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The Charcot foot is a non-infective, destructive type of arthritis that affects between 1-2.5% of diabetics. The incidence of this arthritic process has increased recently due to patients with diabetes mellitus living longer. There is an equal distribution among males and females. The average age of patients developing a Charcot foot is 40 years. 30% of patients develop a Charcot foot in both feet and/or ankles. This form of arthritis can develop suddenly and without pain. In a very short period of time the bones in the foot and/or ankle can spontaneously fracture and fragment.

The final result in the development of a diabetic Charcot foot is severe foot deformity. These deformities may result in difficulty wearing standard footgear. As the deformity progresses the foot takes on the appearance of a "rocker bottom". As the arch of the foot collapses areas of pressure develop on the bottom of the foot that are prone to developing open sores or ulcerations. Loss of ankle stability may occur to such an extent that the patient may not be able to walk without the use of a brace. The vast majority of these deformities can be treated with non-operative care. New advances in technology and the development of new forms of lower extremity braces and splints have provided a wider range of treatment alternatives that are very effective in managing the Charcot foot.

There are situations where non-operative therapy is ineffective in managing a Charcot foot. Surgical management of the Charcot foot may be required to resolve some of the problems associated with the condition. Indications for surgery include: 1) chronic deformity with significant instability that is not amenable to brace treatment, 2) chronic deformity with increased plantar pressures and risk of ulceration, 3) a significant deformity with secondary ulceration that has failed to heal despite non-operative therapy and 4) recurrent ulcers that have initially healed with non-operative care.

Surgical Intervention

Various types of surgery are available and may be required to manage a Charcot foot. The type of surgery that may be necessary depends on 1) the anatomic location of the Charcot deformity (i.e. the midfoot, the ankle. etc.) 2) the stage of the Charcot process (there are three specific stages of the Charcot process) 3) whether or not an ulcer is present. 4) whether or not the deformity is unstable and 5) overall health status of the patient.

The types of surgical procedures include the following:

1. Ostectomy - Ostectomy is a surgical procedure where a portion of bone is removed from the bottom of the foot. This procedure is usually performed for a wound on the bottom of the foot that is secondary to pressure from a bony prominence. An ulcer may or may not be present. The goal of the surgery is to remove the bone causing increased pressure and thereby allowing the ulcer to resolve or prevent the area from ulcerating. This procedure is usually performed as an outpatient or may require a one-night stay in the hospital. The type of anesthesia selected depends upon the health status of the patient and the preference of the surgeon. Recovery time includes 3-4 weeks in a weight-bearing brace or cast. A patient can usually return to extra depth footgear with a diabetic insert following complete healing.
    
2. Midfoot Realignment Arthrodesis - This procedure is usually indicated when there is significant instability of the middle portion of the foot. Usually the foot has collapsed and there is significant bony prominence along the bottom of the foot. Surgery is indicated when a simple ostectomy will not be sufficient. The goal of surgery is to provide stability and a relatively normal arch to the foot. This procedure usually requires a one or two night stay in the hospital. This is usually performed under general anesthesia and requires various types of internal fixation to be placed within the foot. This may include screws and plates. The convalescence associated with midfoot realignment arthrodesis is approximately three months in a non-weight-bearing cast. A patient may then progress to a weight-bearing brace for approximately 1-2 months. The patient will then return to an extra depth shoe with a diabetic insert at 5-6 months following surgery.
    
3. Hindfoot and Ankle Realignment Arthrodesis - Hindfoot and ankle realignment arthrodesis is usually indicated when there is significant instability resulting in a patient being unable to walk. These types of procedures are recommended when bracing has failed. Patients are basically non-ambulatory and many times amputation of the limb is the only other alternative. Realignment arthrodesis of the hindfoot and ankle is a limb salvage surgery. The ultimate goals of the procedure are to maintain a functional limb such that one can transfer within their home and possibly do some walking with the use of a brace or ambulatory assistive device. This procedure usually requires a 1-2 night stay in the hospital. The procedure is performed under general anesthesia and requires the use of various types of internal and external fixation devices. This may include the use of screws, plates, intramedullary nails and external fixators. The postoperative course includes approximately four months in a non-weight-bearing cast followed by a 2-3 month period of walking in a protective rocker bottom brace. A patient will then progress to a custom made brace that may be required throughout the course of their lifetime.

Possible Complications

Surgery in the diabetic patient always has significant risks. People with diabetes mellitus are more susceptible to infection due to their disease process. Therefore, these operations have a high complication rate. The arthrodesis procedures have a greater failure rate, increased risk of complications and longer convalescence relative to simple procedures such as ostectomy. It is recommended that a patient and their family have an extensive consultation with the surgeon to understand all potential risks including limb loss. A patient must be medically fit since this does require a general inhalation anesthesia and an extensive postoperative course. Preoperative work-up should include assessment of cardiac status and must be performed prior to surgical intervention.

Summary

Surgical management of the Charcot foot can be challenging and at times risky, but often the only alternative for limb-salvage. Many of the patients who undergo this type of surgery would otherwise go on to a below-the-knee amputation. Therefore, surgical management of the Charcot foot can be quite gratifying to the patient, the patient's family and the surgeon. The patient and the family should thoroughly understand the risks and benefits of the procedure and have an extensive preoperative consultation with the surgeon. It is recommended that surgery be performed by an experienced practitioner who has a thorough understanding of the disease process and experience with this type of surgery. It may be advantageous to have this type of surgery performed at a tertiary care facility to handle the potential complications that one might incur with these types of patients.

Chronic or repeated ankle sprains result from incompetence of the lateral collateral ankle ligaments. These ligaments function to support and control motion within the ankle joint. When these ligaments have been damaged from previous ankle sprains, they lose their ability to restrain the ankle joint within its normal range of motion. Typical symptoms include chronic ankle pain, difficulty walking on uneven surfaces or a feeling of the ankle "giving way". Initial treatment should consist of muscle strengthening and what is referred to as "proprioceptive rehabilitation". This can be accomplished through a physical therapist that is knowledgeable with rehabilitation of lateral collateral ligament instability. An ankle brace may also provide some external support to prevent recurrent injuries and also control swelling.

Surgical Stabilization of the Ankle

Surgery may be indicated for those cases of chronic ankle sprains failing to respond to conservative treatment. There are various surgical options available. These surgical procedures can be divided into two types. The first type involves the use of local tissue to reconstruct the lateral collateral ligament complex. The second type of surgery involves the use of a tendon graft or some other type of graft material to reconstruct the lateral collateral ligament complex.

The use of regional tissue is typically referred to as Brostrom-Gould procedure. This procedure is usually performed as an outpatient. This can be performed utilizing local anesthesia with IV sedation or a general inhalation anesthesia. The type of anesthesia depends on the surgeon and patient preference. Postoperative convalescence for this procedure includes approximately 4 to 6 weeks in a non-weight-bearing short leg cast. This is then followed by 2-3 weeks of protective weight-bearing in a camwalker or brace. The patient will then progress to standard footgear. This procedure has several advantages including the use of local tissue without sacrificing normal anatomic structures, very little restriction of normal range of motion and good cosmesis with the incision placement.

The second type of surgical procedure is referred to as a tenodesis procedure. This procedure involves a tendon or fascia latta graft that is routed through drill holes within the ankle and foot bones. This is usually performed as an outpatient and requires a general inhalation or spinal anesthesia. Postoperative convalescence includes 6 weeks of non-weight-bearing in a short leg cast. This is then followed by protected wirht-bearing in a camwalker or brace for 3 to 6 weeks. The patient will then return to standard footgear or rocker bottom brace depending on the extent of swelling. Some patients may require physical therapy but this will depend on the patient's specific situation. This procedure has the advantage of providing excellent stability. However, the stability can be at the expense of decreased joint motion and the sacrifice of normal anatomic structures to reconstruct the lateral collateral ligament complex.There are new allogenic grafts that have been developed. This allows the surgical procedure without utilizing normal anotomical structures. Ask your surgeon about this option.

Possible Complications

The major complications following lateral ankle stabilization procedure include decrease in subtalar joint motion. This joint is primarily responsible for the foot's ability to swivel side to side. The other complication not uncommonly seen includes sural neuritis. This is secondary to excessive traction of the sural nerve during the surgical procedure. Sural neuritis is usually transient and will resolve within one year.

Summary

Lateral ankle instability that fails to respond to non-operative care may require surgical management. The type of surgical procedure depends on the patient's activity level, occupation, weight and whether or not previous surgery has failed. The patient should discuss the various options with their surgeon to determine which procedure is best for their situation. The ultimate goal is to have a patient function at their pre-injury level and perform activities of a daily living without continued ankle sprains.

The definitive treatment for a ganglion mass is surgical excision. The surgical excision of a ganglion can be performed under a local anesthesia, intravenous anesthesia or a general anesthesia. It is generally performed in an outpatient surgery center. Under some circumstances the procedure may be performed in the physicians office. Following administration of anesthesia an incision is placed centered over the mass. Care must be taken to protect any skin nerves in the area. The mass is dissected from the surrounding soft tissues and removed. The ganglion mass has a tail that extends from the joint or tendon sheath that it arises from. During the dissection of the mass the tail is identified. Once the tail has been identified and cut the area of exit from the joint or tendon sheath is closed with suture or electrocautery. Following the placement of sutures to close the surgical site a gauze compressive dressing is applied. In some instances the surgeon will apply a splint or below the knee cast.

Recovery Period

The recovery period depends upon the location of the ganglion and the amount of dissection required removing it. In many instances patients are placed in a splint or below the knee cast following the surgical procedure. The surgeon may require the patient to use crutches for several days to up to three weeks. This level of protection may be necessary if the ganglion is near the ankle joint. Movement of the ankle can cause undue stress on the surgical site and delay healing or increase the risk of scaring in the area or recurrence of the mass. The patient is seen for their first follow up visit in 3to 7 days. During this period of time the patient must stay off of the foot, keeping it elevated above the heart. On the first visit the surgeon checks the surgical site and the bandage is reapplied. The sutures are removed in 10 to 14 days following the day of surgery. If a cast or crutches are not necessary the patient is allowed to return to loose fitting shoes within two weeks of the surgery. Limited activity is recommended for a minimum of three to four weeks. The time required to be off from work will depend upon the demands of the job and the shoes required for work. In the best of circumstances the patient should remain off from work for a minimum of one week. Quite often the patient will be required to be off from work two to three weeks or longer. If the patient can return to work while wearing a cast they may be able to return in a shorter period of time. It may take up to six weeks before a patient may return to exercise or sporting activities.

Possible Complications

Overall the surgical procedure is safe and without complications. However, as with any surgical procedure there are possible complications. The possible complications associated with the removal of a ganglion include infection, excessive swelling with delays in healing, damage to surrounding skin nerves or recurrence of the ganglion. It is important that during the period of time that the sutures are in place the foot be kept dry. Moisture will increase the risk of infection. Additionally, it is important the patient stays off the foot and keeps it elevated during the first week to ten days following the surgery. Excessive swelling at the surgical site will lead to delays in the healing process and promote excessive scaring. Excessive movement at the surgical site may weaken the deep sutures and increase the risk of recurrence of the ganglion. On occasion while removing the mass it may be necessary to sacrifice one of the small skin nerves in the area of the surgery. In fact, it is not uncommon for one of these nerves to be invested into the ganglion. When this is the case the nerve must be cut in order to remove the ganglion. When the nerve is cut, it will result in a small area of numbness on the top of the foot. Generally, this does not cause a long-term problem. If excessive swelling or scaring occurs at the surgical site one of the small skin nerves may become caught in the scar tissue and result in pain following the surgery.

A fibroma is a benign fibrous tissue tumor or growth, that can occur anywhere in the body, for example in the uterus they're called fibroids. On the plantar, or bottom surface of the foot, they are called plantar fibromas. Unlike plantar warts, which grow on the skin, these grow deep inside on a thick fibrous band called the plantar fascia. When non-surgical measures for treating plantar fibromas, such as orthotics have failed to provide adequate relief of symptoms, surgical removal is a reasonable option. Attempts may be made to surgically remove solitary nodules (a single lump or bump) with wide excision, however there is reported to be a high incidence of recurrence. Multiple plantar fibromas generally require more extensive excision of the entire fibrous band of plantar fascia (known as a Steindler plantar fascial stripping), inorder to insure complete removal and prevent recurrence.

Description of the Surgery

The surgical procedure involves a long, often curvilinear, incision on the bottom of the foot. The incision extends from the heel to the ball of the foot. The surgeon will dissect through the fatty tissue layer on the bottom of the foot to expose the thick fibrous plantar fascia. The plantar fascia, which includes the multiple benign fibromas, extends from the bottom of the heel, through the arch, all the way to the ball of the foot. The fascia removal requires careful separation from deeper soft tissues structures, and small nerves. Once the fascia has been removed, the bottom of the foot is stitched closed. Often a drain is placed into the surgery site to help prevent blood and other fluids from collecting here. The surgical wound is bandaged and the patient must remain non-weight bearing on the foot (with crutches) for a minimum of three weeks. Normal post-operative care including rest, ice, elevation, and maintaining a clean surgical site would be followed. The drain is usually removed 3 to 5 days after the surgery. The stitches are removed between 2 and 3 weeks after the surgery.

Post Operative Advice

Once the incision site is well healed, the patient may begin gentle calf muscle stretching exercises, and weight bearing with a soft soled shoe. Functional foot orthotics are generally recommended to help support the arch of the foot which has been weakened by removal of the plantar fascia. Although the patient will often resume walking about 1 month after the surgery, normal activities, including sports, will usually resume about three months after the surgery. There may be some residual tenderness in the area of the incision.

Possible Complications

Some possible complications of the surgery include infection, swelling, and numbness on the bottom of the foot. The possibility of uncomfortable scarring on the bottom of the foot may also develop if the patient walks on the foot, damaging the incision, before the incision is properly healed. As previously mentioned, recurrence of the plantar fibroma is also possible, although this becomes less likely with removal of the entire plantar fascia. Other less common risks associated with this surgery should be personally reviewed with your own surgeon, as individual factors may play a role.

The surgical correction of a tailor's bunion deformity is closely related to the surgical correction of bunion deformity about the big toe. A tailor's bunion is the enlargement of the outside of the foot just behind the little toe. Behind each toe is a long bone in the foot. These bones are called metatarsals and numbered one through five with the fifth metatarsal being behind the little toe. A tailors bunion exists when the fifth metatarsal or tissues surrounding the fifth metatarsal are prominent on the outside of the foot causing irritation in shoe gear or pain with walking.

Surgical Correction

Surgical correction of a tailor's bunion is directed at reducing the prominence surrounding the fifth metatarsal. This can be accomplished by a variety of methods depending on the cause of the prominence. Soft tissue enlargements such as a bursa, neuroma or ganglion can be the cause and easily removed in a simple surgery. More commonly this soft tissue enlargement is associated with an abnormality in the fifth metatarsal bone.

The fifth metatarsal bone can be prominent when the end of the bone, called the head, is enlarged near the base of the little toe. Surgical correction involves shaving the enlarged portion of the bone. The fifth metatarsal bone can also be prominent if it bows in the center. Similar to a bunion this is corrected by either shaving off a portion of the metatarsal or creating a surgical fracture and realigning the bone. In most instances the patient is allowed to walk in a surgical shoe following surgery. In extreme cases it may be necessary for the patient to use crutches for up to 6 weeks before allowing full weight bearing on the foot. As with nearly all foot surgeries, the patient is instructed to limit the amount of walking and standing the first few weeks following surgery to better ensure a good result. Typically the patient is instructed to keep the foot elevated during the day when possible. Return to work can be as short as one week and as long as six weeks depending on the amount of walking and standing required. Because surgery does not correct the cause of the deformity it is often recommened that following the surgery the patient wear a functional foot orthotic.These devices can be worn in normal shoes and correct the underlying cause of the deformity.

Anesthesia

Most often the surgery is performed in an outpatient surgery center or hospital. Some surgeons may perform this surgery in their office. Anesthesia for the surgery can be done under strict local anesthesia where that portion of the foot is anesthetized similar to a tooth during dental work. If performed in a hospital or surgery center the local anesthesia is combined with intra-venous sedation to make the patient drowsy. General anesthesia can also be used if preferred.

Possible Complications

Possible complications associated with surgical correction may include: infection, over or under-correction of the deformity, joint stiffness, healing of the bone in the wrong position, delays in healing and non healing of the bone and soft tissue. Following the surgeon's instructions carefully will decrease the risk of complications. Keeping the dressings or cast dry is also essential to prevent infection. Infections are most common in the first three days following surgery, but can occur later in the recovery period.

The soft corn is caused by a section of bone in the fifth toe pressing against the bone in the base of the fourth toe. When this occurs, the skin between the toes is pinched excessively and becomes damaged. Because of moisture between the toes, the "corn" is soft. The skin is often white in appearance. On occasion, a small ulceration can form and the area can become infected. Surgical treatment for this condition is similar to the surgical correction for hammertoes.

Description of the Surgery

An incision is placed on the top of the fifth toe. The ligaments about the joint in the toe are released to allow exposure of the head of the bone called the proximal phalanx. It is this section of the fifth toe bone that is pressing on the base of the fourth toe. The head of the proximal phalanx in the fifth toe is then cut and removed. If the toe is contracted or curled, then the tendon in the bottom of the fifth toe is released. On occasion, the surgeon will also make a small incision at the base of the fourth toe and smooth the bone in this area. In rare instances, the skin between the fourth and fifth toes may be so badly damaged that correcting the bone problem alone will not cure the soft corn. In this instance, the damaged skin between the toes must be removed. This procedure called a syndactylism necessitates removing the damaged skin between the toes and sewing the fourth and fifth toes together. This may sound like a drastic procedure, but it produces no loss of foot function. The procedure can be performed to leave a good cosmetic result. Surgery to correct soft corns can be performed in the doctor's office or in an outpatient surgery center. A local anesthetic is adequate for this surgery in most cases. Recovery from this procedure is much the same as for the correction of hammertoes. At the conclusion of surgery, a gauze dressing is applied.

What to Expect Following the Surgery

The patient should stay off their foot, keeping it elevated above their heart for a minimum of three days. Limited activity is recommended for two to three weeks. The stitches are removed in ten to fourteen days. During this period of time, the foot should be kept dry to reduce the risk of infection. A postoperative shoe is used to accommodate the bandage, and should be worn whenever the patient walks on their foot. Neglecting to wear the shoe while walking will cause the bandage to come loose, resulting in excessive movement at the surgical site, which will cause swelling, delays in healing, and possible infection. Once the stitches are removed, bathing the foot is permitted. Barefoot walking is discouraged for three weeks from the time of surgery. The patient should wear the postoperative shoe until they are able to wear normal shoes comfortably. This may take three to four weeks from the time of surgery. Some patients are able to return to normal shoes as early as two weeks.

Possible Complications

There are relatively few complications associated with this surgery. Excessive swelling which delays the healing process is the most common problem associated with the surgery. Postoperative infection rates are low but the risk increases if the surgical site is not kept dry. A reoccurrence of the condition is possible if enough bone is not removed or if the patient returns to wearing shoes that are too tight. If too much bone is removed then the toe may be floppy. It is normal for the toe to feel floppy for a few weeks following the surgery. The toe generally stiffens over time.

The big toe, called the Hallux, is made up of two small bones called phalanges. This condition presents as a cocking up of the big toe at the joint between these two small bones. In the early stages of the condition the deformity is flexible, in later stages the deformity becomes rigid. It is caused by a variety conditions. Neurological diseases that cause muscle weakness or muscle imbalance in the muscles of the lower leg can result in the formation of Hallux hammertoe. This is commonly seen in patients after they have suffered a stroke or Cerebral Vascular Accident. Damage to certain areas of the brain during a stroke will frequently result in weakness and/or paralysis on one side of the body. If the stroke is not severe the patient may recover a majority of the function of the muscles in the legs and feet. However, a residual result may be a cocking up of the big toe.

Other causes of the condition include damage or laceration to the tendon on the bottom of the big toe. Surgery to correct bunion deformities, in rare cases, may result in an imbalance of the structures about the big toe joint and cause the condition. An additional cause of hallux hammertoe is the absence of two small bones, called sesamoid bones, which are normally present beneath the big toe joint. There is an uncommon condition where a person may be born without these bones. More commonly however, the absence of one or both of the sesamoid bones is due to their surgical removal. In the course of correcting a bunion deformity one of the sesamoid bones may be removed. In another situation, a fracture of one or both of the sesamoid bones may result in the necessity to remove them to cure the pain associated with the injury.

A high arched foot may also result in the formation of, not only a hallux hammertoe, but also hammertoes of all of the toes.

A consequence of having a hallux hammertoe is irritation on the top of the toe from shoe pressure or the development of a painful callus on the end of the big toe. People who have had a stroke or who have diabetes with peripheral neuropathy may not have pain associated with the callus on the end of the toe. These areas may ulcerate and become infected.

Diagnosis

The diagnosis of hallux hammertoe is made by clinical exam. An x-ray is useful in determining the degree of the deformity and the condition of the joint. The presence or absence of the sesamoid bones is also made using an x-ray. If a neurological condition has not been identified and there is absence of trauma or previous surgery in the area, then evaluation by a neurologist may be appropriate.

Treatment

The need for treatment is based upon the level of symptoms the patient may be experiencing. Splitting the toe in an attempt to straighten it is of little value and is certain to fail. If treatment is needed, surgical correction of the deformity has the greatest level of success.

If the deformity is flexible a simple tendon release procedure can be performed. This consists of making a small incision on the side of the toe and cutting the tendon in the bottom of the toe. If an ulceration or open sore is present on the end of the toe cutting the tendon to relax the toe may be all that is necessary to allow the ulceration to heal. This procedure can easily be performed in the doctor's office under a local anesthesia. Following the surgery a dressing is applied to splint the toe in a straightened position. The sutures and the bandage are kept in place for 7 to 10 days. The patient should keep their activities to a minimum during this period of time and keep the area dry. A post-operative type of shoe is worn to accommodate the bandage. Generally a patient can return to normal shoes within two weeks and resume complete normal activities in three weeks.

If the deformity is rigid then fusion of the joint will be necessary to correct the deformity. Under certain circumstances the foot surgeon may elect to fuse the toe when the deformity is flexible. Fusion of the toe requires removing bone at the level of the joint in the toe. The articular surfaces of the joint are removed and the two small bones are abutted up against one another and held in place by a small screw. This fuses the two pieces of bone together resulting in permeate straightening of the toe. This procedure is generally performed in an out-patient surgery center or hospital. The surgery can be performed under a local anesthesia but the patient and surgeon may perfer to use a twilight anesthesia for the patient's comfort. Following the surgery a fluff dressing is applied. The sutures will remain in place for 7 to 10 days. During this period of time the patient should significantly reduce their activities and keep their foot elevated. It takes 6 weeks or longer for the bones to fuse. During this period of time the patient should wear a stiffed-soled post-operative type of shoe. Bending of the toe will delay or inhibit the fusion of the bones. Quite often it takes three months before the patient can return to full-unrestricted activity.

Possible Complications

Possible complications include infection, excessive swelling, and delays in healing or failure of the bones to fuse. Overall the procedure has a very high success rate. On occasion, over time, the screw may begin the cause irritation on the tip of the toe and have to be removed.

Hallux limitus is a reduction in the ability to dorsiflex or move the big toe upward. This inability to move the big toe normally affects the way a person walks and runs. Eventually pain will develop in the joint behind the great toe. This joint is called the first metatarsophalangeal joint. This pain is due to an irritation of the joint capsule and/or destructive changes to the joint surfaces. As destructive changes to the joint surfaces become more severe, the toe gradually loses the ability to move upwards. This condition affects people of all ages and gender equally. There are numerous causes of hallux limitus. These causes include: arthritis both traumatic (ie: caused by injury) and systemic (ie: rheumatoid arthritis), an elongated first metatarsal (the long bone that is directly behind the big toe), an elevated first metatarsal, a first metatarsal bone that has too much motion, and a bunion deformity. All of the above conditions can have profound effects on the motion of the big toe joint. Identifying the cause will determine the various treatment options available to the patient.

Diagnoses

Diagnosis of hallux limitus is made by both physical and x-ray examination. Physical examination will reveal pain and limitation in the motion of the big toe. Pain is particularly severe with dorsiflexion or upward movement of the big toe. There is commonly mild swelling and bony prominences associated with the first metatarsophalangeal joint behind the big toe.

X-ray examination of the foot will reveal the true severity of the patients condition. It will allow the physician to evaluate the joint for bone spurs, decrease in joint space, flattening of joint surfaces, and loose bodies in the joint. X-rays can also reveal the causes of hallux limitus such as an elongated or elevated first metatarsal.

Surgical Treatment

Surgical intervention is utilized when conservative therapy fails or the amount of deformity is too great. The goal of surgery is to obtain a more functional and less painful joint. Mild deformities are usually treated by removing bone spurs and prominences that develop around the first metatarsophalangeal joint. This helps to increase the amount of function and motion of the great toe. Occasionally, cuts in the bones called osteotomies, are made adjacent to the joint to correct for structural abnormalities. Osteotomies are held in place by screws, pins, or wires while the bone heals. By correcting for structural deformity the function of the great toe is increased as well as reducing the possibility for reoccurrence.

Moderate to severe deformities require a more aggressive surgical approach. Moderate deformities are almost always treated with not only removing spurs that inhibit motion but also with osteotomies to realign the joint. Osteotomies are utilized to prevent progression to a more severe deformity. However, it is often difficult to determine in advance if adequate bony correction can be accomplished in order to prevent progression of the condition. Following the surgery the patient should wear a functional foot orthotic. These devices will correct much of the underlying functional cause of the deformity. When errosive changes in the joint result in absence of a large portion of the joint surface it may be necessary to perform a joint destructive procedure. These severe deformities require either a joint replacement or fusion procedure. The appropriate procedure depends on the patient's activity level and age.

Recovery Time

Your surgeon will usually require you to be off work for a minimum of one week. This is necessary to help control pain and post-operative swelling. Your return to work is dependent on the type of surgery that was performed and the demands of the job. Most patients are able to walk in a post-operative shoe or cast boot. Some surgeries however require the use of crutches and avoidance of placing pressure on the operative foot. At the end of one week most patients can return to work if they have a sedentary job. For patients that have an active job requiring a large amount of standing and walking, a longer recovery is necessary. Return to normal shoes and activities are dependent on the type of procedure and should be discussed with your surgeon. Following recovery from the surgery most surgeons will prescribe a functional foot orthotic. These devices are useful in reducing the reoccurrence of the condition and continued deterioration of the joint.

Potential Complications

Complications are rare, however they can occur in all surgeries. The most likely complications include: infection, delay or failure of the bone to heal, continued joint stiffness and pain, and prolonged swelling. Many complications can be avoided by taking prescriptions as directed and strictly following your surgeon’s post-operative instructions.

Hindfoot and ankle deformity may result in decreased activity levels, inability to maintain meaningful employment, inability to walk or difficulty getting through activities of daily living. These severe deformities are often the result of previous trauma, congenital birth defects, acquired from degenerative changes throughout the course of one's adult life or may be secondary to systemic disease. Diseases such as diabetes mellitus, rheumatoid arthritis and various types of neuromuscular conditions may result in severe foot and ankle deformity. The deformities ultimately result in pain and difficulty walking.

Non-operative therapy including orthotics, injection therapy, anti-inflammatory medications, bracing, etc. are the first lines of treatment to provide comfort and maintain activities of daily living. However, certain deformities may fail to respond to non-operative care. Surgery can eliminate the deformity, decrease pain and increase activity level. Surgery is the ultimate solution to restore a relatively normal functioning foot that will permit a person to get through activities of daily living or maintaining meaningful employment.

Surgical Intervention

Surgery often consists of arthrodesis (fusion) procedures that permit a realignment of the existing deformity. The ultimate goal is to reconstruct the bony architecture of the foot so that the foot may be placed into appropriate footgear or bracing so that a patient can walk without pain. The exact surgery depends on the specific nature of the deformity. Realignment arthrodesis sometimes requires a 1-2 night stay in the hospital but is usually performed as an out-patient. These procedures are preformed under general inhalation anesthesia. Various types of internal and external fixation devices are often required either temporarily or permanently to maintain the foot or ankle in the appropriate alignment during the healing process.

Recovery Time

The postoperative convalescence includes three months in a non-weight-bearing short leg cast. This is followed by protected weight-bearing in a rocker bottom brace for an additional 2-3 months. The patient is then ultimately placed in custom molded or extra depth shoe with an appropriate orthotic or a permanent brace.

Possible Complications

Complications include infection, nonunion (failure of bones to heal together), fixation problems and malalignment (failure of realignment to be maintained). Additionally, stress fractures of the tibia (long leg bone) have been reported. These complications are managed by early recognition and prompt intervention. These complex procedures often require revisonal surgery to address complications.

Summary

Realignment arthrodesis of the hindfoot and ankle can be a very gratifying procedure. The ultimate goal is to have a patient who can walk without pain. Although surgery does provide realignment, some type of support in the form of an orthotic or brace is often required. The postoperative convalescence is quite extensive and the patient and their families should have a thorough consultation by the surgeon. It may take 6-12 months for a patient to get back to pre-surgical activity levels. A surgeon who is thoroughly experienced in hindfoot and ankle surgery should perform these procedures. The surgeon performing these types of procedures should have specialized continuing medical education, special postgraduate training and extensive experience with hindfoot and ankle surgery.