Anna Nicholas - Hand and Foot Surgery

Patient at graduation after hand and foot surgeryFew would argue that Anna Nicholas personifies determination. Nicholas has achieved the two goals she set for herself almost four years ago. The 26-year-old walked across the stage at Virginia Tech in December 2007 to receive her undergraduate degree in business management/ human resources. And she accepted her degree without having to use a wheelchair.

Nicholas, diagnosed with a cascading series of critical medical problems associated with a condition called hemolytic uremic syndrome (HUS) had developed severe deformities in both of her ankles and feet as a result of high calcium in her blood after her kidneys failed. She also had been diagnosed with Whipple’s disease, a rare bacterial infection that triggered contractions in both of her feet as well as her right hand and wrist.

“In just over a three-year period, she was diagnosed with multiple complications including pancreatitis, hypercalcemia, life-threatening cardiac arrhythmia, and renal failure that required dialysis three times a week,” says Jeffrey E. Johnson, MD, a board-certified orthopedic surgeon and Chief of Foot and Ankle Surgery with Washington University Orthopedics. “Her conditions led to severe muscle and skin contractures that caused her feet to curl to a point where she was unable to walk and had become wheelchair-bound. Her foot was so contracted that the top of her foot was in alignment with her shin bone (tibia), much like a ballet dancer en pointe.”

Hypercalcemia also may have led to the formation of extra bone around the joints of Nicholas’ legs and feet, which made the joints frozen. Overall, each foot had a deformity at the ankle, the arch of the foot, and the toes.

In her right hand, Nicholas was unable to pick up any items because of the contractures. “Her wrist was flexed downward and her fingers were clenched into a fist, making function impossible,” says Charles Goldfarb, MD, a board-certified orthopedic hand surgeon with Washington University Orthopedics.

“You would have had difficulty putting something as thin as a pencil into my fist,” recalls Anna. “My wrist went from having a normal range of motion to being so severely contracted that my fingers could touch the inside of my wrist several inches below where the wrist and hand connect. It was a mangled mess.”

Working together, Drs. Goldfarb and Johnson developed a comprehensive surgical and rehabilitation plan for Nicholas.

Dr. Johnson first tackled the complex foot problems by surgically cutting and then lengthening the Achilles tendon and several muscles in Nicholas’ right leg. He then attached an external fixation device called the Taylor Spatial Frame to her leg and ankle bones. Screws on the frame were turned daily in minute increments over four weeks to pull her ankle into a more normal position.

“My dad did the adjustments for me throughout the day,” says Nicholas. “He had to tighten the screws on the frame several times each day, but we slowly started to see good results.”

She returned to the operating room and the frame was modified to adjust the alignment of the arch of the foot. Dr. Johnson also repositioned the flexor tendons in the foot leading from the ankles to the toes, cleared out abnormal bone growth, and strategically inserted pins up the length of the toe bones to re-align Nicholas’ foot. Weeks later, he repeated the entire process with the other foot.

During the same time frame, Dr. Goldfarb corrected Nicholas’ wrist deformity by first performing a proximal row carpectomy, a procedure that removed one of two rows of bones found in the wrist, and then a wrist fusion. “The procedure shortens the wrist and draws the hand closer to the forearm, in effect allowing the tendons to become more flexible since they don’t have to stretch as far,” says Dr. Goldfarb. “We then lengthened the tendons a bit more by cutting them and stretching them further.”

The procedure allowed Nicholas’ wrist to become more flexible and straighten. And while Dr. Johnson performed the last foot and ankle procedure, Dr. Goldfarb used straightened the bones in Nicholas’ fingers and inserted pins in both her hand and wrist to maintain a better hand position.

In all, Nicholas required two highly specialized orthopedic surgeons and five trips to the operating room over a four-and-a half-month period to correct her deformities. Comprehensive physical therapy along with custom-designed braces enabled Nicholas to progress from using her wheelchair to using a walker and then a cane. She also is now able to hold items with her right thumb and index finger. Now back at Virginia Tech, she still uses her walker to maintain her strength and balance while walking on the large campus, but is actively using only her cane in her apartment. She also uses special orthotics at times to minimize any potential for recurring contractures.

“Some of the conditions we treat are very uncommon, but because we see these types of complex referrals frequently, we have become comfortable with offering treatment,” says Dr. Goldfarb. “Throughout our practice, we are able to collaborate on multiple issues and conditions to offer the best treatment options for our patients.”

“What Dr. Johnson and Dr. Goldfarb did to help me was amazing,” says Nicholas. “Once we went to their office, the team could see the problem and envision what they needed to do to fix my hand and get me out of my wheelchair and back on my feet. From being stuck in that chair for three years to walking at my graduation — it’s a great feeling.”

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