Should you consider Orthopedic Foot or Ankle Surgery?

When is it time to consider surgery as a solution for foot, ankle or joint pain? A couple of indications that you might be ready for surgery are: you have pain that keeps you awake or awakens you at night. You have foot pain, which limits activities necessary to go about your daily routine. You have ankle pain that limits activities that give you pleasure. You have tried other treatments for a reasonable period of time, and you still have persistent joint pain. Consult with an orthopedic specialist prior to making any big decisions. If surgery is the route you choose, here are some reasonable expectations:

Lateral Malleolus Fracture

The lateral malleolus fracture is a fracture of the fibula. There are different levels at which that the fibula can be fractured. The level of the fracture may direct the treatment.

Surgical Treatment

If the fracture is out of place or your ankle is unstable, your fracture may be treated with surgery. To make your ankle stable, a plate and screws on the side of the bone or a screw or rod inside the bone may be used to re-align the bone fragments and keep them together as they heal.

Medial Malleolous Fracture

Fractures can occur at different levels of the medial malleolus. Medial malleolar fractures are sometimes isolated but often occur with a fracture of the fibula, posterior malleolus, or an injury to the ankle ligaments, as well.

Surgical Treatment

If the fracture is out of place or the ankle is "unstable," surgery may be offered.
Occasionally, surgery may be considered even if the fracture is not out of place. This is done to decrease the risk of the fracture not healing (nonunion), and to allow you to start moving the ankle earlier.

Sometimes, the fracture can include "impaction," or indenting of the ankle joint. This can require bone grafting to repair it, in order to lower any later risk of developing arthritis.

Different techniques for surgery can be used. Screws, a plate and screws, or different wiring techniques can all be used, depending on the fracture.

Posterior Malleolus Fracture

A posterior malleolus fracture is a fracture of the back of the "shin bone" at the level of the ankle joint.
This is usually not an isolated injury. Often, the lateral malleolus is also fractured because it shares ligament attachments with the posterior malleolus. There can also be a fracture of the medial malleolus.

Depending on how large the broken piece is, the back of the ankle may be unstable. Some studies have shown that if the piece is bigger than 25% of the ankle joint, the ankle becomes unstable and should be treated with surgery.

A fracture of the posterior malleolus is important to diagnose because the piece is covered by cartilage. Cartilage is the smooth surface that lines the joint. If the broken piece is larger than about 25% of your ankle and is out of place more than a couple of millimeters, the cartilage surface will not heal properly and the surface of the joint will not be smooth. This uneven surface typically leads to increased and uneven pressure on the joint surface, which leads to cartilage damage and the development of arthritis.

Surgical Treatment

If the fracture is out of place or if the ankle is unstable, surgery may be offered.
Different surgical options are available for treating posterior malleolar fractures. One option is to have screws placed from the front of the ankle to the back, or vice versa. Another option is to have a plate and screws placed along the back of the shin bone.

Bimalleolar Fracture

"Bi" means two. "Bimalleolar" means that two of the three parts or "malleoli" of the ankle are broken.
A bimalleolar fracture most commonly means that the lateral malleolus and the medial malleolus are broken and the ankle is not stable.

A bimalleolar equivalent fracture means that the ligaments on the inside, or "medial," side of the ankle are injured along with one of the other "malleoli." Malleoli is pleural for malleolus. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable.

A "stress test" X-ray may be done to see whether the medial ligaments are injured.

Bimalleolar fractures or bimalleolar equivalent fractures are unstable fractures and can be associated with a dislocation.

Surgical Treatment

Usually, surgical treatment is recommended because these fractures make the ankle unstable.
Lateral and medial malleolus fractures are treated with the same surgical techniques as written above for each fracture listed.

Trimalleolar Fracture

"Tri" means three. Trimalleolar fractures means that all three malleoli of the ankle are broken. These are unstable injuries and they can be associated with a dislocation.

Surgical Treatment

Each fracture can be treated with the same surgical techniques as written above for each individual fracture.

Syndesmotic Injury

These are also known as "high" ankle sprains when there is no fracture. Depending on how unstable the ankle is without a fracture, these injuries can be treated without surgery. However, these sprains take longer to heal than the normal ankle sprain.

When there are fractures of other bones in the ankle, these are unstable injuries. They do very poorly without surgical treatment. Certain types of bimalleolar ankle fractures have an associated syndesmotic injury. Your physician may do a "stress test" X-ray to see whether the syndesmosis is injured.

Surgical Treatment

Syndesmosis injuries that cause ankle instability may require surgery. Some doctors prefer to try nonsurgical treatment first. However, if at any point during treatment an X-ray shows a diastasis, surgery will probably be recommended.

Screw Fixation

Surgery for a syndesmosis injury is designed to reduce the separation between the tibia and fibula. If there are no barriers keeping the tibia and fibula apart, the surgeon may simply need to place screws through the two bones to hold them together while the ligaments heal.

To begin the procedure, the surgeon bends the ankle slightly upward. A clamp may be placed around the lower leg to squeeze the tibia and fibula together, reducing the separation. This places the two bones in the proper alignment.

Working from the outer side of the leg, the surgeon inserts a screw through fibula into the tibia. This is done with the aid of a fluoroscope. A fluoroscope is a special X-ray machine that allows the surgeon to see the live X-ray picture on a TV screen during surgery. Using the fluoroscope allows the surgeon to direct the drill and place the screws into the right spot to hold the bones in the right position. This can usually be done through small, quarter-inch incisions in the side of the ankle. Some surgeons place a second screw right above the first screw.

Arthritis of the Foot and Ankle

Arthritis is the leading cause of disability in the United States. It can occur at any age, and literally means "pain within a joint." As a result, arthritis is a term used broadly to refer to a number of different conditions.

Although there is no cure for arthritis, there are many treatment options available. It is important to seek help early so that treatment can begin as soon as possible. With treatment, people with arthritis are able to manage pain, stay active, and live fulfilling lives, often without surgery.
 

Surgical Treatment

If arthritis doesn't respond to nonsurgical treatment, surgical treatment might be considered. The choice of surgery will depend on the type of arthritis, the impact of the disease on the joints, and the location of the arthritis. Sometimes more than one type of surgery will be needed.

Surgery performed for arthritis of the foot and ankle include arthroscopic debridement, arthrodesis (or fusion of the joints), and arthroplasty (replacement of the affected joint).

Arthroscopic Debridement

Arthroscopic surgery may be helpful in the early stages of arthritis.

A flexible, fiber-optic pencil-sized instrument (arthroscope) is inserted into the joint through a series of small incisions through the skin.

The arthroscope is fitted with a small camera and lighting system, as well as various instruments. The camera projects images of the joint on a television monitor. This enables the surgeon to look directly inside the joint and identify the problem areas.

Small instruments at the end of the arthroscope, such as probes, forceps, knives, and shavers, are used to clean the joint area of foreign tissue, inflamed tissue that lines the joint, and bony outgrowths (spurs).

Arthrodesis or Fusion

Arthrodesis fuses the bones of the joint completely, making one continuous bone.

The surgeon uses pins, plates and screws, or rods to hold the bones in the proper position while the joint(s) fuse. If the joints do not fuse (nonunion), this hardware may break.

A bone graft is sometimes needed if there is bone loss. The surgeon may use a graft (a piece of bone, taken from one of the lower leg bones or the wing of the pelvis) to replace the missing bone.

This surgery is typically quite successful. A very small percentage of patients have problems with wound healing. These problems can be addressed by bracing or additional surgery.

The biggest long-term problem with fusion is the development of arthritis at the joints adjacent to those fused. This occurs from increased stresses applied to the adjacent joints.

Arthroplasty or Joint Replacement

In arthroplasty, the damaged ankle joint is replaced with an artificial implant (prosthesis).

Although not as common as as total hip or knee joint replacement, advances in implant design have made ankle replacement a feasible option for many people.

In addition to providing pain relief from arthritis, ankle replacements offer patients better mobility and movement compared to fusion. By allowing motion at the formerly arthritic joint, less stress is transferred to the adjacent joints. Less stress results in reduced occurrence of adjacent joint arthritis.

Ankle replacement is most often recommended for patients with:

• Advanced arthritis of the ankle
• Destroyed ankle joint surfaces
• An ankle condition that interferes with daily activities

As in any joint replacement surgery, the ankle implant may loosen over the years or fail. If the implant failure is severe, revision surgery may be necessary.

Surgical Recovery

Foot and ankle surgery can be painful. Pain relievers in the hospital and for a time period after being released from the hospital may help.

It is important to keep your foot elevated above the level of your heart for one to two weeks following surgery.

Your doctor may recommend physical therapy for several months to help you regain strength in your foot or ankle and to restore range of motion. Ordinary daily activities usually can be resumed in three to four months. You may need special shoes or braces.

In most cases, surgery relieves pain and makes it easier to perform daily activities. Full recovery takes four to nine months, depending on the severity of your condition before surgery, and the complexity of your procedure.

Fractures of the Heel

It's not easy to break your heel bone (calcaneus). Because it takes a lot of force, such as that sustained in a motor vehicle accident or a fall from a height, you may also incur other injuries as well, particularly to the back.

Surgical Treatment

If the bones have shifted out of place (a displaced fracture), you will most likely need surgery. A metal plate and small screws are used to hold the bones in place. A bone graft may be used to aid in the healing of the fractures. The incision will be bandaged and a splint applied until it is healed. Then, you'll get a removable splint so that you can begin exercising the joint. You won't be able to put any weight on your foot for approximately 10 weeks after surgery. When you begin walking, you may need to use a cane and wear a special boot. It may take up to a year for the injury to heal completely. Depending on the type of job you have, you may not be able to return to the same type of work. Because of the amount of force needed to break the heel bone initially, even if your fracture heals properly, your foot may never be the same as it was before the injury. You may continue to experience stiffness and you may need to wear a heel pad, lift, or cup as well as special shoes with extra depth in the toe compartment.

Lisfranc (Midfoot) Fracture

Lisfranc injuries occur at the midfoot, where a cluster of small bones forms an arch on top of the foot between the ankle and the toes. From this cluster, five long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

Surgical Treatment

Often, operative treatment is needed to stabilize the bones and hold them in place until healing is complete. Pins, wires or screws may be used. Afterwards, you will have to wear a cast and limit weight-bearing on the foot for six to eight weeks. A walking brace may be prescribed when the fixation devices are removed. You may also have to wear an arch support and a rigid soled shoe until all symptoms have disappeared. In some cases, if arthritis develops in these joints, the bones may have to be fused together.

It is important to follow your doctor's orders and refrain from activities until you are given the go-ahead. If you return to activities too quickly, you may easily suffer another injury, resulting in damage to the blood vessels, the development of painful arthritis and an even longer healing time.

Shinbone Fractures

A broken or fractured shinbone (tibia) is the most common long-bone injury. Several types of fractures can occur, ranging from the hairline stress fractures common in runners to severe open fractures (where the skin is broken) resulting from motor vehicle crashes.

 

Surgical Treatment

 

Your doctor may recommend surgery for your fracture if it is:

• An open fracture with wounds that need monitoring
• Extremely unstable because of many bone fragments and large degrees of displacement
• Not healed with nonsurgical methods

Intramedullary nailing

 The current most popular form of surgical treatment for tibial fractures is intramedullary nailing. During this procedure, a specially designed metal rod is inserted from the front of the knee down into the marrow canal of the tibia. The rod passes across the fracture to keep it in position.

Intramedullary nailing.

 

Intramedullary nails come in various lengths and diameters to fit most tibia bones. The intramedullary nail is screwed to the bone at both ends. This keeps the nail and the bone in proper position during healing.

Intramedullary nailing allows for strong, stable, full-length fixation. The technique also makes it more likely that the position of the bone obtained at the time of surgery will be maintained when compared with casting or external fixation.

Intramedullary nailing is not ideal for fractures in children and adolescents because care must be taken to avoid crossing the bone's growth plates.

 

Plates and screws

 

Tibial shaft fractures were once routinely treated with plate and screw constructs. These tools are reserved for fractures in which intramedullary nailing may not be possible or optimal, such as certain fractures that extend into either the knee or ankle joints.

During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with special screws and metal plates attached to the outer surface of the bone.

 

External fixation

 

In this type of operation, metal pins or screws are placed into the bone above and below the fracture site. The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal.

While external fixation has yielded some reasonable results, having implants outside the body has proven to be somewhat unpopular with many patients and physicians.

Toddler’s Fracture

A toddler (one to three years of age) can fracture the shinbone when he or she trips over a toy or falls down a stair while learning to walk. These fractures usually do not break the skin, and the bone stays fairly well-aligned. There will be acute pain and possibly some swelling. The toddler may refuse to get up and walk again. The area of the fracture may be very tender.

It may be difficult to see this type of fracture on an X-ray, and your physician may request a bone scan to verify the diagnosis. These fractures heal quickly and can be treated with only a short leg weight bearing cast.

Growth Plate Fractures

Growth plate fractures are more common in older children and adolescents. These injuries occur near the ends of the bones at the ankle or knee. Bones do not grow from the center out, but from these growth plate areas. A fracture can disrupt the bone's development, leading to unequal limb length.

Growth plate fractures need to be identified early and watched carefully until the child reaches skeletal maturity to ensure that there is no shortening of the limb. The orthopedic surgeon may need to use internal fixation devices, such as screws or nails, to stabilize the bone.

Treatment depends on the fracture type, as described under "Classification" above.

In addition, there are other factors that may affect the bone growth and fracture healing. These include such things as the age and health of the patient, associated injuries, and the amount of displacement of the broken ends of the bone (occurring through the growth plates).

Type III Fractures

This Type III fracture of the thighbone (femur) goes through the growth plate and down into the knee joint. The fracture is fixed in place with screws. This restores normal joint alignment.

 

• These fractures are more common in older children. Because the center of the growth plate has begun to harden, the fracture does not continue across the bone, but angles down and breaks the bone end.
• A Type III fracture is treated with surgery and internal fixation to ensure proper alignment of both the growth plate and the joint surface.

Stress Fractures

Stress fractures are overuse injuries that occur when fatigued muscles can no longer absorb shock and transfer the load to the bone. More than 50 percent of all stress fractures occur in the lower leg. Stress fractures can develop gradually, with swelling and pain during activity.

The most important treatment for stress fractures is rest. It takes six to eight weeks for most stress fractures to heal. During that time, the individual should not participate in the activity that caused the fracture, but can participate in other pain-free activities.

Surgical Treatment

Some stress fractures require surgery to heal properly. In most cases, this involves supporting the bones by inserting a type of fastener. This is called internal fixation. Pins, screws, and/or plates are most often used to hold the small bones of the foot and ankle together during the healing process.

Closed Fractures

In a closed fracture, the skin is not broken. Closed fractures may be classified in several different ways, depending on the force of the injury, the stability of the bone, and the type and location of the break. The mechanism of the injury, such as a direct blow to the bone or an indirect twisting injury, can also cause soft-tissue damage.

Many stable closed fractures can be aligned without surgery, immobilized in a cast, and later supported by a fracture brace until healing is complete. However, if there is severe soft-tissue injury or if the fracture is grossly unstable, the orthopedic surgeon may not be able to manipulate the bone into alignment and surgical treatment may be necessary. Surgery can be immediately required in situations when there is internal bleeding on the tissues and when the bones have been shattered into small pieces. Internal fixation uses devices like rods, screws, and plates that are implanted inside the body and used to hold bones together that are fragmented.

Open Fractures

Because the shinbone is so close to the skin surface, a high-energy direct force may push the bone through the skin, resulting in an open fracture. All open fractures have an increased risk of infection and require surgical exploration and treatment. Open fractures are also often associated with trauma elsewhere in the body.

The use of small-diameter, interlocking nails to stabilize the fracture can result in less deformity, improved limb function, and shorter healing times. External fixators, such as a frame constructed around the leg, may also be used for the more severe, contaminated fractures, although these generally have higher rates of infection, poor alignment, or nonunion. In severe cases, amputation may be necessary.

Fracture of the Talus

The talus (TAY-lus) is a small bone that sits between the heel bone (calcaneus) and the two bones of the lower leg (tibia and fibula). It has an odd humped shape, somewhat like a turtle. The bones of the lower leg "ride" on top and around the sides to form the ankle joint. Where the talus meets the bones of the foot, it forms the subtalar joint, which is important for walking on uneven ground. The talus is an important connector between the foot and the leg and body, helping to transfer weight and pressure forces across the ankle joint.

Most injuries to the talus result from motor vehicle accidents, although falls from heights also can injure the talus. These injuries are often associated with injuries to the lower back. An increasing number of talar fractures result from snowboarding, which uses a soft boot that is not rigid enough to prevent ankle injuries.

Surgical Treatment

A talar fracture that is left untreated or that doesn't heal properly will create problems for you later. Your foot function will be impaired, you will develop arthritis and chronic pain, and the bone may collapse.

Immediate first aid treatment for a talar fracture is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf. Elevate the foot above the level of the heart and apply ice for 20 minutes every hour or two until you can see a doctor. Don't put any weight on the foot.

In rare cases, a talar fracture can be treated without surgery if X-rays show that the bones have not moved out of alignment. You will have to wear a cast for at least six to eight weeks and will not be able to put any weight on the foot during that time. Afterwards, your doctor will give you some exercises to help restore the range of motion and strength to your foot and ankle. Most fractures of the talus require surgery to minimize later complications. The orthopaedic surgeon will realign the bones and use metal screws to hold the pieces in place. If there are small fragments of bone, they may be removed and bone grafts used to restore the structural integrity of the joint.

After the surgery, your foot will be put in a cast for six to eight weeks and you will not be able to put any weight on the foot for at least three months. As the bones begin to heal, your orthopedist may order X-rays or a magnetic resonance image (MRI) to see whether blood supply to the bone is returning. If the blood supply is disrupted, the bone tissue could die, a condition called avascular necrosis or osteonecrosis. This could cause the bone to collapse. Even if the bones heal properly, you may still experience arthritis in later years. Most of the talus is covered with articular cartilage, which enables bones to move smoothly against each other. If the cartilage is damaged, the bones will rub against each other, resulting in pain and stiffness. Treatments for arthritis include activity modifications, ankle-foot orthoses, joint fusion, bone grafting and ankle replacement.

Toe and Forefoot Fractures

Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) is often painful but rarely disabling. Most of the time, these injuries heal without operative treatment.

Surgical Treatment

See a doctor as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the leg and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take an analgesic such as aspirin or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole.

Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for three to four weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your doctor or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence. The bone ends of a displaced fracture must be realigned and the bone kept immobile until healing takes place. If you have a broken toe, the doctor will "buddy-tape" the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you are diabetic or have peripheral neuropathy (numbness of the toes), do not tape the toes together. You may need to wear a rigid flat-bottom orthopedic shoe for two to three weeks.

If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace, or a rigid, flat-bottom shoe. It could take six to eight weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, the doctor may request another set of X-rays to ensure that the bones remain properly aligned. As symptoms subside, you can put some weight on the leg. Stop if the pain returns.

Surgery is rarely required to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.

If you are suffering from foot, ankle or joint pain, please contact our office immediately to schedule an evaluation.

Dallas Orthopedics Institute
 9330 Poppy Drive
Dallas , TX 75218