a curative effect on your current infection, and likewise on any potential agressive infection in the future. You should have the plate removed. It is improbable that your leg will require amputation - unless an agressive re-infection occurs and becomes uncontainable.
Hey Dr. JP. I broke my right radial head closest to my wrist into 3 pieces about 9 months ago and had ORIF surgery to treat it (small plate and 5 screws). I've been able to regain about 90% of the functionality in the injured wrist, but it's still sore at times, mostly with supination/pronation movements. I recently started lifting weights again and have experienced some soreness, which I presume to be normal. What I'm concerned about, however, is that I've experienced some swelling at the base of the plate about 2.5 inches from my wrist. The swollen area hurts when I push on it (not excruciating pain but probably a 5 on the "1-10" scale) and is not where the original injury occurred, leading me to believe the screws or plate are the problem. Being an engineer, what you said above about bone and metal having different material properties as well as the stress concentrations caused by the screws really make sense to me. It feels like my wrist is, for the most part, healed but the plate and screws are what is causing the discomfort/swelling from the lifting. I'm 23, very active, and would like to continue lifting if my wrist will allow it. Do you think I'm rushing back into things? Could removal of the plate in my case potentially be beneficial? Should I see another orthopedic surgeon (I've graduated and moved so the doctor that performed the surgery is 300 miles away) for an opinion? Thanks in advance for your response!
The plate lies on the surface of the radial metaphysis (not the head). Overlying the plate is a complex set of tendons, some running obliquely across others. It will be clear that there is little space between the plate and the skin to accommodate the volume of the tendons etc. and now there is the additional volume of the plate. It is not rare for the tendons to abrade against the plate (or one of the screw heads). If this happens the tendon can become painful and the surrounding "tendon sheath” becomes swollen. This can be verified by ultra-sound visualization. In real time it can show if the swelling is related to the tendon, and also if the tendon is elevated significantly by the plate. If this is the case there would be good reason to remove the plate. It is not unknown for the plate to abrade the tendons sufficiently to cause one or more to rupture. This is serious in that it is difficult (or impossible) to repair that ruptured tendon.
hello I'm 25 years old. About 14 years ago I undergone a bone surgery in my left femur due to a fall that cracked my leg. It was not bothering me at all until now. I can walk properly after the surgery, continued my studies, done exercises. I also gave birth to a healthy baby though this concerns me much during my pregnancy until today. Does this has to be remove? when is the right time? Will it take risk n my health in the future? One problem this that, I have no news or not meet the surgeon who operated me since after my surgery. Please help me. Thank you
Hello, I broke my fibula bone on the end near the ankle on Dec. 6, 2012. I had a plate and 7 screws put in. 5 days later, on a knee walker, tipped over and fell all my weight on that foot.Pulled all the hardware out it re-broke in the same place and also broke in 2 other places where screws were put in. Soon after that a 2nd surgery to replace with a bigger plate and 9 screws later. I also tore the ligament on the inside ankle the first time. It has been agonizing recovery from both injuries back-to-back. Finally, I've been able to use my boot. BUT< it is "rubbing" ,irritating so much on my ankle (outside). It feels like maybe the plate? and/orscrews are rubbing against the boot? I cannot seem to get it comfortable enough to walk enough without have to constantly fiddle with it adding air, taking air out, etc. I put a high knee sock on to see if that helps, but nothing does. The ankle is read and irritated-that's how for my scar runs down to and over making it more sensitive. Also, is it possible for a plate to "bend"? I had a "ring" around my ankle (swelling) from my (first) shorter sock I had on and there seems to be a divot in an area over the plate. That is not painful though. Can a plate bend? I'm wondering if the pressure from my boot against my ankle/plate could have bent it? Thank you...
It is unlikely that the plate could be bent by pressure from the boot. However, it is important that you are comfortable - discomfort implies damage. The boot must fit your foot, not your foot fit the boot. You might try crutch walking for a time, to allow any irritation to settle. Swelling should be managed by a below knee stocking. That alone migh make for great comfort.
Hello there!:) I just came out of surgery a week ago to fix my wrist due to a fracture caused by a bike accident. I ended up having a steel plate and 10 screws in my right radius (4 for support and 6 on the very tip to attach the pieces i had broken.) I am currently in the process of recovery, and I have my cast. No pain at all since the surgery, but I couldn't stand and look up people with similar problems as me to see how they ended up doing. My surgeon told me the screws and plate would stay in, I thought that was cool, until I read a lot of different stories about having screws and plates removed._. What are the cons and pros about having metalwork? Honestly, I find it amusing and can be a conversation starter with anyone. :P But I did noticed that two screw tips slightly, very slightly go through my bone. I don't know how that is gonna affect my whole movement from now on, but since the surgeon saw it and has my x-rays, I don't think it's gonna be that bad because he did not mention anything about it. You get me?? If it would be something bad, he would of told me. I can send you my x-rays if you want and I would appreciate your honest opinion. :)
Because I know so little about the type and particular anatomy of your injury I cannot give useful advice. A good talking relationship with your orthopaedist would be best - putting your questions and concerns to him first.
My husband has had a recent scan of his left hip and pelvis. This is after a “resurfacing” with a Du Puy implants, which have subsequently been recalled (what does that mean?) The scan showed that the mechanics of the hip (re-surfacing) joint are OK. The orthopaedic surgeon he saw recently has requested that he have a sonar scan at the end of January, to assess whether he has some inflammation in and around the joint. My husband has pain in his hip joint, especially when he is lying down and sometimes when he is out walking. He can, however, do his regular exercises, jump on his mini trampoline etc., without any pain. What should he do?
As has been said often only an exceedingly small number of recipients have had problems after their resurfacings, and only incrementally more than the frequency of complications in other replacements. From what I know you do not seem to have the unpleasant events or reaction which have initiated the recalls. Some pain / discomfort is frequent after any hip replacement. The reality is that these are never replacements, and the term is inappropriate. They are hip substitutes. None will exactly duplicate the original, natural hip joint. For that reason the "substitutes" should not be regarded as, or used in the way that the natural joint could have been used. Remember, too, that some aberration of function destroyed the original hip joint, and those (unknown largely) factors will also apply to the new substitute. Therefore these substitutes should be coddled, and much restraint is wise. Do not challenge the joint. For example I would not advise using a trampoline, which inflicts considerable impact and rotational leverages on the joint. Having said that it would also be wise to remain in contact with your surgeon for many years ahead, and report any difficulties which might arise.
I want to publicly thank Dr. Driver-Jowitt for the information he provides. It is remarkable that a doctor of his stature presents expert information without selling products. I am grateful for his efforts and all the time he must spend doing this. Thank you, Doctor.
I looked up compartment syndrome on the internet. Would this be an easy detection for the doctor yesterday? or is this something that continues to progress? Example the more numbness and tingling he is experiencing in his toes? I'm very concerned. I saw where they can do blood, urine tests and pressure tests. What should we do? On the internet I saw where the problem was more in the leg not the foot. Jared's swelling is on the ankle of the foot.
His fractured fibula was five inches above the ankle, with likely much impact on the soft tissues. At that level it is possible to have a compartment syndrome. The tingling / numbness of a compartment syndrome are most likely in the first day or two, but can persist.
I hope your not tired of hearing from me! We decided to change doctors to one with much more experience and specialty of the foot and ankle. We feel better about our decision. Waiting the extra week gave us time to research. We meet with him on Monday and hopefully surgery next week. However, the last couple of days JP, my son, has had night sweats and a low grade fever. Is this normal? The first hospital visit in the emergency room put a support cast on his leg no cleaning of the leg. Then when we visited the doctor on the following Monday there was a small scrape that they cleaned and put something on it and re-supported his leg with a partial cast. He doesn't move much and keeps his leg elevated with ice. Not sure why he's not feeling well? He did stop taking the pain medication on regular 4 hour intervals. His pain was not that great - it aches. I told him the medicine was as needed, but he thought the doctor wanted him to take if every 4 hours. Now he's taking the pain medication once a day to help sleep. Could stopping the medication quickly have effects? I'll be so glad when we can move on with this! It has been a very stressful week!
A temperature after trauma does not necessarily imply infection. Collections of blood ("bruises") can raise body temperature, as can thromboses in the veins.
Thank you for your quick response! I wonder about the ligaments that were torn in his ankle. The doctor said they do not repair those anymore that letting them scar has the same outcome as repair of the ligaments have had in the past. Is this accurate? You also, mentioned delayed management, as one of your philosophies, but I'm having trouble finding information on what kind of delays? Such as when is it best to have a fracture surgery after the injury? One more question: My son is taking pain medicine every four hours. Should I be concerned about the type of pain medication and the length of time he is taking this? He is on Norco 325 mg. It has been 5 days since his football injury. I wished you would do my son's surgery! I would feel much better! It is not easy trying to find someone that has the same type of experience and who really cares enough to dig deeper into what is best practice based on the "uniqueness" of the patient. Thanks again!
"Repairing" ligaments was always a fatuous ritual. Ligaments cannot be repaired, they can only heal. Does operating help the healing? There is no evidence of that. What happens, instead, is that the surgery interferes with the regional blood supply by cutting (i.e. damaging) even more tissues, and so adding even more swelling and inflammatory response. The ligaments are usually shredded, and any form of secure mechanical reconstruction is impossible. Those surgeons who did operate could have seen, and should have known, this to be the case. Instead they performed a perfunctory idealization of what the patient wanted to believe - that they were being repaired, in a fantasy parody of a mechanical repair to machinery. Then the incised skin needed to be opposed, with more puncture wounds and (usually) tight sutures. As the swelling followed, these sutures became even tighter, with more tissue damage, more risk of infection and more pain. Even the idea that the tissues were being “put back into the right place” is wrong. The volume underneath the skin cannot do more than accommodate the tissues in their anatomical sites. Providing skin, bone and joint are intact, these tissues cannot move more than millimeters, which is inconsequential, and a very acceptable trade-off against open surgery. The ligament sutures, tied tightly around living tissues, strangled the blood supply within the ligament, causing more dead tissue, introducing foreign material, more to become rancidly infected, more pain and, and less living material to partake in the healing mechanisms. What would worry me more than the dose of analgesics your son is receiving is why he still has such sever, extended pain. [ligament "replacement", "substitution", "re-routing", "augmentation", "creation", are a different domain, usually elective surgery, but which also demand critical appraisal]
I asked my son about his pain. He said it aches a lot after the medicine wears off and he can't sleep. He can't sleep with the medicine until he becomes exhausted, which usually isn't until morning when he finally falls asleep. He doesn't move much right now. He only uses his crutches to the bathroom. He is tall and lean: 6'5, 215 lbs. He is waiting on surgery, but most likely not until next Thursday because of the blisters on his ankle. The doctor said there would only be a 20% chance of having to open the ligament area up; which would only happen if the ligaments were under the bone and he couldn't line the fibula properly. But, he wasn't comfortable operating until that area healed more just incase of infection and the cut site not healing well knowing the soft tissue is severely damaged in the ligament ankle area. However, after reading your response, that doesn't sound like that could happen? His skin, bone and joint are intact. Another concern I have is knowing in the past my son gets keloid scarring. Will this effect his healing and mobility? Thanks again for answering my questions!
An injury to a limb is usually described in terms of which bone is broken, "I had a fractured tibia" and similar. This is because the most graphic X-ray display is of the bones. However, it is never a broken tibia: it is always a broken LIMB. At times the soft tissue damages (seldom shown on X-ray) are the most important injuries. This is because the functional, dynamic, machinery of the limb is the soft tissue. The bone is a relatively inert, passive accomplice of the soft tissues. At times the most important long term complications are in the damaged soft tissue, such as fibrous shortening of soft tissue following a "compartment syndrome". If pain persists it is imperative to constantly re-visit and reconsider the reasons for this. Keloids exist primarily in particular parts of the skin : It is unlikely that this tendency will interfere with the recovery of the limb injuries.
My son recently had a football injury, blew his deltoid ligaments and broke the fibula about 5 inches from the ankle. We talked with his orthopedic surgeon about removing the screws connecting the fibula with the tibia. He said it wasn't necessary, but he could take them out in 12 weeks. I said I had been reading and thought 6 weeks would be better to avoid them breaking off in his leg. He said that would be too soon that the ligaments would not have had time to heal. I also asked about removing the plates and screws. He said he would not do that that it opens him up for infection and the nerve could get damaged which were unnecessary risks. He said if the plate was closer to the ankle that might be different because the plate is closer to the surface of the skin. I respect your experience as I have been reading on your site. What would your response be to this doctor? My son's surgery was postponed a week because of blood blisters from the injury in the ligament area.
All surgical decisions depend on variables of context which include (at least) the uniqueness of the patient, type of injury, parallel illnesses, surgical know-how, available medical resources, and finance. Because of this I cannot reconstruct any idealized approach from a distance. All I can usefully contribute is what I regard, in my context, as "basic principles" (which comes to mean science based learning) into which I try and meld empirical experience. Surgery can never be an arena of “absolutes" and (heaven forbid) a rigid algorithm of tick boxes. Much of my philosophy, such as delayed management of fractures, and the removal of metal implants if good reason exists, you will already know from other comments. Regard a surgeon of rigid dictums with caution.