How is a Bunion Fixed?

One of the most common surgical procedures that a podiatrist performs is bunion correction.  Bunions are a result of hallux abducto valgus, a deformity of the foot that leads to increased pressure at the first metatarsophalangeal joint.  Bunions can become extremely painful, and can limit a person’s activity level and restrict them to only certain types of shoes.  Conservative therapy can help to alleviate some of the symptoms of bunions, but even the best methods of strapping and bracing do not correct the problem.  Surgical correction of hallux abducto valgus and the bunion associated with the deformity is paramount to treatment.

A small incision is made along the medial side of the metatarsaophalangeal joint, where the bunion is.  This incision site is then deepened until the joint is reached, being careful to avoid the nerves and veins that run in the area.  Once the joint is reached, the joint capsule can be cut to access the bone.

The surgical approach to bunions most commonly involves an osteotomy, or cutting of the bones, at the head of the first metatarsal.  This is the part of the metatarsal that is closest to the joint.  By cutting the metatarsal, the operating surgeon is able to reposition the head of the metatarsal in a more functional position, thus eliminating the bunion.  The bone is then fixed with one or two screws, which keep the two pieces of the bone in place while it can heal.  Any remaining bone in the area that may be prominent or painful is also removed.

Some other approaches to bunions may involve simply removing the painful bump, repositioning the metatarsal head to gain more motion at the joint, or the use of joint implants.  Some bone cuts may be positioned further away from the joint, which allows for a greater correction of a more significant bunion.  A number of different surgical osteotomies have been used over the years.

A lateral release may be performed as well, which is when the tendons on the lateral side of the metatarsophalangeal joint are cut.  The tendons that course through the foot and function at the first metatarsophalangeal joint often become contracted in the presence of hallux abducto valgus.  These structures are cut in order to reposition the toe in a more straightened position. 

Following all of the corrective procedures in bunion surgery, the final step is to close everything up, layer by layer.  The joint capsule is often closed using a technique to tighten it, as the once prominent joint has now been removed.  This leaves an excess of tissue that should be addressed.  The skin is then closed with suture, and stitches may be left in for two or three weeks.  Some sutures are absorbable, and there is no need to take them out. 

After the surgery, the patient is usually placed in a bandage and a surgical shoe, which they are allowed to walk in.  Patients receiving bunion surgery are instructed to only walk a little bit, and to keep the foot elevated most of the time.  This is done so that the body has time to heal the surgical wounds that have been created.  They are typically seen in the podiatrist’s office following the surgery, or in some sort of follow-up clinic. 

Some amount of pain and swelling is to be expected following surgery, as the surgery itself can be rather traumatic.  This swelling should resolve after a week or so, and the pain should go away also.  Pain is usually addressed with oral pain medications.  Elevation of the foot and ice placed behind the knee or calf for fifteen minutes at a time will also help with pain and reducing swelling. 

Typically the skin will heal after two or three weeks, at which time the sutures, if necessary, can be removed.  Once the sutures are removed and the skin is healed, the patient may either continue in the surgical shoe, or return to a stiff-soled shoe or gym shoe.  Much of the post-operative treatment plan is surgeon-dependent.  The bones will typically heal in six to eight weeks.  In the post-operative period, it is common for the surgeon to obtain x-rays to evaluate the status of the bones.  This helps to determine the post-operative course.

Bunions are sometimes corrected in conjunction with other deformities of the foot, such as hammertoes or tailor’s bunions.  If there are other areas of pain in the foot besides the bunion, be sure to point them out to your doctor.

Talk to your podiatrist if you have painful bunions or any other painful foot condition.  Conservative therapy will generally be attempted first, but surgical intervention should be discussed with the operating doctor.  They will be able to fill you in on details regarding pre-operative preparation, the surgery, and the post-operative treatment protocol.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
863-299-4551 
www.FLFootandAnkle.com

Cavus Foot

The cavus foot, or pes cavus, comes in a variety of forms.  Most notably, it is characterized by a high arch.  While many may think that having a high arch is a good thing, having too high of an arch can lead to difficulty fitting shoes, pain in the ball of the foot (metatarsalgia), painful hammering of the toes, and increased pressure on the lateral or outside of the foot.  This increased pressure may result in pain and even fracture of the bones.  Callus development in areas of increased pressure is typical.  Advanced cases of pes cavus can often lead to a feeling of instability, particularly in the ankles. 

An important aspect in the diagnosis of pes cavus is the etiology of the condition.  Many times this foot type is associated with neurological disease and weakness of the peroneal muscles and/or the anterior muscles of the leg.  These muscles insert into the foot, and control the motion and function of the foot.  Some neurological causes of pes cavus include Charcot-Marie-Tooth, cerebral palsy, muscular dystrophy, spina bifida, poliomyelitis, and tumors of the central nervous system. While these condtions can be rare, it is important to let your doctor know of any progression of the deformity, any numbness or tingling in the feet and/or hands, and any other associated symptoms such as tripping or instability. 

When the etiology of the cavus foot is unknown, it is referred to as idiopathic.  This diagnosis is one of exclusion, and should not be made until a through evaluation is performed.

The next step in evaluating the cavus foot should be to determine whether the deformity is flexible or rigid.  In other words, is the foot stuck in the high-arched position, or is it able to be manipulated into a more normal position?  This helps determine treatment methods that your doctor may suggest.  It also helps determine surgical procedures that may be required in the future to correct the deformity, should they become necessary.

The apex of the deformity should then be determined.  This is done by looking at x-rays of the feet.  The deformity may be coming from one of three main regions of the foot; the forefoot, midfoot, or hindfoot.  In forefoot deformities, it is often one or more of the metatarsals that are malpositioned, causing the rest of the foot to alter its motion to accommodate the deformity.  The apex may also be located in the midfoot, with the lesser tarsal bones such as the cuneiforms, navicular, and cuboid defining the deformity.  In rearfoot pes cavus, the position of the talus and the calcaneus determine the position of the rest of the foot.  Of course, combinations of several deformities can exist as well.

Along with a thorough history and physical, nerve conduction studies and/or muscle testing may be performed to help determine the cause of the deformity.  The treating physician should have a high index of suspicion for a neuromuscular etiology.  Family history of neurological disorder or of pes cavus running in the family should be mentioned.

Treatment of pes cavus is initiated with conservative measures in the vast majority of cases.  This may include things like physical therapy, custom molded or over-the-counter orthotics, shaving of painful calluses, and bracing for unstable ankles.  A large percentage of patients will find great benefit from conservative treatment alone.

In cases of failed conservative treatment, surgical intervention may become an option.  Pes cavus has been discussed in the medical literature for over one hundred years.  Much of our understanding of surgical correction of the deformity comes from cases of polio, where those affected by the disease were left with non-functional limbs.  Research and technology have improved the outcomes of surgical correction for pes cavus drastically over the years.

For those with flexible pes cavus, soft tissue procedures may provide adequate correction of the deformity.  This can include a plantar fasciotomy and/or various tendon transfer procedures.  For those with a non-progressive form of pes cavus, this may be the only correction needed. 

For those with rigid deformity, or those with more advanced pes cavus, bone cuts may be necessary to bring the foot to a normal position.  Depending on the apex of the deformity, this may include cuts in the metatarsals, in the calcaneus, and/or cuts in the lesser tarsal bones. 

In progressive deformity, fusion of joints is usually required to establish a more normal foot.  Arthrodesis, or joint fusion, can help prevent recurrence of severe deformity in those with a progressive cavus foot type.

Of course, a through evaluation is required before any decisions can be made regarding treatment of the cavus foot.  It is important to discuss with your doctor and a foot and ankle surgeon the various options for treatment.  Be prepared to answer questions regarding the progression of the deformity, any signs of neurological involvement such as numbness, burning, or tingling in the hands and/or feet, and if there is a family history of similar conditions.  These are all important aspects of the diagnosis and treatment of the cavus foot.  

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Rehabilitation of Foot and Ankle Injuries

One of the most important aspects of foot and ankle injuries is the rehabilitation of those injuries, and a return to normal activity.  This is often done through strengthening, stretching, and balance exercises.  When combined, these three things can be a powerful means of rehabilitation and the return to previous mobility. 

As an example of how these activities work, let’s look at a typical ankle fracture that was repaired surgically, and is now being treated in a rehabilitation center by physical therapy.  For a patient coming in after surgery, the first thing that must be done is a thorough evaluation of the patient’s current level of mobility, strength, and balance. 

The patient’s mobility is assessed by measuring active movement and passive movement.  Active movement is the patient’s ability to move their ankle on their own.  Passive movement will involve the physical therapist or the treating physician moving the ankle joint through its normal range of motion with the  patient relaxed.  The patient may experience some pain with these mtoins, and it is important to let the treating practitioner know of this pain.  If the range of motion is limited, this will be an area to focus during rehabilitation.

Stretching is the only way to increase the amount of movement at a joint such as the ankle.  For ankle fractures, calf stretches are used to increase this motion.  However, stretching can be painful at the beginning of rehabilitation.  During this early period, range of motion exercises may be used instead in order to maintain the current amount of movement available at the joint.  This may involve the patient actively moving their foot up and down slowly, in a pain free range.  This is opposed to stretching, which is a prolonged hold at the end of the range of motion. 

Strength will also be assessed in the rehabilitation of an ankle fracture.  This is done by the practitioner applying pressure at the foot and asking the patient to hold and maintain their foot in the correct position while the practitioner pushes in the opposite direction.  If the patient is unable to perform this activity, it is seen as a deficit in strength. 

To strengthen the muscle groups involved, various exercises may be used.  In physical therapy, this will often involve the use of resistance bands or manual pressure from the therapist. 

Balance is assessed by asking the patient to stand on one leg and measuring how long they can stand like that.  This may be very difficult for paitients with a history of an ankle fracture.  It also may be assessed with the eyes closed or by having the patient stand or walk on an uneven surface.  Balance is only assessed in the beginning in the clinic for safety reasons.

Balance training exercises include the use of a balance board or wobble board, which forces the patient to balance on an uneven surface.  The ankle plays a critical role in balance, so restoring this function is a priority.  Increasing one’s balance after an ankle injury can also help prevent a future ankle injury. 

Later in rehab, the physical therapist will progress the patient to their previous activity level, whether that is walking, running, climbing stairs, or returning to sports.  The physical therapist, therefore, plays an important role in the rehabilitation of foot and ankle injuries.   

Central Florida Foot & Ankle Center, LLC 
101 6th Street N.W. 
Winter Haven, FL 33881 
Phone: 863-299-4551 
www.FLFootandAnkle.com

Preventing Falls in the Elderly

The podiatrist’s role in preventing falls in the elderly has recently got some attention at the international level. At the national meeting of the American Podiatric Medical Association, podiatrist Doug Richie Jr. presented information regarding the podiatrist’s role in preventing falls in the elderly. Some of the research that he presented was from a study by a podiatry group in Australia, who have contributed significantly to the understanding of the topic.

The Australian study led by by Dr. Martin J. Spink of La Trobe University looked at the effect of a multi-faceted podiatry intervention for older adults compared to routine podiatry care. Multi-faceted intervention was defined as the use of customized foot orthoses, advice on footwear and a subsidy for footwear, home-based foot and ankle exercises, a pamphlet of information regarding fall prevention, and routine podiatry care for a period of 12 months.

The study found that the group receiving the multi-faceted podiatry intervention suffered from 36% fewer falls than the patients randomized to the routine podiatry care group. Muscle strength, range of motion, and balance were all significantly and statistically improved in the intervention group when compared to the routine care group.

This study, in combination of what we already know about falls in the elderly, could be a very important piece of information in the way that health care is delivered. Fall prevention is a major priority in hospitals, with everyone involved in patient care also involved in the prevention of falls. Falls in the elderly can lead to disabling and even life-threatening injuries such as fractures and head injuries. It has been reported that over half of people over the age of 65 years will experience a fall each year, and that a third of these falls will lead to significant injury. The amounts to a health care cost exceeding $20 billion in the management of these injuries, which is projected to double in the next 15 years due to the aging population in the United States. Clearly, the cost associated with these serious injuries is a potential source of savings when discussing Medicare/Medicaid funding.

The role of the podiatrist in preventing falls is likely to increase with more knowledge and awareness of the subject. This prevention hinges on early detection of potential risk factors, including existing foot and ankle pathology, diabetic neuropathy, impaired vision, and impaired mobility just to name a few. Conservative measures such as muscle strength testing, range of motion testing, gait analysis, and the use of customized orthotics and bracing can have a great impact on the health and well-being of the elderly patient, and prevent a potential fall.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Tightrope Fixation for Syndesmotic Injuries

A newly emerging trend in foot and ankle surgery is the use of the Tightrope end-button device made by Arthrex. The device is a special type of suture material called fiberwire, attached to two small buttons at either end. A small needle is used to pass the suture through two bones, and then the suture material can be tightened to bring the bones together.

One of the uses of the device is in injuries to the tibiofibular syndesmosis. The syndesmosis is composed of several ligaments, including the anterior tibiofibular ligament, posterior tibiofibular ligament, and the interosseous tibiofibular ligament. Together this structure helps keep the fibular and tibia together, adding stability to the ankle joint.

In ankle fractures, the tibiofibular syndesmosis is often disrupted. If left unaddressed, the diastasis, or separation, between the tibia and fibula can lead to dysfunction and arthritis. A syndesmosis injury can often occur as an isolated event, sometimes referred to as a high ankle sprain.

The standard method of addressing this injury is to place a screw across the syndesmosis, sometimes referred to as a trans-syndesmotic screw. These are often placed through the bones until the ligaments can heal, and is then removed. However, complications such as broken screws and failed healing of the syndesmosis lead to research into alternatives.

The Tightrope design allows for some motion to occur at the tibiofibular syndesmosis. This allows for a more natural motion at the joint. The manufacturers state that the device never needs to be removed, so long as there aren’t any complications with the fixation, due to its allowance of micro-motion. This is in contrast to screw fixation, which necessitates another surgery.

Studies have shown good short-term results using the Tightrope for repair of syndesmotic injuries. It has been shown to be as effective as screw fixation in allowing for healing. While there are no long-term results available yet, nor are there any published studies comparing Tightrope fixation to screw fixation, the results thus far have been promising. Several studies are in development to more rigorously study this new form of fixation.

At least one study, however, has shown some complications from the use of the Tightrope device. Wilmott et al (Injury 2009) showed several soft tissue complications resulting from the use of the Tightrope. There study was small, however, and the patients involved in the study did show healing of the syndesmosis with use of the fixation device.

While it may be a new trend emerging in foot and ankle surgery, there is certainly more evidence necessary before Tightrope fixation for syndesmosis injuries can become the standard of practice. Larger, long-term studies will be necessary, comparing the device to fixation with screws.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Swanson Implants for First MTP Joint Arthritis

The first metatarsophalangeal joint (MPJ, MTP Joint, or MTPJ) is highly susceptible to arthritis. This is the joint in your foot that attaches the big toe to the first metatarsal. It is a very important joint, and allows for propulsion during gait. There is a great amount of force that is put through the joint when walking, which is quickly absorbed through a number of joints in the foot. Because of this great amount of force place through the joint, it is also highly susceptible to arthritis.

Arthritis of the great toe joint, much like arthritis of any other joint, can be very difficult to treat. It is a painful condition that doesn’t always respond well to medications. There is no real cure for arthritis, and some people are affected by it at a much earlier age than others. Arthritis of the first MPJ is complicated by the fact that it is a weight-bearing joint.

Conservative treatment of first MTPJ arthritis is generally focused on preventing the advancement of arthritis by accommodating any foot deformities that may be present with orthotic devices. A foot deformity that increases pressure or force at the first MTPJ will speed up the progression of arthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used, such as naproxen or ibuprofen. Icing, protective measures, heat, and a number of other non-surgical therapies are often used with varied results.

Surgical options for the treatment of first MTPJ arthritis include a number of procedures, including fusion of the joint, osteotomies (bone cuts), resection of some of the bone, and joint implants, to name a few. Joint implants come in a variety of designs.

One of the types of implants commonly used is the Swanson-type implant. This is an implant that is made of a silicone, and has two stems. One stem is placed into the metatarsal, and the other into the proximal phalanx. Some of the bone must be removed for each stem to fit into its respective end, and a small hole is reamed out to place the stem. Once the implant is placed, it creates a false joint. The first MTPJ, therefore, would have a more functional and painless range of motion. This is the goal of the surgery.

The implants have a lifespan of around 30 years, and are generally well tolerated. Occasionally the implants can breakdown at a faster rate, and cause a condition known as detritic synovitis. This is a condition caused by small particles of the silicone being sheared off within the joint, which leads to inflammation.

These double stem silicone implants are not for everyone, and are generally not used in younger patients, due to the lifespan of the implant. There are a number of different surgical methods for treating first MTPJ arthritis; this type of implant is only one.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Classification of Ankle Fractures

Ankle fractures are one of the most common injuries to the lower extremity. The injuries are almost always due to a twisting injury, where the foot is planted flat on the ground and the leg is forced in a twisting or sliding pattern. Ankle fractures are a frequent occurrence in high impact sports, as well as from everyday-type injuries. The anatomy of the ankle helps to define this injury, and a number of structures are at risk.

The ankle joint is composed of the tibia and fibula, which are the bones of the lower leg, as well as the talus, which is a bone of the foot. The tibia and fibula join at the syndesmosis, a structure that is key in holding the ankle in place. The tibia and fibula form a groove for the talus to move through, ensuring stability through range of motion at the ankle. A number of ligaments hold these structures together, mainly the lateral ankle ligaments and the medial ankle ligaments. The medial ankle ligaments are commonly referred to as the deltoid ligament.

A series of tendons run across the joint from the leg into the foot. These tendons belong to muscles that control the movement of the foot, including plantarflexion (pointing the foot in a downward position), dorsiflexion (bringing the foot upwards), inversion, and eversion. There are also a number of arteries, veins, and nerves that run across the ankle joint that provide blood and sensation to the foot.

Injuries to the ankle, as common as they are, can be described by several different classification systems. The two most commonly used are the Lauge-Hansen and Danis-Weber systems.

The Lauge-Hansen system classifies ankle fractures based on the mechanism of injury, taking into account both the position of the foot at the time of injury as well as the movement of the leg. For example, one of the categories for the classification is supination-external rotation. The first term denotes that the foot was in a supinated position at the time of injury. The second term indicates that the leg was externally rotated in relation to the foot, causing the injury. The four categories originally described by Lauge-Hansen included supination-external rotation (the most common mechanism of ankle fracture), pronation-external rotation, supination-adduction, and pronation-abduction. Another category was later added, pronation-dorsiflexion, indicating that the force causing the injury was an axial force through the bottom of the foot that would drive the talus bone up through the tibia. This, however, is more appropriately addressed as a pilon fracture.

Within each category of Lauge-Hansen mechanism, there are different stages indicating how extensive the damage is to the ankle joint. These stages correlate with the ankle structures effected by the injury. Shown in the diagram above, starting from top left and moving clockwise, are the supination-adduction, pronation-abduction, pronation-external rotation, and supination-external rotation injuries. The stages indicate the structures involved.

Another commonly used classification system for ankle fractures is the Danis-Weber classification. This is based on the anatomy involved in the injury, particularly the tibia-fibula syndesmosis, which is the joint between the two bones. The classification is based on the level of the fibular fracture associated with the injury. If the fracture is below the level of the syndesmosis, it is considered a type A injury. Type B would be at the level of the syndesmosis, and type B would be above the level. Danis-Weber classification helps to indicate the amount of damage to the tib-fib syndesmosis. Levels B and C are associated with damage to the joint, which may lead to instability of the ankle if not addressed during the treatment of the fracture.

The classification of ankle fractures is a very academic topic, and is used primarily to communicate between physicians treating the injured patient. Other descriptors may be beneficial in describing the injury, but the classification systems are a quick and easy way to relate what is going on with the injury between doctors and those involved. Because of the reliable patterns of ankle fractures, these classification systems are fairly universal, and have a good inter- and intra-observer reliability.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

863-299-4551

www.FLFootandAnkle.com

Accessory Navicular

The navicular bone, located on the medial (inside) foot, is sometimes associated with an accessory bone. This accessory bone is most commonly referred to as an accessory navicular or os tibiale externum, but may also be called navicular secundum, prehallux, bifurcate navicular, accessory tarsal scaphoid, extra scaphoid, or a divided navicular. The accessory bone may be fused (attached) to the navicular, or it may be located within the tendon of the posterior tibial muscle, which attaches to the navicualr at this point.

Accessory navicular is present from birth, and results from a secondary ossification center of the bone. This means that there is an additional area of bony growth in the growing foot, which may eventually attach to the main portion of the navicular by either a bony attachment or with cartilage.

Symptoms of an accessory navicular include pain associated with shoes rubbing against the bony prominence, or pain developing from an eversion-type twisting injury. In the event of a twisting injury, the accessory bone may become detached from the main body of the navicular, essentially acting as a fracture of the bone.

Identification of the os tibiale externum, or the accessory navicular, begins with a thorough hirtory and physical examination. Frequently the accessory bone can be felt through the skin, or even seen on gross examination. X-rays are typically required to differentiate the accessory bone from an enlarged navicular or any other type of fracture of the bone. An MRI is not always necessary, but may be ordered if the diagnosis is not definite.

Once the condition is recognized, treatment may begin with conservative therapy, often involving padding the area and preventing it from rubbing against a shoe. In the event of a fracture through the bone, or a detachment of the bone from the main body of the navicular, it may be immobilized in a hard or soft cast. A number of factors play a role in this clinical decision-making.

Eventually, surgical removal of the accessory bone may be required to alleviate the symptoms. Depending on the particular type of accessory navicular, a number of different surgical techniques may be used. This is at the discretion of the treating foot and ankle surgeon. Typically, the offending bone will be removed in order to relieve the symptoms.

Post-operative care generally consists of protection with a cast, or a soft bandage and a surgical boot. Keeping off of the foot is usually indicated in allowing the foot to heal. Some pain and swelling should be expected. Analgesics may be used to alleviate some post-op pain, and elevation, ice, and rest are typically used to remove some of the swelling associated with the surgery. Details of the surgery may be discussed with your foot and ankle surgeon, including post-operative planning and the risks associated with surgery.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com