Complex Foot and Ankle Surgeries

What are Complex Foot and Ankle Surgeries?

Complex foot and ankle surgeries are procedures employed to treat foot and ankle structures with deformities, injuries, structural issues, and damage from diseases like diabetes or arthritis.

Anatomy

The foot and ankle are complex joints involved in the movement, and providing stability and balance to the body. They are flexible structures that consist of 26 bones, 33 joints, and many muscles, tendons, and ligaments. 

The foot is usually differentiated into 3 parts: the forefoot, comprising of 5 toes, the midfoot, comprising of 5 bones that form the arch of the foot, and the hindfoot, forming the heel and ankle. The ankle is a large joint made up of 3 bones: the tibia, fibula, and talus. Ligaments and tendons run along the surface of the feet promoting easy and flexible movement.

Common Foot and Ankle Conditions 

Some of the conditions that may require foot and ankle surgeries include:

• Hallux valgus: Hallux valgus, commonly called a bunion, is a common toe deformity in which the great toe is shifted laterally and lies over the second toe. A bony bump forms at the base of the toe. A fluid-filled sac (bursa) may form by the continuous irritation and inflammation of the bunion when it rubs against your shoes. The factors that cause hallux valgus include structural foot abnormalities(which may or may not be congenital) and wearing narrow shoes that cause the toes to curl or fold. Hallux valgus is usually associated with pain, swelling, redness, thickening of the skin, calluses, or corns.
• Hammertoe: Hammertoe is a deformity in which there is downward bending of the middle joint (proximal interphalangeal joint or PIP joint) of the toe. Although it can affect any toe, hammertoe most commonly forms in the second toe. It may be present at birth or result from wearing shoes that are too tight, which forces the toe to bend forward. Over time, you may lose the flexibility of the toe and not be able to straighten it. With constant rubbing from ill-footing footwear, the top region of the toe may form a corn and the sole may form a callus. Wearing shoes and walking usually becomes painful. 
• Plantar fasciitis: Plantar fasciitis refers to the inflammation of the plantar fascia, a thick band of tissue that is present at the bottom of the foot. It runs from the heel bone to the toes and forms the arch of your foot. The plantar fascia functions as a shock absorber and supports the arch of your foot. Excessive pressure over the fascia may strain and tear the tissue, causing heel pain. Repeated overstretching or overuse causes irritation or inflammation of the fascia. The most common symptom is stabbing pain on the bottom of the foot, near the heel.
• Morton’s neuroma: Morton’s neuroma refers to a nerve injury that occurs between the toes, usually the third and fourth toes, causing pain and thickening of the nerve tissue. Compression or chronic irritation of this interdigital nerve is the main cause of Morton’s neuroma. Excess pressure exerted on the nerves due to the narrowing of the gap between the toe bones can cause thickening of the nerve tissue from scar tissue formation. The symptoms include burning pain in the ball of the foot, numbness in the affected toes, and inability to walk.
• Achilles tendon rupture: The Achilles tendon is a strong fibrous cord present behind the ankle that connects the calf muscles to the heel bone. It is used when you walk, run and jump. The Achilles tendon ruptures most often in athletes participating in sports that involve running, pivoting and jumping. When the Achilles tendon ruptures, you will experience severe pain in the back of your leg above your heel, swelling, stiffness, and difficulty standing on tiptoe and moving the leg when walking. A popping or snapping sound may be heard when the injury occurs.
• Foot and ankle arthritis: Arthritis of the foot and ankle is the inflammation of joints as a result of degeneration of the smooth cartilage that lines the ends of bones in a joint. This degeneration of the cartilages leads to painful rubbing of the bones, swelling, and stiffness in the joints, resulting in restricted movements. Arthritis of the foot and ankle can occur due to fractures, dislocation, inflammatory disease, or congenital deformity. The common types of foot and ankle arthritis include osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

Surgeries for Complex Foot and Ankle Conditions

Some of the surgeries employed to treat foot and ankle conditions include:

• Achilles tendon repair: This procedure is employed to treat Achilles tendon rupture. The surgery is usually performed as an outpatient procedure, under a nerve block and sedation. An incision is made at the back of your leg. Your surgeon will stitch the torn tendon back together with strong sutures. Your surgeon may reinforce the Achilles tendon with other tendons depending on the extent of the tear. If the tendon has avulsed or pulled off the heel bone, your surgeon will reattach the tendon to the heel bone.
• Ankle arthrodesis: This procedure is recommended for the treatment of severe end-stage arthritis. It can be performed as an arthroscopic or traditional open surgery. The approach for an open technique can be either from the anterior (front) aspect or lateral (side) aspect of the ankle. The joints are then fused together with the help of screws, wires, plates or rods. Bone grafting is recommended in cases of substantial bone loss. This is done using a graft taken from the patient (autograft) or donor tissue (allograft).
• Ankle joint replacement: This is a procedure employed to treat severe end-stage arthritis. Your surgeon makes an incision over the front of the ankle. The muscles are retracted, and tendons and ligaments moved away to expose the ankle joint. The damaged regions of the tibia, fibula and talus bone are then removed using special instruments, and the remaining healthy bones are reshaped to fit an artificial joint or prosthesis. A bone graft is inserted between the tibia and fibula to create a fusion of the two bones and prevent loosening of the prosthesis. The prosthetics are kept in position with special bone cement and instrumentation such as screws to support the artificial ankle. At the end of the surgery, tendons and other structures are positioned back to cover the new joint.
• Foot reconstruction: This is a surgery performed to correct the structures of the foot and restore the natural functionality of the foot that has been lost due to foot conditions, such as hammertoes and bunions. The surgery is performed either arthroscopically or by open surgery. Several tiny incisions are made by your surgeon to insert an arthroscope and miniature surgical instruments into the joint. The camera attached to the arthroscope displays the internal structures on a monitor and your surgeon uses these pictures to evaluate the joint and direct the small surgical instruments either to repair, or remove the damaged bone or tendon depending upon the extent of the injury.
• Bunionectomy: This is a procedure to treat bunions or hallux valgus. During the surgery, a surgical cut is made over the swollen area at the first joint of the big toe. The enlarged lump is removed. The bones of the big toe may need to be realigned. This could require more than one surgical cut. The bone itself may need to be cut. If the joint surfaces have been damaged, the bones may be held together with screws, wires, or metal plates. In severe cases, the entire joint may need to be removed and a joint replacement inserted. When completed, the surgical cuts are closed with sutures and steri-strips may be applied. A compression dressing will also be wrapped around the surgical wound.
• Hammertoe correction surgery: The type of procedure employed will depend upon the severity of the hammertoe. If the toe is somewhat flexible, your surgeon will be able to do a tendon transfer, which involves redirecting tendons from the bottom of the toe to the top where it is bent. The rerouted tendons can help straighten the toe. If your hammertoe has become stiff or fixed, your surgeon has two choices: fusion or joint resection. During joint resection, a surgical cut is made on the upper part of the toe to reach the tendons and ligaments underneath. The tendons and ligaments may be cut to help straighten the toe. The end of one bone is taken off so that the toe can be fully extended. Small metal pins or rods are mostly used to keep the toe straight during healing. The pins are usually removed a month or so after surgery. With fusion, tendons and ligaments are also cut to straighten the toe. During this procedure, however, the ends of the two bones that form the affected joint are cut to make the toe straight. Screws or pins are used while the ends of the bone fuse or heal together.
• Correction surgery for Morton’s neuroma: Surgical procedures to treat Morton’s neuroma may include:
  • Neurectomy, where part of the nerve tissue is removed
  • Cryogenic surgery, where nerves and the myelin sheath covering them are destroyed using extremely cold temperatures
  • Decompression surgery, where pressure on the nerve is relieved by cutting ligaments and other structures around the nerve