Rearfoot osteotomies
These are procedures which are designed to change the position of the heel into an
inverted or supinated position (the opposite of everted and pronated which are found in
flat feet.) An osteotomy is a surgical cut in the bone. Often, a wedge of bone is removed
to change the angle of the heel bone (calcaneus). Other procedures are
transpositional and involve sliding of one part of the bone along the other part of the
bone. (E.g. the Koutsogianis procedure). Other procedures involve adding a bone graft and
opening the wedge to change the angle of the calcaneus.( E.g. the Evans Procedure). These
osteotomies are generally held together with special screws, pins or bone staples and
require a period of casting and immobilization for several weeks.
Medial column stabilizations
These procedures involve fusing two or more of the bones along the medial side (inner
side) of the foot. Common fusion sites are the navicular and medial cuneiform. These
bones have often dropped in a flat foot and fusing them provides more stability. These
osteotomies are generally held together with special screws, pins or bone staples and
require a period of casting and immobilization for several weeks.
Tendon transfers
Sometimes the insertion sites of tendons are detached and then reattached to bones at
different locations. The result is a dynamic stabilization. Repositioning of the tendons
allows the muscles that pull them to exert their force in a more beneficial way to help
support the arch. The Young tenosuspension procedure reattaches the Tibialis Anterior
tendon to a better position beneath the medial arch where it can pull up on the arch to
support it.
Tendon lengthening
Often, the Achilles tendon is tight and is a major deforming force contributing to
flat foot conditions. A condition associated with a tight Achilles tendon is known as
equinus. An Achilles tendon lengthening procedure is often effective at reducing this
deforming force. The calf is made up of 2 gastrocnemius muscle bellies as well as the
soleus muscle. The Achilles tendon attaches to all three. An Achilles tendon lengthening
lengthens the whole group together. Sometimes, the gastrocnemius muscles are tight while
the soleus is not. In this case, a gastrocnemius recession can be performed to lengthen
only the gastrocnemius while leaving the soleus alone.
Arthroeresis
These are procedures in which a peg made of plastic or titanium is placed in front
of a bone to limit its motion. A common location for placement of such a device is the
Sinus Tarsi which is a cone-shaped space between the talus and calcaneus bones. The peg
helps to limit pronation. This is often just a temporary measure with the peg left in for
a few years and then removed.
Arthrodeses
An arthrodesis is a fusion of two bones. In addition to the medial column
stabilization fusions discussed above, rearfoot bones may also be fused. Rearfoot fusions
are generally reserved for the most severely deformed, arthritic and painful feet . A
Triple Arthrodesis is a fusion of the Talo-calcaneal, Talo-navicular and Calcaneo-cuboid
joints. This is one of the most complex foot surgeries performed since all three joints
must be aligned and fused properly to achieve a satisfactory result. In addition, because
motion in the rearfoot is eliminated, the ankle joint and other joints in the foot may be
forced into compensating to provide additional motion which could result in future
symptoms in those places. These fusions are generally held together with special screws,
pins or bone staples and require a period of casting and immobilization for two or three
months.
More on Flat Feet- Common Foot Problems
page
Tarsal Tunnel Syndrome
Tarsal tunnel
surgery is usually performed to reduce pressure on the Tibial nerve as it travels below
the medial malleolus (ankle bone on the inner side of the foot). A curved incision is
usually made and after releasing the ligament that sits over the nerve (flexor
retinaculum). Occasionally, there may be an abnormal mass (e.g. an enlarged vein, a cyst
or a benign tumor) sitting near the nerve. Any abnormal mass is removed to reduce pressure
on the nerve. Additionally, if the nerve is being entrapped by a muscle (e.g. Abductor
Hallucis) as it leaves the tarsal tunnel, the entrapped area is loosened. Most people are
able to bear weight immediately following the surgery. Patients commonly wear a surgical
shoe for about 3 weeks.
Bunions (Hallux Abducto Valgus)
see Bunion
page for information about bunion surgery
Hammertoes
The most common procedures used to correct hammertoe deformities and painful corns are the digital
"arthroplasty" and the digital "arthrodesis". An arthroplasty consists
of the removal of part of the bone within one of the toe joints (proximal or distal
interphalangeal joints). This allows the toe to straighten from its deformed, contracted
position and allows for removal of the often enlarged, prominent bone that can be felt
beneath a corn.. An arthrodesis procedure is similar but instead of removing the bone and
leaving a new 'joint' space between the two bones, the two bones are fused together. An
arthrodesis creates a rigid toe but there may be less chance of recurrence. In addition to
these 2 procedures, it may also be necessary to lengthen the tendon and loosen the joint
behind the toe (metatarsophalangeal joint) to completely remove the hammertoes deformity.
These procedures are often done under local anesthetic and walking is possible
immediately. A surgical sandal is usually worn for about 3 weeks or until swelling has
reduced enough to return to regular shoes. There is usually only mild pain after surgery,
primarily for the first 2 or 3 days. This is often well controlled with analgesics.
Sports
Medicine and Traumatic Injuries
Heel Pain
and Plantar Fasciitis
see Heel Pain page for information about heel surgery
Fractures
Some fractures (broken bones)
can be treated with a cast. However, if the fracture is out of place or subject moving,
surgery may be necessary to hold the bone together. Often, fractures of toes do not
require surgery and are simply splinted. However, fractures of metatarsal bones and ankle
bones often require surgery (open reduction with fixation) to stabilize and realign them
properly. This can be accomplished with special bone screws, plates and wires. Casting
after the surgery is usually required. Bone generally takes about 6 to 8 weeks to heal.
Tendonitis
Sometimes chronic tendonitis or
tenosynovitis requires surgery to remove inflammatory tissue or parts of the tendon that
have died. Often, there is a structural (bony) deformity that has contributed to the
abnormal tendon condition. If that is the case, the structural deformity should also
be addressed to help reduce a recurrent problem. Common tendons requiring surgery are the
Tibialis posterior and the peroneal tendons.
Sprains
The most common sprains in the
foot are ankle sprains. A sprain is another name for a torn ligament. A ligament connects
two bones at a joint and prevents them from moving in the wrong direction. After a
sprained ankle has healed, the joint is almost always looser than it was before the
injury. After repeated sprains, the ankle joint can become quite loose, predisposing
it to additional sprains. Surgery may be performed to stabilize the ankle. There are many
different procedures that can be performed to accomplish this goal. These procedures are
known collectively as lateral ankle stabilizations. In these
procedures, a piece of a nearby tendon may be used to "re-create" the
lateral ankle ligaments. In addition, there is often a bony deformity that has contributed
to the recurrent ankle sprains. Most commonly, this consists of a high arched or cavus
foot. A wedge of bone may need to be removed from the heel bone (Dwyer procedure) or the 1st metatarsal bone to
bring the foot into a straighter position.
Conditions
Related to Systemic Diseases
Diabetes
see Diabetes page
Diabetic Foot Surgery
Considerations
Deep Space infections
Circulation
Problems (Peripheral Vascular Disease, PVD)
Charcot
Joint ( Diabetic Neurotrophic Osteoarthropathy)
Arthritis
Osteoarthritis
The treatment for osteoarthritis varies depending on
the severity of the condition and on which joint or joints are affected. Surgical
treatment options often range from a simple exostectomy to joint arthroplasty or
joint fusion. An exostectomy is simply the removal of a bone spur. This may be performed
when the primary symptom is a painful prominence around a joint. An arthroplasty is the
removal of part of a joint (cartilage and bone, usually from one of the two bones that
make up the joint.) Sometimes this is performed along with insertion of an artificial
joint or a joint spacer. This is performed when the joint has become stiff and painful as
a result of the arthritis . The procedure allows improved motion and function and
alleviation of the pain. In other cases, the painful, arthritic joint is fused( an
arthrodesis). The fusion alleviates pain which was caused by the grinding of two bones
against each other at a joint in which the cartilage has been eroded. Ordinarily, the
cartilage serves as a lubricant and allows for smooth, gliding, pain free motion at a
joint. Since the normal cartilage cannot be regenerated, fusion of the joint may be a good
way to eliminate arthritic symptoms. Fusion may be chosen over arthroplasty when stability
of a joint is required. Some joints such as the subtalar joint in the rearfoot are almost
never conducive to arthroplasties and require a fusion when surgery is indicated. The
post-operative course varies from immediate weightbearing in a surgical shoe with an
exostectomy or arthroplasty to non-weightbearing and a cast for more than 8 weeks with
certain fusions.
Rheumatoid Arthritis
There are many joints of the foot that may be affected by rheumatoid arthritis that could require
surgery. The classic pattern of a rheumatoid foot deformity is a bunion and hallux abducto valgus
deformity along with hammertoes and prominent
metatarsal bones at the ball of the foot. Often, the hammertoes are dislocated from the
metatarsal bones and push down on them, making the ball of the foot quite painful
(metatarsalgia.) This is complicated by the fact that the fat pad cushion at the ball of
the foot may be severely atrophied (shrunken or absent.) This complex deformity of the
entire front half of the foot is often treated with what may be referred to as a Hoffman
procedure. In this procedure, all of the metatarsal heads are removed to eliminate the
bony prominences at the ball of the foot. In addition, the hammertoes
may be treated with either arthroplasties or arthrodeses.The big toe deformity (Hallux
Abductovalgus) may be treated with an arthroplasty
or arthrodesis
(fusion). Occasionally, implants or joint spacers may be inserted.
Gout
In the foot, gout most commonly
affects the 1st metatarsophalangeal joint (the joint behind the big toe). Gout results in
erosions around the joint. It also results in the deposition of uric acid crystals and
chalky deposits called tophi. The cartilage of the joint may become severely eroded.
Surgical treatment options are similar to those of osteoarthritis and often include
arthroplasty or arthrodesis. An arthroplasty is the removal of part of a joint (cartilage
and bone, usually from one of the two bones that make up the joint.) Sometimes this is
performed along with insertion of an artificial joint or a joint spacer. This is performed
when the joint has become stiff and painful as a result of the arthritis . The procedure
allows improved motion and function and alleviation of the pain. In other cases, the
painful, arthritic joint is fused( an arthrodesis). The fusion alleviates pain which was
caused by the grinding of two bones against each other at a joint in which the cartilage
has been eroded. Ordinarily, the cartilage serves as a lubricant and allows for smooth,
gliding, pain free motion at a joint. Since the normal cartilage cannot be regenerated,
fusion of the joint may be a good way to eliminate arthritic symptoms. Fusion may be
chosen over arthroplasty when stability of a joint is required.
Conditions of the Toenails
Fungal Toenails
(Onychomycosis)
See Fungal
Nails page
Ingrown Toenails (Onychocryptosis)
Once a nail has become ingrown, it usually must be removed to eliminate the pain and inflammation. Soaking
and antibiotics alone, without excision of the nail is usually ineffective.There are
basically three ways this could be done:
1. Slant back nail avulsion. This may be done if the nail is not
deeply embedded. This may be just a temporary measure and is often done without
anesthetic. In this procedure, a nail clipper is used to create a tapered edge of the
remaining toenail as the ingrowing portion is removed.
2. Partial nail avulsion. The toe is numbed with local anesthetic
and the ingrowing portion of nail is removed by splitting the nail longitudinally at the
affected side. The side of the nail takes several months to regrow and may become ingrown
again as it grows out, particularly if the nail is deformed.
3. Partial nail avulsion with matrixectomy. This procedure is
identical to the partial nail avulsion with the additional step of destroying the nail
matrix so that the corner of the nail does not regrow. A chemical such as phenol or sodium
hydroxide is often used to deaden the nail matrix. There is not usually any pain when
the anesthetic wears off (although there may be some mild tenderness if a very tight
shoe is worn) and most people are able to return to work and regular activities
immediately. There is often some mild drainage from the healing area which is normal and
not a sign of infection. A Band-Aid is usually all that is needed until the drainage stops
completely.
Conditions of the Skin
Calluses
and Plantar Keratoses
Calluses and
plantar keratoses are most commonly treated with periodic trimming and by using
special insoles or orthotics. Since these conditions are caused by excessive pressure
beneath a bony prominence, measures to rebalance the weight beneath the ball of the foot
may help to slow down the rate of recurrence. Occasionally, surgery is performed to
elevate one or more metatarsal bones to take pressure of a deep intractable keratosis.
These procedures are not as predictable and the success rates are not as high as most
other foot surgeries. This is due to the fact that it is very difficult to gauge exactly
how much to elevate a particular metatarsal bone. If the bone is elevated too much, weight
may be transferred to the adjacent metatarsal which develops a similar keratosis referred
to as a "transfer lesion". If the bone is not lifted high enough, the keratosis
may persist. Most people are able to walk immediately following the surgery. Patients
commonly wear a surgical shoe for about 3 to 6 weeks. Sometimes a cast may be utilized for
the the first few weeks.
Corns (Heloma
Durum)
Since corns are most
often the result of an underlying hammertoe deformity, eradication of the condition
usually requires removal of the hammertoe. There is no "root" that can be dug
out. Simply shaving off the corn results in a recurrence since the prominent bone beneath
it is still subject to irritation and pressure. The most common procedures used to correct
hammertoe deformities and painful corns are the digital "arthroplasty" and the
digital "arthrodesis". An arthroplasty consists of the removal of part of the
bone within one of the toe joints (proximal or distal interphalangeal joints). This allows
the toe to straighten from its deformed, contracted position and allows for removal of the
often enlarged, prominent bone that can be felt beneath a corn. An arthrodesis procedure
is similar but instead of removing the bone and leaving a new 'joint' space between the
two bones, the two bones are fused together. An arthrodesis creates a rigid toe but there
may be less chance of recurrence. In addition to these 2 procedures, it may also be
necessary to lengthen the tendon and loosen the joint behind the toe (metatarsophalangeal
joint) to completely remove the hammertoes deformity. These procedures are often done
under local anesthetic and walking is possible immediately. A surgical sandal is usually
worn for about 3 weeks or until swelling has reduced enough to return to regular shoes.
There is usually only mild pain after surgery, primarily for the first 2 or 3 days. This
is often well controlled with analgesics.
Soft Corns
(Heloma Molle)
Soft corns are like
hard corns except they are caused by pressure between two toes rather than by shoe
pressure on a single toe. To permanently remove a soft corn, one or both of the involved
toes must be treated. This may be accomplished with an arthroplasty procedure. An
arthroplasty consists of the removal of part of the bone within one of the toe joints
(proximal or distal interphalangeal joints). This allows for removal of the often
enlarged, prominent bone that can be felt beneath a corn. Sometimes a syndactylization
procedure is performed, particularly in the case of recurrent soft corns where prior
surgery has been unsuccessful. In this procedure, the skin at the bases of the two toes
are sown together to create a partial webbing of the toes where the soft corn previously
resided.These procedures are often done under local anesthetic and walking is possible
immediately. A surgical sandal is usually worn for about 3 weeks or until swelling has
reduced enough to return to regular shoes. There is usually only mild pain after surgery,
primarily for the first 2 or 3 days. This is often well controlled with analgesics.
Warts
Surgical excision of warts is often
limited to cases that have not responded well to non-surgical measures such as acid
treatments. Although the procedure itself is quite simple, there is a risk of developing a
painful scar. There may also be recurrence of the warts, even with surgery. Also, if there
are very large or multiple warts, excision may not be practical due to the extensive
defect in the skin that would need to fill in. This could take several weeks and could be
quite tender. There would also be a greater risk for infection and there may be the
need to keep the foot dry ( in other words, no showers) for several weeks. Excision of the
wart is usually done in the office under local anesthetic. A small gauze dressing may need
to be worn for several days or a few weeks, depending on the extent of the wart
involvement.
Ulcers
Surgery for ulcers consists of an assortment of measures such as debridement, incision
and drainage as well as promotion of off-loading by either simple removal of bone or
reconstructive foot surgery. See the ulcer
management section of the Diabetes page for more information.
