© 2019 by Orthopaedic Research Clinic Alaska

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The American Board of Orthopaedic Surgery

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Foot & Ankle

Foot & Ankle Procedures

Your feet are responsible for many roles in everyday activity: supporting your bodyweight, providing leverage during movement and adjusting to varying surfaces. Mobility between the foot and ankle is crucial, and the foot and ankle complex is a complicated hinge joint. Composed of the talus of the ankle, fibula and tibia of the shin, and a number of ligaments and tendons, the health of the foot and ankle is based on how well and cohesive its anatomy is.

Common foot and ankle injuries include ankle sprain, plantar fasciitis and achilles tendonitis. ORCA advocates nonoperative care whenever possible but understand that operation may be the only solution.

 
Lateral Ligament Reconstruction

The goal of lateral ankle ligament reconstruction is to restore healthy stability to the ankle. Patients with unstable ankles tend to report pain and the feeling that the ankle “gives way” to pressure. In general, an individual will undergo lateral ankle ligament reconstruction if their ankle injury does not improve after nonsurgical treatment. Surgery is only recommended for an individual after at least six months of nonsurgical treatment. A physician can diagnose an unstable ankle with a clinical examination and X-rays.


In most cases, lateral ligament reconstruction is an outpatient surgery performed when the patient is under regional or general anesthesia. In some cases, the surgeon will perform other procedures at the same time as the ALR. Lateral ligament reconstruction frequently involves arthroscopic surgery for the ankle joint. Usually, a surgeon needs to make at least one relatively large incision for the lateral ligament reconstruction.


Surgeons will use one of many different techniques depending on the case. For example, a surgeon may use stitches to repair the existing ligaments of the patient. Supports from other healthy tissue often makes this repair stronger and more reliable. This technique is called the modified Bröstrom procedure. Surgeons can also replace damaged ligaments with a tendon. This technique is far more similar to what a knee ligament reconstruction procedure involves. No matter the technique, patients can expect to wear a cast or splint for about two weeks after the surgery. Within a little more than a month, the patient should be able to place weight on the ankle.

Autologous Cell Implantation

Autologous cell implantation is a new procedure that was developed to treat articular cartilage defects in the ankle and foot. The FDA has approved the ACI procedure to treat cartilage defects in the ankle as well as the knee and other joints in the body. The autologous cell implantation is a surgical procedure that occurs in two separate stages.


The first stage of the ACI procedure takes about half an hour when performed arthroscopically. The surgeon will take a biopsy by removing a small piece of articular cartilage from the patient’s ankle. The surgeon will send the biopsy to a laboratory to be treated and analyzed. The lab will treat the biopsy with enzymes and use various techniques to isolate the chondrocytes, which are the cells that produce cartilage. The lab will increase the number of chondrocytes and send them back to the surgeon.


In the second stage, the surgeon will inject the harvested and expanded cells in patch sewn over the articular cartilage defect. The cells will produce a hyaline-like cartilage at the site of the defect. The patient may need to undergo a few months of training to improve strength and the range-of-motion for the ankle.

 
Ankle Arthroscopy

Ankle arthroscopy refers to a surgical procedure that is minimally invasive. Orthopedic surgeons will perform this surgical procedure to treat a damaged ankle joint. During an ankle arthroscopy, the surgeon will use an arthroscope to view images of the internal ankle on the video screen. The main goals of the ankle arthroscopy is to improve the function of the ankle and reduce the pain.


Patients with end-stage arthritis may undergo ankle arthroscopy as treatment. Ankle arthroscopy provides surgeons with a minimally invasive way to perform an ankle fusion procedure. The results for an ankle arthroscopy are equal to or better than the results of open techniques.


Surgeons may perform an ankle arthroscopy in conjunction with open techniques to repair a fracture. Ankle arthroscopy can help ensure proper alignment of the cartilage and bone. In some cases, a surgeon will rely on ankle arthroscopy to identify cartilage injuries within the ankle.


Ankle instability is another injury that may call for an ankle arthroscopy as treatment. The ligaments within the ankle can stretch out over time. This gives patients the feeling that their ankle is giving out. Open surgery in conjunction with arthroscopic techniques can help identify the problem and tighten the ligaments.


Sometimes, scar tissue will develop within an individual’s ankle. This condition is referred to as arthrofibrosis, which can cause a stiff and painful joint. Surgeons may perform an ankle arthroscopy in order to diagnose arthrofibrosis and remove the accumulated scar tissue.

 
 
Peroneal Tendon Repair/Reconstruction

Physicians will usually recommend surgery to treat a tear in the peroneal tendon. A surgeon is also capable of repairing the tissues responsible for holding the peroneal tendons in the area behind the lateral malleolus, or ankle bone. Individuals who continue to suffer from ankle pain after a month or so of non-invasive treatment will become a candidate for peroneal tendon repair/reconstruction surgery to treat the disorder. In most cases, repairing or reconstructing a peroneal tendon will involve open surgery. However, patients are usually able to be discharged from the hospital the same day of the surgery.
 

Peroneal tendon repair and/or reconstruction usually takes one or two hours to perform. The surgeon administers spinal anesthesia to the patient in order to numb him or her from the waist to the feet. The patient is then sedated so that he or she will sleep throughout the entirety of the procedure.


The surgeon will make an incision along the outside of the ankle. The incision will be along the peroneal tendons. The surgeon will then identify any longitudinal tears by opening up the sheath encompassing the peroneal tendons. If less than 50 percent of the peroneal tendon is torn, the surgeon will likely use stitches to repair the tear. On the other hand, the surgeon will likely need to perform tenodesis if more than 50 percent of the tendon is damaged or torn. The surgeon will remove the damaged portion of the tendon and sew the remaining portion to an adjacent tendon. The peroneus brevis is the tendon most likely to be torn. Therefore, most peroneal tendon repair/reconstruction procedures involve sewing the damaged peroneus brevis to the healthy peroneus longus.


If a tendon is dislocated, it is likely that the tissue that holds the peroneal tendons in place will be loose. The surgeon may need to sew this tissue to tighten the peroneal tendon tunnel. A tighter tendon tunnel will reduce the likelihood of tendon dislocations in the future. The surgeon will use stitches to close the skin and tendon sheath incisions. The ankle will be placed into a splint to ensure the ankle is immobile for the recovery process.

 
Subtalar Fusion

The subtalar joint is located between the calcaneus bone and the talus bone below the ankle joint. The purpose of the subtalar joint is to permit the foot and ankle to move side-to-side. This movement is necessary for walking, particularly on uneven surfaces.


The purpose of a fusion surgery is to make two bones that move through a joint against each other heal together. If a surgeon cannot replace a joint, fusion is considered an appropriate treatment option for a diseased joint. Once the bones heal together, it will act as a single unit, relieve pain, and restore function. Most fusions are very durable.


The purpose of a subtalar fusion to correct the instability or rigid deformity of the subtalar joint. A surgeon may also perform a subtalar fusion to eliminate painful arthritis. During the subtalar fusion procedure, the surgeon will remove the joint between the calcaneus bone and talus bone to fix the joint surface together. Subtalar fusion improves function and reduces pain and other symptoms.


People with subtalar issues usually experience pain below the ankle along the outer side of the foot. Some patients mistake pain of the subtalar for general ankle pain. A common sign of subtalar joint issues is limping. The limp often favors the afflicted foot and there may swelling below the ankle. Patients suffering from subtalar issues usually complain of stiffness in the foot and pain or difficulty when walking on uneven surfaces.


A surgeon will perform a subtalar fusion in order to treat painful arthritis, correct a deformity, or correct an instability. The main causes of arthritis are degeneration, trauma, infections, and rheumatologic conditions.

 
MTP Fusion

If the first metatarsophalangeal joint, which is the biggest joint of the big toe, is afflicted with arthritis, pain and swelling may occur. Patients with arthritis of the MTP joint may encounter pain when wearing certain footwear. These individuals may also feel pain and discomfort when performing mild activities like walking. When the cartilage within the MTP joint wears down, arthritis may develop, causing the two bones of the MVP to rub against each other.


The goal of the MTP fusion is to permanently fuse the two bones of the MTP joint permanently. This eliminates the joint so that the pain diminishes or disappears completely. The need for the MTP fusion depends on the severity of the arthritis. Patients with stiffness and pain in the big toe should undergo surgery. Other good candidates for the MTP fusion procedure are individuals who cannot wear certain types of shoes or participate in certain activities due to discomfort or pain. If a patient suffers from this condition in both feet, the MTP procedure will be performed on the most painful foot.


An orthopedic surgeon can evaluate the severity of an arthritic MTP joint. Before undergoing the MTP fusion procedure, patients should attempt conservative treatment for a few months. Non-invasive treatments include steroid injections, changes in activity, and changes in footwear. For example, patients can try carbon shoe inserts and wearing shoes with round bottoms to reduce joint motion.


During the ankle fusion procedure, the surgeon will make an incision on the top of the large toe. The surgeon will remove the remaining cartilage to make it easier for the two bones to heal together. The surgeon will then position the two bones and uses a metal plate to hold the two bones together. The surgeon will use a screw across the MTP joint for additional compression and stability to promote healing. The surgeon can insert two screws across the MTP joint without use of a plate. After inserting the hardware, the surgeon will use stitches to close the suture and use a splint to limit movement of the foot.

 
Ankle Fusion

The purpose of an ankle arthrodesis, also referred to as an ankle fusion, is to improve function and relieve pain for patients suffering from ankle arthritis. Ankle arthritis involves the degeneration of the cartilage at the end of the bones in the ankle joint. These bones are the talus, tibia, and fibula. Movement usually makes pain in an arthritic ankle worse. During an ankle fusion procedure, the surgeon takes the bones in the ankle and fuses them to form one bone. The ankle fusion eliminates movement and reduces or eliminates pain entirely.


The best candidates for ankle fusion are patients who suffer from serious ankle arthritis. Patients should try non-invasive treatments before opting for the ankle fusion procedure. Some conservative treatments include pain pills, walking aids, steroid injections, change of footwear, specialty braces, and changes of activity. However, none of these treatments are capable of reversing arthritis of the ankle. These treatments may provide temporary or permanent relief from pain for patients. These non-invasive treatments help some patients avoid surgery and the associated possible complications.

 

However, if these treatments fail to maintain function or reduce pain, a patient may be able to undergo ankle fusion.
Usually, the patient is sedated or put to sleep before the procedure so that he or she does not feel pain. The surgeon will make a number of incisions around and in the ankle to gain access to the joint. The physician will remove any cartilage that remains in the ankle joint to ensure contact between all the bony surfaces. A metal hardware will be used to hold the ankle in the most optional position in terms of function. The metal hardware will help the bones in the ankle joint heal properly.

 
Posterior Tibialis Reconstruction

One of the most commonly diagnosed issues afflicting the foot and ankle is posterior tibial tendon dysfunction. This condition occurs when the posterior tibial tendon is damaged, torn, or inflamed. A damaged posterior tibial tendon may not be able to provide sufficient support and stability for the foot’s arch. Flatfoot is a common sign of posterior tibial tendon dysfunction.


Most patients can use braces and orthotics to correct the issue without surgery. However, in some cases, braces and orthotics are not enough to provide relief. In such cases, posterior tibialis reconstruction may be an effective method for pain relief. Posterior tibialis reconstruction can be as simple as repairing a small tear or removing inflamed tissue. However, most of the time, the surgery is very complex and lengthy. After posterior tibialis reconstruction, patients may be somewhat more limited in the activities they can participate in.


Acute injuries like falls can damage the posterior tibial tendon and cause it to be inflamed. This tendon can also become damaged or inflamed due to overuse. Tears of the posterior tibialis from overuse are common especially common in individuals who participate in high-impact sports, such as soccer, basketball, and tennis. If the tendon becomes torn or inflamed, the foot arch will collapse progressively.


The dysfunction of the posterior tibial tendon is most common in people older than 40 and women. Those who suffer from obesity, hypertension, and diabetes are also more likely to suffer from posterior tibial tendon dysfunction. Some signs of this condition are pain along the tendon in the foot and ankle, swelling, difficulty standing or walking, and pain on the outside ankle. Usually, pain associated with the dysfunction of the posterior tibial tendon is worse with increased activity. Running and other high-impact and high-intensity activities are often difficult and painful.