Foot Procedures

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

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

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

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

• Bunions
• Hammer toes
• Metatarsalgia
• Big toe arthritis
• Flat feet
• Ankle Arthritis
• Achilles Tendon Rupture
• Toe Deformities

Procedure

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

Bunions

A bunion is an enlargement of bone in the joint at the base of the big toe. Bunions are most often inherited. Tight shoes do not cause bunions, but they can aggravate them. There are several types of bunions and surgical treatments for each. (See Bunions)

Hammertoes

A muscle imbalance or abnormal bone length can make one or more small toes buckle under, causing their joints to contract. This in turn, causes the tendons to shorten. Corns (build-ups of dead skin cells where shoes press and rub) often form on the contracted joint, and may become irritated and infected.

Flexible Hammertoes

When hammertoes are flexible, you can straighten the buckled joint with your hand. Flexible hammertoes may progress to rigid hammertoes over time. Corns, irritation, and pain are common symptoms. Function is often limited as well.

Rigid Hammertoes

A rigid hammertoe is fixed; you can no longer straighten the buckled joint with your hand. Corns, irritation, pain, and loss of function may be more severe for rigid hammertoes than for flexible ones.

Curled Fifth Toe

The little toe may curl inward underneath its neighbor so that the nail faces outward. With this inherited problem, the fat pad on the bottom of the toe (normally used for walking) loses contact with the ground. Corns and pain may result.

Second Metatarsal Plantar Callus

When the second metatarsal bone is longer or lower than the others, it hits the ground first - and with more force than it is equipped to handle at every step. As a result, the skin under this bone thickens. Like a rock in your shoe, the callus causes irritation and pain. The treatment for this is an osteotomy. The second metatarsal bone is cut, and the end of the bone is then "lifted" and aligned with the other bones.

Heel Spurs

A heel spur is a bony overgrowth on your heel bone (see Plantar Fascitis). It may be stimulated by muscles that pull from the heel bone along the bottom of the foot. High-arched feet are especially apt to have too-tight muscles here. Heel spurs may cause pain when the foot bears weight. They can be treated first with an injection, anti-inflammatory medication, as well as arch supports if indicated. If this fails, they can then be treated with surgical excision and a plantar release. The band of tight muscles is released to relieve the abnormal stress. The bone spur is surgically removed.

Neuromas

When a nerve is pinched between two metatarsal bones (usually the third and forth metatarsals), enlargement of the nerve may occur. Abnormal bone structure contributes to the cause, but too-tight shoes can aggravate the condition. You may experience sharp pain in your toes that may become severe enough to keep you from walking.

Excision: A small portion of the nerve is removed. As a result of this, a small area is usually permanently numbed, but this is preferable to pain.

You can usually bear weight right away, but you must return to have your dressing changed. Keep your incision dry until the stitches are removed.

High-Arched Feet (Pes Cavus)

The shape of your foot often determines the kinds of foot problems you will have. Your feet may have unusually high arches due to an imbalance of muscles and nerves, which is usually inherited. Too high arches can cause various problems - tired or aching feet; and calluses. High arches are not usually investigated with surgery but most often treated with arch supports.

Flat Feet

Flat feet can be hereditary and are caused by a muscle imbalance. Feet with low, relaxed arches may bring on such problems as hammertoes and bunions; arch, foot, and leg fatigue; calf pain; and an overly tight heel cord (which makes the foot even flatter). Loose joints move to freely, causing pain and instability. Flat feet are also usually treated with arch supports.

Orthotics

Orthotics are prescribed, custom made arch supports. They fit inside most shoes. A podiatrist may prescribe them to help correct such problems as high arches and flat feet. Also, following some foot surgeries, orthotics can help support the correction that was achieved.

To be fitted with orthotics, the podiatrist will first take an impression of your feet. Orthotics are then fashioned from leather, plastic, or other materials. Their fit is checked at an office visit and adjustments can be made as they are worn.

Surgery

If your bunions or hammertoes are bad enough, they may need surgical correction. This is a gratifying operation that can provide both pain relief and improved appearance.

Risks

All surgery carries risks. Make sure you understand the risks and alternatives prior to surgery.

Post operative Care

These tips facilitte faster recovery without complications,

Pain: To help relieve pain and reduce swelling in the first 24 to 48 hours after surgery, apply an ice pack to the affected area and elevate the foot above heart level, as recommended. Pain is usually most severe the second and third days after surgery. Walking again may also be painful.

Bathing: You will need to keep your foot dry. Getting the stitches wet can lead to infection, so be sure to keep your foot outside the shower or bath.

Weight-Bearing: Bearing weight and walking can stimulate circulation and promote healing. But overtaxing a healthy foot can detract from the results of your surgery.

Shoes: a wide surgical shoe to wear on the affected foot may be necessary.. A surgical shoe stabilizes and protects the foot as it heals.

Returning to Work: timing of return to work depends on the type of surgery and the activities the job requires. Returning to a desk job is usually faster than returning to a job that requires a lot of walking.

Conservative Treatment

Non-surgical bunion treatment options may include:

• Medications to help alleviate pain and symptoms
• Ice packs to reduce inflammation
• Broad-toed shoes that fit properly to reduce the compression of the toes.
• Bunion pads, cushions, and splints to alleviate pain and protect the foot
• Properly fitted shoes that match the shape of the feet

Surgery

The surgical method of removal of a bunion is known as bunionectomy. The goal of bunion surgery is to restore the normal position and function of the big toe. However, bunions can recur if the causation is not corrected.

Surgical complications may include infection, blood clot formation, bleeding, and unrelieved pain and nerve damage. Surgery is also recommended when conservative measures fail to treat the symptoms of bunion.

There are many surgical options to treat a bunion. The common goal is to realign the bones in the foot, correct the deformity, and relieve pain and discomfort. The surgery is usually performed as a day procedure, under the effect of a light general anesthetic and a regional nerve block. Osteotomy is a common type of bunion surgery and involves realigning the bones around the big toe. There are three main types of osteotomies and the foot and ankle surgeon will select the appropriate procedure based on the severity and type of the bunion.

• Akin osteotomy
  Akin osteotomy is a surgical procedure that corrects sideways deviation of the big toe. A small cut is made at the base of the big toe, and a wedge of bone is removed to straighten the big toe. The bony fragments are then stabilized using a screw or staples. This procedure is often used in conjunction with the other procedures below.
• Chevron osteotomy
  A chevron osteotomy is usually recommended for mild to moderate bunion deformities and can be performed minimally with keyhole incisions. An incision may be made over the big toe, the joint capsule opened, and the bunion removed. The metatarsal bones are shifted to bring the big toe into its normal position. The bunion is shaved, and the soft tissues are realigned to correct the position. Akin osteotomy may be performed if necessary. The mobility of your big toe is examined, and the capsule and wound are closed with sutures.
• First Metatarsophalangeal Arthrodesis
  This is a procedure usually used for severe bunions with arthritis and involves fusing the two bones that form the big toe joint. Pain and deformity are controlled but movement of the big toe is decreased following the procedure.
• Proximal First Metatarsal Osteotomy
  This osteotomy is usually recommended for moderate to severe bunions and is a very powerful corrective procedure with good long-term results. An incision along the big toe, the joint capsule is opened to expose the bunion and then the bump is removed. The first metatarsal bone is then cut, and the surgeon will correct the cut bone with plates and screws. The joint capsule and surgical wounds are then re-approximated using dissolvable sutures keeping your toe in a straight position. Crutches or a walker are usually recommended for 4-6 weeks after surgery.

Following bunion surgeries, patients should elevate the foot and restrict walking as much as possible to minimize swelling and pain. Post operative shoes may be prescribed to protect the surgery for up to six weeks.

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

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

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

Foot reconstruction is a surgery performed to correct the structures of the foot and restore the natural functionality of the foot that has been lost due to injury or illness.

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

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

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

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

This procedure is usually performed under general anesthesia. Several tiny incisions are made by your surgeon to insert an arthroscope and miniature surgical instruments into the joint. The camera attached to the arthroscope displays the internal structures on a monitor and your surgeon uses these pictures to evaluate the joint and direct the small surgical instruments either to repair or remove the damaged bone or tendon depending upon the extent of injury.

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

Some of the advantages of arthroscopic surgery include:

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

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

• Make sure you get adequate rest. Avoid using the affected foot for a few weeks.
• Take medications to help alleviate pain and inflammation as prescribed by your doctor.
• Apply ice bags over a towel to the affected area for about 15-20 minutes to reduce post-operative pain and swelling.
• Compression dressings (bandage) are used to support the foot to reduce swelling. Take care not to wrap too tightly which could constrict the blood vessels.
• Keep the foot elevated at or above the level of your heart. This helps minimize swelling and discomfort.
• A wheelchair might be required for a few days in more severe cases.
• Start rehabilitation (physical therapy) as recommended by your surgeon to improve range of motion.
• Crutches or a walker may be used to maintain balance or stability while walking. You should begin appropriate exercises to stretch and strengthen the muscles.
• Cover the splint while showering to keep it clean and dry.
• Return to sports once the foot has regained normal strength and function with your surgeon's approval.

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

The Academy of ORthopaedic Surgeons provides valuable resources for additional information about a variety of foot conditions and surgeries