Surgical Treatments

A bunion, also known as hallux valgus, is bony prominence at the base of the big toe, which often results in pain, redness and rubbing in footwear. The 1^st metatarsal bone abnormally angles outward towards the other foot from its joint in the midfoot. A bunion can change the shape of your foot, make it difficult for you to find shoes that fit correctly and worsen the symptoms if left untreated.

Causes

Although it is not clearly understood why bunions occur, possible causes include:

• Family history and genetics
• Arthritis (inflammation of the joints) including rheumatoid arthritis, psoriatic arthritis and gout
• Neuromuscular conditions such as cerebral palsy (affects movement and co-ordination)
• Connective tissue disorders such as Marfan’s syndrome (affects the connective tissues)
• Tight fitting shoes that are too tight, narrow or high heeled.

Signs and symptoms

The main indication of a bunion is the pointing of the big toe towards the other toes of the foot. Other signs and symptoms include:

• Pain and swelling over the big toe that increases while wearing shoes
• Swelling with red, sore and calloused skin at the base of the big toe
• Inward turning of the big toe pushes the second toe out of place
• Bony bump at the base of the big toe
• Sore skin over the bony bump
• Difficulty walking and wearing shoes

Diagnosis

The diagnosis of a bunion by an orthopedic surgeon includes taking a medical history, and performing a physical examination to assess the extent of misalignment and damage to the soft tissues. Your surgeon will usually order weight bearing X-rays (i.e. taken while standing) to access the severity of the bunion and deformity of the toe joints. 

Treatment

Your GP may have already initially recommended conservative treatment measures with the goal of reducing or eliminating your foot pain.

Such measures can include:

• Medications for relieving pain and inflammation
• Wearing surgical shoes with a wide and high toe box, avoiding tight, pointed or high-heeled shoes.
• Use of orthotics to realign the bones of your foot and ease pain.
• Padding of bunions
• Ice applications several times a day

Conservative treatment measures can help relieve the discomfort of a bunion, however these measures will not prevent the bunion from becoming worse.

Surgery

Surgery is the only means of correcting a bunion. Surgery is also recommended when conservative measures fail to treat the symptoms of bunion. 

There are many surgical options to treat a bunion. The common goal is to realign the bones in the foot, correct the deformity, and relieve pain and discomfort. The surgery is performed as a day procedure, under the effect of a light general anesthetic and a regional nerve block. When you wake up, you will not be in pain and will be able to walk on your foot straight away.

Osteotomy is a common type of bunion surgery that involves the surgical cutting and realignment of the bones around your big toe. Your surgeon selects the appropriate surgical procedure based on the type of bunion and its severity.

There are 3 main types of osteotomies used by foot and ankle surgeons; namely akin osteotomy, chevron osteotomy, and scarf osteotomy.

Akin Osteotomy

Akin osteotomy corrects the sideways deviation of the big toe. In this procedure, your surgeon makes a small cut in the proximal phalanx (base of the big toe) and removes a wedge of bone to straighten the big toe. The bony fragments are then stabilized using a screw or staples. This procedure is often used in conjunction with the other procedures below.

Chevron osteotomy

A chevron osteotomy is usually recommended for mild to moderate bunion deformities. During this procedure, your surgeon will make an incision over your big toe. The joint capsule is opened and the bunion is removed using a surgical saw. A

V-shaped cut is made on your big toe and the metatarsal bones are shifted to bring your toe into its normal anatomical position. The bunion is then shaved and the soft tissues are realigned to correct the position. Akin osteotomy may be performed if necessary. The mobility of your big toe is examined, and the capsule and wound are re-approximated with sutures. Screws or pins are used to hold the bones in their new position until healing. 

This procedure can also be performed minimally invasively with keyhole style incisions.

Arthrodesis: Involves fusing the two bones that form the big toe joint. This procedure is used for severe bunions and when arthritis has set in. The movement of your big toe is reduced following this procedure but pain and deformity are very well controlled.

Scarf Osteotomy

Scarf osteotomy is usually recommended for moderate to severe bunion deformities.

Your surgeon will make an incision along your big toe and open the joint capsule to expose the bump. The bump on your big toe is then removed using a bone saw. Your first metatarsal bone is then cut in a Z shape and realigned to correct the deformity. Your surgeon will fix the cut bone with pins or screws. The joint capsule and surgical wounds are then re-approximated using dissolvable sutures keeping your toe in a straight position. This is a very powerful corrective procedure with excellent long term results.

Risks and complications

As with any surgery, bunion surgery involves certain risks and complications. They include:

• Infection
• Recurrence of the bunion
• Nerve damage
• Unresolved pain and swelling
• Joint stiffness or restricted movement
• Delayed healing or healing in the wrong position

In rare cases, a second surgery may be necessary to correct the problems.

Post-operative care

Patients should follow all instructions given by the surgeon following the surgery. These include:

• Keep your dressings dry and leave them in place until your next outpatient appointment.
• Minimize walking where possible.
• Elevate the foot to minimize swelling as much as possible for the first 6 weeks.
• You will have to wear specially designed post-operative shoes to protect the wounds and assist in walking

You may not be able to wear regular shoes for 6 weeks

Foot reconstruction 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 injury or illness. Ideally, any foot surgery for reconstruction is done to improve the appearance and function of the foot so that patients can maintain their quality of life.

The foot is formed by several bones, ligaments, joints and muscles, which function collectively to control the various movements like walking and running. This complicated structure of the foot permits them to resist heavy forces every day. As the feet are a common area for wounds and injuries, they are susceptible to various mistreatments in the form of ill-fitting shoes, sports injuries, work-related trauma, or the strain of walking. Various outside forces tend to harm the feet and cause pain and discomfort.

Indications for foot reconstruction:

A variety of reconstructive procedures are designed to treat many foot disorders and restore your foot back to its original health and function. Following are the indications:

• Common foot ailments like bunions or hammertoes
• Postural deformity such as severe flat feet
• Pain while walking on hard surfaces
• Difficulty wearing shoes
• Problems with standing or other movements of the foot
• Fractures sustained because of accident/trauma
• Athletic injuries like Achilles tendon tears, foot/ankle fractures, ligament injuries and several others
• Plantar fasciitis, a common cause of heel pain
• Heel and bone spurs
• Joint or bone deformities due to arthritis
• Infections
• Tumors and lesions
• Metabolic disease such as diabetes

Foot reconstruction surgery:

The primary objectives of foot reconstruction are reduction of pain and restoration of function and appearance. The surgery to be performed depends on several factors such as the age of the individual, type of foot disorder, and severity and duration of the symptoms.

Reconstructive foot surgery facilitates to correct birth defects, diseases and other foot ailments that can greatly benefit patients’ medical and aesthetic needs. It is often recommended when conservative treatments fail to resolve the symptoms. It is a good choice in permanently treating various foot disorders.

With the new advancements in surgical technology, the traditional method of treating foot disorders is replaced by a minimally invasive technique (arthroscopy) which can be performed on an outpatient basis.

This procedure is usually performed under general anesthesia. 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 injury.

At the end of the procedure, the surgical incisions are closed by sutures or protected with skin tapes and a soft dressing pad is applied. Depending upon the surgery, your surgeon will place a cast or a splint to prevent movement of the foot until it regains normal functioning capacity.

Some of the advantages of arthroscopic surgery include:

• Minimal trauma to the surrounding structures
• Shorter recovery time with less post-surgical complications
• Greater range of motion with less post-operative pain
• Decreased muscle atrophy

Post-operative care:

Following are the post-surgical guidelines to be followed after reconstruction:

• Make sure you get adequate rest. Avoid using the affected foot for a few weeks.
• Take medications to help alleviate pain and inflammation as prescribed by your doctor.
• Apply ice bags over a towel to the affected area for about 15-20 minutes to reduce post-operative pain and swelling.

• Compression dressings (bandage) are used to support the foot to reduce swelling. Take care not to wrap too tightly which could constrict the blood vessels.

• Keep the foot elevated at or above the level of your heart. This helps minimize swelling and discomfort.
• A wheelchair might be required for a few days in more severe cases.
• Start rehabilitation (physiotherapy) as recommended by your surgeon to improve range of motion.
• Crutches or a walker may be used to maintain balance or stability while walking. You should begin appropriate exercises to stretch and strengthen the muscles.
• Cover the splint while showering to keep it clean and dry.
• Return to sports once the foot has regained normal strength and function with your surgeon's approval.

The outcome of foot reconstruction surgery is greatly improved when you, your surgeon, and the physical therapist work together as a team.

Subtalar arthrodesis is the surgical fusion of bones that form the subtalar joint. The subtalar joint is a complex joint located below the ankle joint and is formed by the union of the heel (calcaneus) and the talus (ankle) bone. The subtalar joint allows side-side movement of the foot.

The goal of subtalar arthrodesis is to relieve pain in the affected joint. This is achieved by surgically eliminating the joint.

Subtalar arthrodesis is recommended for the treatment of severe end stage arthritis that has not responded to conservative treatment measures such as medications, injections, and bracing. The other indications include fracture, flatfoot deformity, and other degenerative bone diseases.

A complete medical history, including a history of any previous ankle injuries, and a physical examination is essential for an accurate diagnosis of the condition. Imaging tests such as X-rays, 99Tc bone scan, or MRI may be ordered.

Subtalar arthrodesis can be performed as an arthroscopic or open traditional surgery. The approach for an open technique is from anterior (front) aspect of the ankle. The access is gained to the joint surface and is followed by removal of the degenerated cartilage tissue. 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). The recovery time following fusion will depend on the technique employed and the health status of the individual patient.

The post-operative guidelines to be followed immediately after subtalar arthrodesis include:

• Keep your cast or dressing dry and do not remove for the specified time given by your surgeon
• Avoid bearing weight on the operated ankle and use crutches or wheelchairs for a few weeks
• Elevate the foot above heart level to minimize swelling.
• Eating a healthy diet and quitting smoking will help with healing.

Subtalar arthrodesis is usually a safe procedure and complications are uncommon. However, apart from general complications related to any surgery, complications after subtalar arthrodesis can include infection, nerve damage, unresolved pain, non-union and malunion of bones, and irritation from foreign material such as pins or screws.

Ankle arthroscopy is a minimally invasive surgical procedure in which an arthroscope, a small, soft, flexible tube with a light and video camera at the end, is inserted into the ankle joint to evaluate and treat a variety of conditions.

An arthroscope is a small, fiber-optic instrument consisting of a lens, light source, and video camera. The camera projects an image of the inside of the joint onto a large screen monitor allowing the surgeon to look for any damage, assess the type of injury, and repair the problem. 

Indications

Ankle Arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, has proved to be highly effective in managing various ankle disorders including ankle arthritis, unstable ankle, ankle fracture, osteochondral defects of the talus, infection, and undiagnosed ankle pain.

The benefits of arthroscopy compared to the alternative, open ankle surgery, include:

• Smaller incisions
• Minimal soft tissue trauma
• Less pain
• Faster healing time
• Lower infection rate
• Less scarring
• Earlier mobilization
• Shorter hospital stay

Procedure

Your surgeon will make 2 or 3 small incisions around the ankle joint. Through one of the incisions an arthroscope is inserted. Along with it, a sterile solution is pumped into the joint to expand the joint area and create room for the surgeon to work.

The larger image on the television monitor allows the surgeon to visualize the joint directly to determine the extent of damage so that it can be surgically treated. Surgical instruments will be inserted through the other tiny incisions to assess and treat the problem.

After the surgery, the instruments are removed, and the incisions are closed and covered with a bandage. 

Post-surgical care

After the procedure, you will be taken to a recovery room. The ankle joint will be immobilized with a splint or cast. The nature and duration of immobilization will depend on the type of repair performed and the preference of the surgeon. The surgical site should be kept clean and dry during the healing process. Patients may be prescribed pain medication for the management of pain. Elevation of the ankle and ice application helps to reduce pain and swelling.  Follow your post-operative instructions for the best outcome.

Risks and complications

Ankle arthroscopy is a safe procedure and the incidence of complications is low. However, as with any surgery, risks and complications can occur.  Some associated risks with ankle surgery can include infection, damage to blood vessels or nerves, bleeding, and compartment syndrome.

Minimally Invasive Foot Surgery (MIFS) uses the latest advanced technology to treat foot and ankle pain caused by a variety of conditions. Special surgical instruments, devices and advanced imaging techniques are used to visualize and perform the surgery through small incisions. The aim of MIFS is to minimize damage to the muscles and surrounding structures enabling faster recovery and less pain.

The benefits of MIFS over the traditional open foot surgery include:

• Small surgery scars
• Less risk of infection
• Minimal blood loss during the surgery
• Minimal post-operative pain
• Quicker recovery
• Shortens the hospital stay
• Quicker return to work and normal activities

Some of the foot and ankle conditions treated using MIFS technique include:

• Bunions
• Hammer toes
• Metatarsalgia
• Big toe arthritis
• Flat feet

• Ankle Arthritis
• Achilles Tendon Rupture
• Toe Deformities

Procedure

Minimally invasive foot surgery is performed through very small incisions. Through these small incisions, segmental tubular retractors and dilators are inserted to retract muscles away from the operative area and provide access to the affected area of the foot. This minimizes the damage to the muscles and soft tissues and lessens blood loss during the surgery. An endoscope, a thin telescope-like instrument with a video camera on the end is inserted through one of the tiny incisions to provide images of the operation field on the monitor in the operating room. Special tiny surgical instruments are passed through the working channel of the endoscope to perform the surgery. Sometimes surgical microscopes may also be used to magnify the visual field. Once the surgery is complete, the tissues fall back in place, as the various instruments are removed. The incision is then closed and covered with surgical tape.

Risk and Complications

As with any surgical procedure, there are risks involved with minimally invasive foot surgery. The risks and complications of MIFS may include infection, bleeding, nerve injury as well as complications due to general anesthesia.

Injuries during sports are common. They can result from accidents, inadequate training, improper use of protective devices, or insufficient stretching or warm-up exercises. Injuries to the foot and ankle are common while playing sports such as football, hockey, skating and in weekend athletes. Common sports injuries include sprains and strains, ankle fractures, and Achilles tendinitis.

The most common treatments recommended for injury to the foot and ankle include:

• Rest, ice, compression and elevation (RICE)
• NSAIDs and pain relieving medications
• Steroid injections at the location of pain to relieve pain
• Orthotics
• Braces, casts or splints to immobilize the injured part of the foot/ankle and promote healing
• Surgery to excise deformities, release or repair damaged tendons and ligaments, and align and fix fractures with pins, screws and plates
• Physical therapy to stretch and improve range of motion

Some of the measures that are followed to prevent sports related injuries include:

• Follow an exercise program to strengthen the muscles.
• Gradually increase your exercise level and avoid overdoing the exercise.
• Ensure that you wear properly-fitted protective gear including comfortable, well-fitting athletic shoes before playing any sports activity, which will help to reduce the chances of injury.
• Make sure that you follow warm up and cool down exercises before and after a sports activity. Exercises will help to stretch the muscles, increase flexibility, and reduce soft tissue injuries.
• Maintain a healthy diet which will nourish the muscles.
• Avoid playing when you are injured or tired. Take a break for some time after playing.
• Ensure that you are physically fit to play the sport.

To support the entire body’s weight on your two feet, the inner middle portion of each foot (midfoot) is raised off the ground to form an arch. A cavovarus foot deformity is characterized by a higher-than-normal arch of the inner midfoot. This results as the two ends of the foot - the heel and toes - abnormally draw towards the inside of the foot, causing the foot to rest on its outer side. This deformity produces pain in your heel, ball of the foot and outer edge of the foot, instability of gait, frequent ankle sprains, difficulty wearing shoes, callus formation and sometimes stress fractures in the bones on the outer side of the foot.

The cause for cavovarus foot deformity is usually unknown, but it may be associated with neuromuscular conditions such as Charcot-Marie-Tooth disease (progressive muscle weakness), stroke, head injury and poliomyelitis (viral infection that causes paralysis). It may be produced by an imbalance in the strength of the foot muscles, causing muscle contractures (stiffness) or due to bony deformities of the heel bone.

Cavovarus deformity may be corrected by conservative methods, such as bracing, to help with ankle instability and sprains, and shoe inserts, to raise the lateral border of the foot and accommodate the middle region of the foot. If cavovarus deformity is not adequately controlled by conservative means, your doctor will recommend surgical treatment. Weak muscles and contractures are corrected by a tendon transfer surgery, while bone deformities are corrected by cutting (osteotomy) or fusing bones (arthrodesis) to allow the foot to evenly contact the floor.

Foot reconstruction 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 injury or illness.

Flat foot or pes planus is a condition in which the foot does not have a normal arch when standing.

Flat Foot Reconstruction:

The primary objectives of flat foot reconstruction are reduction of pain and restoration of function and appearance. This can greatly benefit patients’ medical and aesthetic needs. The surgery to be performed depends on several factors such as the age of the individual, severity and duration of the symptoms.

It is often recommended when conservative treatments fail to resolve the symptoms.

The traditional method of treating flat foot is replaced by a minimally invasive technique (arthroscopy) which can be performed on an outpatient basis.

This procedure is usually performed under general anesthesia. 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 injury.

At the end of the procedure, the surgical incisions are closed by sutures or protected with skin tapes and a soft dressing pad is applied. Depending upon the surgery, your surgeon will place a cast or a splint to prevent movement of the foot until it regains normal functioning capacity.

Some of the advantages of arthroscopic surgery include:

• Minimal trauma to the surrounding structures
• Shorter recovery time with less post-surgical complications
• Greater range of motion with less post-operative pain
• Decreased muscle atrophy

After the surgery

Following are the post-surgical guidelines to be followed after reconstruction:

• Make sure you get adequate rest. Avoid using the affected foot for a few weeks.
• Take medications to help alleviate pain and inflammation as prescribed by your doctor.
• Apply ice bags over a towel to the affected area for about 15-20 minutes to reduce post-operative pain and swelling.

• Compression dressings (bandage) are used to support the foot to reduce swelling. Take care not to wrap too tightly which could constrict the blood vessels.

• Keep the foot elevated at or above the level of your heart. This helps minimize swelling and discomfort.
• A wheelchair might be required for a few days in more severe cases.
• Start rehabilitation (physical therapy) as recommended by your surgeon to improve range of motion.
• Crutches or a walker may be used to maintain balance or stability while walking. You should begin appropriate exercises to stretch and strengthen the muscles.
• Cover the splint while showering to keep it clean and dry.
• Return to sports once the foot has regained normal strength and function with your surgeon's approval.

The outcome of flat foot reconstruction surgery is greatly improved when you, your surgeon, and the physical therapist work together as a team.

Ankle arthrodesis is the surgical fusion of bones that form the ankle joint. The ankle joint is formed by the tibia, talus, and the fibula bones.

The goal of ankle arthrodesis is to relieve pain in the affected joint. This is achieved by surgically eliminating the joint.

Ankle arthrodesis is recommended for the treatment of severe end stage arthritis that has not responded to conservative treatment measures such as medications or injections. The other indications include ankle infections, neurological ankle instability, and tumors.

Ankle conditions should be evaluated for proper diagnosis and treatment. Accurate diagnosis comprises of a detailed medical history and physical examination. Imaging tests such as X-rays, Doppler Test, and MRI may be ordered.

Ankle arthrodesis can be performed as an arthroscopic or open traditional surgery. The approach for an open technique can be either from 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). The recovery time following fusion will depend on the technique employed and the health status of the individual patient.

The post-operative guidelines to be followed immediately after ankle arthrodesis include:

• Keep your cast or dressing dry and do not remove for the specified time given by your surgeon
• Avoid bearing weight on the operated ankle joint and use crutches or wheelchairs for a few weeks
• Elevate the foot above heart level to minimize swelling.
• Eating a healthy diet and quitting smoking will help with healing.

Ankle arthrodesis is usually a safe procedure and complications are uncommon. However, apart from general complications related to any surgery, complications after ankle arthrodesis can include infection, nerve damage, unresolved pain, non-union of bones, excessive swelling and stiffness, and irritation from foreign material such as pins or screws.

A sprain is stretching or tearing of a ligament.  Ligaments connect adjacent bones in a joint and provide stability to the joint.

An ankle sprain is a common injury and occurs when you fall or suddenly twist the ankle joint or when you land your foot in an awkward position after a jump. It most commonly occurs when you participate in sports or when you jump or run on a surface that is irregular.

Ankle sprains can cause pain, swelling, tenderness, bruising, and stiffness, numbness in the toes, and inability to walk or bear weight on the ankle accompanied by persistent discomfort.

Inadequate healing of a sprained ligament or incomplete rehabilitation of the affected ligament can result in instability of the ankle.

A complete medical history, including a history of any previous ankle injuries, and a physical examination is essential for an accurate diagnosis of the condition. An X-ray may be ordered to confirm the diagnosis.

Treatment

Acute injuries can be managed with conservative treatment measures such as RICE method (rest, ice, compression and elevation), medications, bracing, and physical therapy.

Surgical intervention to reconstruct the injured ligament may be considered in patients with a high degree of instability and in those who have failed to respond to non-surgical treatments.

Ankle ligament reconstruction may be performed arthroscopically under general anesthesia. Your surgeon will make small incisions in your ankle. A tiny camera and a few special instruments are inserted through the incisions to repair and strengthen the ligaments. Stretched or torn ligaments will be shortened and stitched as needed. Sometimes, a weakened ligament is reconstructed with a section of tendon derived from the foot and around the ankle.

The recovery time after ankle ligament reconstruction depends on the extent of injury and the procedure performed. For the first few weeks after surgery, you will be instructed to use crutches or a wheelchair and avoid bearing any weight on the reconstructed ankle joint.

Specific complications of ankle ligament reconstruction include infection, nerve damage, ankle joint stiffness, and recurrent instability.

Ankle tenotomy is a surgical procedure to lengthen the Achilles tendon enabling the ankle to flex upward and allowing the heel to be placed flat on the floor. It is indicated in patients that have an abnormally developed Achilles tendon or one that has become shortened and difficult to stretch. The surgery is done to restore the normal range of motion of the ankle.

It is commonly indicated in the treatment of the below conditions when conservative measures such as physical therapy and splinting have failed:

Clubfoot: A developmental disorder where one is born with one or more abnormally short ankle muscles which turn the feet inward. Ankle tenotomy is usually performed after the Ponseti method to treat clubfoot.

Contractures: Muscles become stiff after a period of immobilization.

Ankle tenotomy is performed under local anesthesia. A knife is inserted into the skin at the region of the tendon and cuts are made. As the cut edges draw apart, the tendon lengthens and heals in this position. For more severe cases, your child’s doctor may expose the tendon through an incision under general anesthesia and cut the tendon, which is then joined by sutures to form a lengthened tendon. Casts are then applied with the tendon in the correct anatomic (stretched) position. After two to three weeks, your child’s doctor will remove the cast and order physical therapy to improve ankle strength and keep the tendon stretched.

As with all surgical procedures, ankle tenotomy may be associated with certain complications such as nerve and blood vessel damage, infection, over-lengthening of the tendon or shortening of the tendon as your child grows which may require a second surgery.

Ankle instability surgery is performed to treat an unstable ankle and involves the repair or replacement of a torn or stretched ligament.

There are two types of ankle instability surgery:

• Anatomic repair: This surgery involves shortening and tightening the stretched ligament; and
• Non-anatomic repair: This surgery uses a tendon as a graft to replace the damaged ligament.

Disease Overview

Ankle instability is a chronic condition characterized by a recurrent slipping of the outer side of the ankle. Instability is generally noticed during movement of the ankle joint but can also occur during standing as well.

Symptoms include the following:

• The ankle feels unstable
• The ankle turns repeatedly while walking on uneven surfaces or during a sporting activity.
• Pain, tenderness and swelling is present in the ankle joint.

Ankle Instability usually results from repeated ankle sprains. Inadequate healing of a sprained ligament or incomplete rehabilitation of the affected ligament can result in instability. Recurrent injury to the ligaments further weakens them and aggravates the instability which predisposes to the development of additional ankle problems.

Indications

Surgery is recommended in patients with a high degree of ankle instability and in those who have failed to respond to non-surgical treatments.

• Anatomic repair is preferred in most cases of ankle instability.
• Non-anatomic repair is performed in obese patients requiring increased stability or when tightening of the stretched and scarred ligaments is not strong enough and needs to be reinforced with a tendon graft.

Surgical procedure

Ankle instability surgery involves the repair or reconstruction of the injured ankle ligaments.  Ankle-instability surgeries can be categorized into either anatomic repair or non-anatomic repair, also called reconstructive tenodesis.

Anatomic repair involves reconstruction of the stretched or torn ligaments. The surgery is performed under epidural anesthesia. Your surgeon makes an incision on the ankle to expose the damaged joint and ligaments. The joint capsule and ligaments are examined and the edges of the torn ligament are shortened and repaired with sutures. The ends may be overlapped and then sutured to strengthen the ligament. Your surgeon then covers the repaired ligament with the extensor retinaculum, a dense band of connective tissue, to reinforce the ligament further. Range of motion is evaluated; the incision is closed and a sterile bandage is applied.

Reconstructive tenodesis is a tendon transfer procedure that uses your own tendon or a cadaver tendon as a graft to replace the damaged tendon. The surgery is performed under epidural anesthesia. Your surgeon makes an incision on your ankle. Drill holes are created where the damaged ligament normally attaches to the lower end of the fibula (calf bone) on one side and the talus (anklebone) on the other end. Your surgeon then harvests the peroneus brevis muscle tendon, found on the outer edge of the small toe, and weaves it through the drill holes to form a ligament complex. Range of motion is evaluated; the incision is closed and a sterile bandage is applied.

Post-Operative Care

After surgery, your foot will be immobilized with a cast or splint. You will be provided crutches to avoid bearing weight on the operated ankle. Your doctor will remove the splint and provide a removable boot to be worn for 2 to 4 weeks. Physical therapy will be initiated to strengthen your joint and improve range of motion. Complete recovery may take 10 to 12 weeks.

Advantages & Disadvantages

The advantages of the anatomic repair include:

• Simple surgical procedure that makes use of your own anatomy to repair the damage
• Preserves complete joint mobility
• Rapid recovery
• Smaller incision
• Fewer complications

The disadvantage of the anatomic repair includes:

• Loosening of the ligaments, requiring additional repairs

The advantages of the nonanatomic repair include:

• Provides increased strength
• Can be used when host tissues are severely damaged
• Provides additional stability in obese patients

The disadvantages of the nonanatomic repair procedures include:

• Decreased rear foot motion
• Does not preserve the peroneus brevis, an important structure for the ankle’s dynamic stability

Risks and complications

As with all surgical procedures, ankle instability surgery may be associated with certain complications including:

• Injury to the superficial nerves
• Chronic pain
• Stiffness
• Need for second surgery (rare)

Tenex FAST procedure is a minimally invasive method to identify and remove pain generating scar tissue from tendons in the elbow, knee, ankle, foot and shoulder which can occur due to various musculoskeletal conditions such as tennis elbow, golfer’s elbow, jumper’s knee, plantar fasciitis, swimmer’s shoulder and Achilles tendonitis.

The procedure is performed under local anesthesia to numb the affected area.  The micro tip of the TX1 tissue removal system, the size of a tooth pick, is inserted into the affected area under ultrasound guidance. The tip releases ultrasonic energy which breaks and emulsifies the scar tissue which is then aspirated. It takes about 15 minutes and the tiny opening is covered with an adhesive bandage with no sutures required.

You will be able to return to normal activities in approximately a month after the procedure.  Tenex FAST procedure is the treatment of choice for tendon pain when compared to conventional treatment which involves rest, medication, and physical therapy.   Recovery from conventional treatment can take a few years and restrict your activities during this time. Tenex FAST is also safer when compared to open surgery through an incision.