Ever since she was young, Amy Bruce, DPM, loved to build and fix things. So it’s not surprising that she gravitated toward a career in surgery. The foot and ankle surgeon, who joined Trinity Health Of New England and the Saint Francis Hospital staff in September, says she was attracted to podiatry in part because of the wide array of patients and pathologies treated within the specialty. “Also,” she says, “the foot and ankle are the foundation of the body, so it is essential that they function well. Being able to ensure that was really interesting to me.”
A native of Providence, Rhode Island and the daughter of a university professor and a physician, Dr. Bruce – who also teaches medical students and residents – was exposed to both medicine and academia as a child. A dual major in anthropology and biology at Boston University bridged her interests in science and culture. She homed in on health and wellness, and earned her medical degree, at Temple University School of Podiatric Medicine.
Dr. Bruce completed a four-year residency in reconstructive foot and ankle surgery at the University of Pennsylvania-Penn Presbyterian Medical Center in Philadelphia. “The program focused on understanding that you treat the patient as a whole, and not just as a body part,” she says. Indeed, notes Dr. Bruce, systemic medical conditions can present with symptoms in the feet. Thus, as a resident, she rotated through many specialties, including plastic surgery, orthopedics, vascular surgery, internal medicine, rheumatology, and infectious disease.
Dr. Bruce says she was especially excited by trauma and reconstructive surgery – just as her childhood self was always enthusiastic about “putting things back together.” She completed an advanced specialty fellowship in trauma and reconstructive foot and ankle surgery at Kaiser Permanente and Emory Healthcare in Atlanta, Georgia.
A Return to New England
Dr. Bruce was drawn to Trinity Health because of the medical center’s large network of specialized providers and its multidisciplinary approach to patient care. “I’m thrilled to be back in New England,” she says. “And I love finally being able to spend time with my husband, who is also a foot and ankle surgeon practicing in the Hartford area, as we were long distance for years, with all the training we were doing.”
Dr. Bruce admits that it is challenging to start a new position in the middle of a pandemic. But she stresses that her offices and the hospital take every precaution to keep patients safe, including mandatory mask-wearing by all patients and staff, social distancing, COVID-19 screenings, temperature checks, and limiting the number of patients allowed in the office at any one time.
Telemedicine, she says, has also served as a useful bridge to care during the pandemic, enabling high risk patients to consult with Dr. Bruce virtually. “I can ask the patient to show me the foot and I direct them to touch in certain areas and see where they have discomfort,” she says. “I guide patients to do the same maneuvers I would be doing in the office, to gauge what’s going on and what needs to be done next.” For some patients, a virtual visit is sufficient; others are asked to come in person for further assessment and/or treatment.
As with other areas of medicine, “prevention is key” when it comes to patients with chronic diseases that affect the feet, Dr. Bruce says. She emphasizes that patients with diabetes, who are at risk for serious foot issues like diabetic neuropathy, Charcot neuroarthropathy, amputation, and infection, as well as those with vascular problems that interfere with wound healing, should should stay on top of routine surveillance, even during the pandemic. Patients neglecting the health of their feet could face limb-threatening or even life-threatening consequences in some cases, she says.
From Arthritis to Fractures
Dr. Bruce treats patients for all medical and surgical conditions affecting the foot and ankle, from arthritis to fractures. Her special interests include reconstructive foot and ankle surgery, sports/athletic injuries, and bunion and hammer toe correction.
“I see a lot of arthritis in the ankle or great toe joint,” she says. “I usually encourage trying conservative measures first – like topical medications, orthotics, braces, or even changing to a different type of shoe.” Dr. Bruce says that for patients with arthritis in the metatarsophalangeal – or big toe – joint, stiff or “rocker-bottom” shoes are helpful so that you have the support of the shoe and are not rolling off the joint as you walk.
The gold standard surgery for patients with high levels of pain that is not alleviated by more conservative measures, she says, is fusion of the two bones that connect at the MTP joint.
“The one thing patients have to be mindful of is that the joint won’t move anymore, but that will not limit their function and it will alleviate their pain,” she adds. “There are other options, such as joint implants, for patients depending on their age, activity level and goals.”
Fixing foot deformities
Dr. Bruce also treats many patients with bunions. A bunion is a bony bump at the base of the big toe that forms because of a change in the alignment of the bones in the foot. It occurs in 25-36 percent of adults, depending on age (they are more common among people over 65).
“Bunions tend to run in families, and we often see them in patients with flatter feet, as opposed to a high arch foot,” says Dr. Bruce. There is a dynamic relationship between the muscles, tendons, and ligaments that work around the great toe joint; an imbalance, such as that caused by pronation, or a rolling inward when walking – which exerts excess pressure on the inside of the foot – can lead to a bunion, she explains. “A bunion deformity can be exacerbated by wearing tight, ill-fitting shoes,” she adds.
Conservative measures to alleviate bunion pain include changing to wider-toed shoes, to ensure that there is no pressure on that area, wearing arch supports or orthotics in your shoes, and using toe spacers or padding and taping to realign the great toe joint, Dr. Bruce says. But years of abnormal functioning can lead to worsening deformity, arthritis in the joint, or even development of a hammertoe deformity, in which the second toe curves due to a bent middle-toe joint. This occurs because as the bunion grows, the first toe drifts toward the second toe, displacing it.
A small bunion can be corrected using minimally invasive surgery, Dr. Bruce says. “This results in smaller incisions, smaller scars, early range of motion, and early function.” Minimally invasive bunion surgery, with its new advancements in technology and techniques, is an exciting developing field. The long-term outcomes are still being reviewed. Those with more severe bunions and hammertoes might require traditional surgery. A misaligned toe joint that functions abnormally for years often ends up developing arthritis, Dr. Bruce says, so there are benefits to addressing a bunion earlier rather than later, especially if the bunion is causing pain.
Sprains and breaks
Though Dr. Bruce treats and manages patients with sprains and fractures throughout the year, ankle injuries are even more prevalent during this season, because of snow and ice. The most common athletic injuries, she says, are ankle sprains and stress fractures. “Most ankle sprains respond to conservative treatments like rest, ice, and elevation, followed by physical therapy focused on strengthening the muscles around the ankle, working on balance, and restoring ankle alignment,” she says. Sometimes, she says, what patients assume are sprains are actually fractures that need to be stabilized with a boot or cast.
Athletes develop stress fractures from repetitive stress on the bones: the continuous stress from running, for example, can cause small micro-fractures in the bone. “They typically need a period of rest, and proper orthotics to support any deformities so there isn’t too much stress on one bone,” Dr. Bruce says. In some cases, normal stress on unhealthy bone – say, bone that is weakened by osteopenia or osteoporosis – can lead to stress fractures as well. “You want to make sure these patients are optimized from a vitamin D and calcium standpoint,” she says.
The trend toward minimally invasive surgery has been an exciting advance in podiatry, Dr. Bruce says. Arthroscopic surgery – a procedure performed using a fiber-optic video camera attached to a narrow tube inserted through a small incision – has been around for a while, but is being applied more frequently to foot and ankle surgery. “Using arthroscopy, we can remove bone spurs, repair ligaments, repair cartilage and bone defects, and anatomically repair and reduce fractures through tiny incisions as small as 5 millimeters.”
Dr. Bruce stresses that treatment is not “one size fits all,” but rather is tailored to a patient’s age and activity level. “Patients really respond well and have better outcomes when a procedure is picked for them according to their lifestyle,” she says.
Dr. Bruce says she finds foot and ankle surgery to be extremely rewarding, because patients can see immediate results, whether that means a deformity is gone or a patient is finally pain free. “There is a lot of gratification in fixing something right then and there – and in seeing patients happy, and back on their feet.”
Lori Miller Kase writes frequently about medicine and health. She lives in Simsbury.
Photography by Stan Godlewski. Stan Godlewski is an editorial, corporate and healthcare photographer based in Connecticut and working primarily between Boston and New York City.