Foot and ankle surgery

What are different types of foot surgery?

What is the recovery time for ankle surgery?

What should you do after you go home?

What are the different types of ankle surgery?

How long does it take to walk after foot surgery?

Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Orthopedic surgeons are medically qualified, having been through four years of college, followed by 4 years of medical school to obtain an M.D. or D.O. followed by specialist training as a resident in orthopedics, and only then do they sub-specialize in foot and ankle surgery. Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school (D.P.M.), 3–4 years of a surgical residency and an optional 1-year fellowship.

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The distinction between a podiatric and orthopedic foot and ankle surgeon is important: an orthopedic surgeon has a Doctor of Medicine or Doctor of Osteopathic Medicine medical degree and training that encompasses both orthopedic residency and an optional 6-month to one year of fellowship training specific in techniques of foot and ankle surgery, while the training of a Doctor of Podiatric Medicine consist of a podiatric medical degree and three to four-year residency training specific to foot and ankle medicine and surgery, with an optional additional 1-year fellowship in foot and ankle trauma, reconstruction, or diabetic limb salvage.

In the UK much controversy exists on the scope of podiatrists practicing surgery and the British Orthopedic Association, and the British Orthopedic Foot and Ankle Society produced a position statement on the importance of training and ongoing regulation of podiatrists practicing podiatric forefoot surgery after certification and recommended that this should be to the same standard as that of medically qualified trauma and orthopedic surgeons operating on the foot and ankle.

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Clinical scope

Foot and ankle surgeons are trained to treat all disorders of the foot and ankle, both surgical and non-surgical. Additionally, the surgeons are also trained to understand the complex connections between disorders and deformities of the foot, ankle, knee, hip, and the spine. Therefore, the surgeon will typically see cases that vary from trauma (such as malleolar fractures, tibial pilon fractures, calcaneus fractures, navicular and midfoot injuries and metatarsal and phalangeal fractures.) Arthritis care (primarily surgical) of the ankle joint and the joints of the hindfoot (tarsals), midfoot (metatarsals) and forefoot (phalanges) also plays a rather significant role. Congenital and acquired deformities include adult acquired flatfoot, non-neuromuscular foot deformity, diabetic foot disorders, hallux valgus and several common pediatric foot and ankle conditions (such as clubfoot, flat feet, tarsal coalitions, etc.) Patients may also be referred to a foot and ankle surgeon for proper diagnosis and treatment of heel pain (such as a consequence from plantar heel fasciitis), nerve disorders (such as tarsal tunnel syndrome) and tumors of the foot and ankle. Amputation and ankle arthroscopy (the use of a laparoscope in foot and ankle surgical procedures) have emerged as prominent tools in foot and ankle care. In addition, more applications for laser surgery are being found in the treatment of foot and ankle disorders, including treatment for bunions and soft tissue lesions. A patient may also be referred to a foot and ankle surgeon for the surgical care of nail problems and phalangeal deformities (such as bunions and bunionettes.)

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Surgical treatments

The vast majority of foot and ankle conditions do not require surgical intervention. For example, several phalangeal conditions may be traced to the type of foot box used in a shoe, and a change of a shoe or shoe box may be sufficient to treat the condition. For inflammatory processes such as rheumatoid arthritis, non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDS) may be used to manage or slow down the process. Orthotics, or an externally applied device used to modify the structural or functional characteristics of the neuromusculoskeletal system specifically for the foot and ankle, may be used as inserts into shoes to displace regions of the foot for more balanced, comfortable or therapeutic placements of the foot. Physical therapy may also be used to alleviate symptoms, strengthening muscles such as the gastrocnemius muscle (which in turn will pull on the heel, which will then pull on the plantar fascia, thus changing the structure and shape of the foot).

Anterior and lateral view x-rays of fractured left leg with internal fixation after surgery

Surgery is considered to be a last option when more conservative approaches fail to alleviate symptoms. Techniques such as bunionectomies may be used to surgically remove bunions and other foot and ankle deformalities, arthrodesis (or fusion of joint spaces) for inflammatory processes, and surgical reconstruction (i.e. invasive measures of manipulating neuromusculoskeletal structures) to treat other deformalities. Orthotics, physical therapy, NSAIDs, DMARDs and a change of shoe may act as a complement to surgical intervention, and in most cases will be required for optimal recovery.

What are different types of foot surgery?

• Achilles tendon repair

When the thick tendon that connects the back of the heel to the calf muscles is torn, surgery is often necessary to properly reconnect the torn ends back together. The ends of the Achilles tendon may naturally reconnect without surgery, but nonsurgical treatment often results in the injury occurring again and a slower recovery. This is why athletes usually opt for surgery to repair this injury.

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• Fusion surgery

When a joint has extensive damage and is causing chronic pain, fusion surgery may be recommended. The pain is usually caused by bone-on-bone scraping during movement, as the protective tissues and other elements are degraded and are therefore no longer working properly.

This type of foot surgery is performed to remove the remaining cartilage and to permanently join (fuse) the adjacent bone tissues together. This is done using plates and screws to enable the natural fusion process, which will prevent the movement that is causing pain and other symptoms.

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• Foot fracture surgery

While simple foot fractures may heal on their own, complex fractures require surgery. Surgeries to address foot fractures have a high success rate.

• Metatarsal surgery

Your foot and ankle specialist may recommend metatarsal surgery to repair bunions, rheumatoid arthritis, or another issue that is causing deformity in the foot. The procedure involves cutting the metatarsal bone, repositioning it, and fastening it in place using metal pins, plates, or screws.

• Morton’s neuroma surgery

Morton’s neuroma is a condition that causes pain in the toes and the ball of the foot where a mass of tissue has grown around a nerve. The surgeon will decompress the nerve or to remove the inflamed nerve altogether, thereby relieving the debilitating, burning pain.

• Toe deformity correction surgery

Severe corns, calluses, bunions, and hammertoes can disfigure the feet. A deformed toe causes pain and discomfort, and it increases your risk of falls and other injury-causing accidents. Surgical treatment can be performed to straighten out and reposition the toes so that you can walk properly and without pain.

• Reconstructive surgery

A foot deformity can affect balance and gait, and this should be addressed with reconstructive surgery. Patients with osteoarthritis, rheumatoid arthritis, or a severe injury may require this type of foot surgery.

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What is the recovery time for ankle surgery?

The day of your surgery When you have recovered from the anaesthetic, normally you can get up and walk with crutches. You will be given a special sandal to wear. If any treatment has been performed on your ankle during the arthroscopy, we may ask you to reduce the weight you place on the ankle.

Most patients can go home on the same day as the surgery. Your ankle will be heavily bandaged to protect it and to reduce the swelling. The gauze bandage which is applied in the operating theatre will stay on for 2 weeks. There will be no plaster cast. You must keep your ankle elevated (raised) when you are sitting down. Do not get your bandage wet.

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What should you do after you go home?

This is a general guide only. Patients will progress and recover from their surgery at different rates. If your surgeon gives you different advice, please follow that.

• Days 1-7 after surgery

 The local anaesthetic in the joint will start to wear off the day after surgery, so you will need to start taking painkillers. You should keep the ankle elevated when not walking or exercising for the first week. Whenever the foot is put down, it will swell and become sore. It is normal to see mild bruising and some dry blood on the foot. By the end of this week the post-operative pain should be significantly reduced.

 If surgery was on your left ankle and you have an automatic car you can start driving within a few days. It will be 3 weeks before you can drive if surgery was on your right ankle or you have a manual car.

• Days 8-14 after surgery

Continue to elevate your foot and ankle as much as possible. You may walk short distances within your home or to a car from this week. In week two you can start working from home and possibly return to work but you must try and keep the ankle elevated. If you have a heavy manual job it may be one month before you can return to work.

You will be seen in the outpatient clinic about 2 weeks after your operation. This appointment will be made for you. At this time the wounds will be checked and any stitches removed. The findings during surgery may be explained and any treatment plans discussed.

Physiotherapy may be arranged if necessary but many people do not need it and can exercise on their own. Simple ankle exercises will be shown to you at this appointment. Stiffness of the ankle can be prevented by regularly doing the exercises at home, 3 times a day. Bring a soft shoe with you to this appointment, and you can wear this instead of the sandal.

• Days 21-28 after surgery

 You should remove all the remaining wound dressings at home, by soaking the dressings and taking them off in the shower or bath. You should apply skin emollient (moisturiser) around the healing wound. Once the wound is completely healed, you should apply the moisturiser over the wound as well.

 Continue to perform the exercises, increasing the frequency to 6 times each day. You may go swimming if the wound is dry and healed. Low-impact gym work, such as an exercise bike, can be started.

 At this stage, your foot and ankle may still be swollen.

You can start driving at this point, however, the Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. You should contact your doctor or the DVLA if you are concerned about this. Motor insurance companies vary in their policies. It is best to discuss your circumstances with your insurance company to make sure that you are covered.

• 5-6 weeks after surgery

You may have another appointment to see your consultant in clinic. If they are happy with your progress you may be discharged at this point.

• 3-6 months after surgery

Your foot and ankle may continue to be swollen for up to 3 months after surgery. Return to sporting activities will depend on the damage to your ankle which caused you to need surgery, and on any other treatment done during the operation. You will need to gradually increase your activity levels when you begin sport again. It may take several months to return to your normal sporting activity level.

You are advised not to fly within 12 weeks of foot and ankle surgery due to the increased risk of blood clots.

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What are the different types of ankle surgery?

Ankle surgery may be an option when more-conservative treatments don't relieve ankle pain caused by severe arthritis. The type of surgery that's right for you depends on your age, your level of activity, and the severity of your joint damage or deformity. Severely damaged ankle joints may need to have the bones fused together or even replaced with an artificial joint.

1. Ankle fusion

In this procedure, the surgeon roughens the ends of the damaged bones and then fastens them together with metal plates and screws. During the healing process, the damaged bones fuse together into one combined bone.

Ankle fusion is usually very successful in relieving arthritis pain. But it also reduces the ankle's motion. To make up for this, nearby joints may move more which increases the risk of developing arthritis in these joints.

Ankle fusion is usually recommended for younger people with more-active lifestyles. Compared with ankle replacement, ankle fusion:

• Is generally more durable
• Requires fewer restrictions in activity during recovery

2. Ankle replacement

In this procedure, the surgeon removes the ends of the damaged bones and fits a plastic-and-metal replacement joint onto them. The artificial joint helps the ankle retain more-natural movement, so there's less risk of arthritis developing in nearby joints. However, loosening of the components can occur.

Artificial ankle joints are generally recommended for healthy people over the age of 60 who have less-active lifestyles. High-impact activities such as running and jumping can damage an artificial ankle joint.

Ankle replacement might not be a good choice if you:

• Are younger than 50
• Have weakened ankle ligaments
• Participate in high-impact sports or work
• Have misaligned ankle bones
• Are significantly overweight
• Have nerve damage from diabetes
• Are a heavy smoker

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3. Lateral ankle ligament reconstruction

Lateral ankle ligament reconstruction is a surgery to tighten and firm up one or more ankle ligaments on the outside of your ankle. It’s also known as the Brostrom procedure. It’s most often done as an outpatient surgery, so you can go home the same day.

Your ankle is a hinge joint that allows motion up and down, and from side to side. Your foot and ankle have several ligaments. These are strong band-like structures that keep the bones in your ankle and feet tightly connected. On the outer side of your foot, you have several ligaments. These include the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). These help keep your ankle and foot steady when you walk.

If you have had repeated ankle sprains or if you have certain foot deformities, your ligaments can start to get weak and loose. If this happens, your ankle may become unstable.

During lateral ankle ligament reconstruction, the surgeon makes a small cut on the outside of your ankle. This is done while you are under general anesthesia. Then your surgeon tightens one or more of the ligaments on the outside of your foot.

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How long does it take to walk after foot surgery?

The recovery time following a foot or ankle operation varies widely, depending on factors including how complex the surgery was, your age and general health, and your compliance with instructions (such as weight bearing status, rest, elevation). For most foot and ankle operations, tenderness and swelling can take 3-4 months to resolve, while for more complicated procedures, the recovery may take a full year. Depending on the surgery, at three months, you may be able to walk short distances. The swelling on the surgical foot, and the range of motion of the surrounding joints should gradually improve over the first 6 months and you should be noticeably better than before the operation.

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Is ankle surgery painful?

Orthopedic surgery procedures were among the most painful in ambulatory surgery. In fact, two of the seven most painful procedures were ankle and knee operations.

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