Flat feet

Usually flat feet are asymptomatic, even though flat feet are asymptomatic and they usually do not require any surgical intervention. Although asymptomatic locally they can increase the risk of some health hazards like arthritis, Calluses, corns, bunions, heel pain, knee pain, back pain. Medial arch supports are advice to maintain even weight distribution over feet and maintain alignment of the body.

What are the treatment options? 

Treatment options for flat feet can be both non-surgical and surgical. Non-surgical methods are footwear modification, arch supports, braces, arch strengthening exercises. Combination of these usually sufficient to achieve painless feet. Most commonly used orthotics are 3-D customized insole for minimal deformity and UCBL for severe deformity are best recommended.

What are the surgical procedures? 

Soft tissue balancing procedures like tendons transfer, bony procedures like osteotomy and fusion are being done to reconstruction of arch and maintain foot alignment. Arthroresis a recent advancement in flat feet surgery which provides arch correction with minimally invasive day care procedure. In this procedure one metal screw is inserted between talus and calcaneum bone to realign them and correct the arch.

Tendo Achilles Insertional tendinitis

To beginning with stretching and physiotherapist assisted pain relieving modalities are the most practiced one. These are the combination of activity limitation, ice packs, rest, orthotics, footwear modification, physical therapy, local injections with PRP. In severe and recalcitrant cases surgery is indicated

What are the surgical options? 

• surgical debridement of degenerated part of tendon and reattachment of tendon to heel bone
• calf muscle (gastrocnemius recession) release
• removal bony bump of heel bone (Haglund) if present. 

After surgery how much time it Will take to recover?

Wound healing and tendon adherence will take 6-8 weeks. Post-surgery plaster cast is applied for 3-4 weeks and can walk with aid support, after the plaster removal physical therapy is started to strengthen the muscle and gaining the functional length of the muscle. 

What is the expected outcome after surgery? 

Pain relief and full functional recovery in most of the cases within 4-6 months but some swelling may persist. 

Achilles Tendon Injury/Rupture

What’s are the treatment options for Achilles tendon injury?

Both surgery and non-surgical treatment for Achilles tendon injury is equally acceptable depending on the patient’s age, physical demand and associated pathology. For young athletic surgical repair is indicated and demanding but for older people with diabetes can be managed with functional bracing and active rehabilitation and can expect similar outcome. Sometimes an active old diabetic can also be treated by in-situ tendon transfer with good outcome.

How The tendon repair done?

Tendon repair can be done both by open or closed technique. Closed technique is faster and convenient with a favourable outcome. 

How the tendon transfer done?

Tendon of Flexor Hallucis Longus is incised midway to its insertion and fixed to the heel bone through a bone tunnel and screw in the line of Achilles tendon insertion at heel bone.

What is the rehabilitation protocol for both these two surgery?

For both these surgery ankle is immobilized with a plaster cast for 6 weeks. Post cast removal rehabilitation is done in the form of ankle movement, power training, balancing and gait. Return back to professional sports carrier after this injury takes a longer time than any other injury but most of the time it’s not the same performance level.

Plantar fasciitis

Surgery is the last resort for the treatment of planter fasciitis, but for some there is no other options. There are lots of myths in the treatment of planter fasciitis. Many patients enquires about removal of the bony growth at heel bone presuming the cause of the pain. But the original surgical exercise are done away from this.

Is there any other treatment options other than surgery in planter fasciitis?

Lots of other treatments are being practiced in planter fasciitis other than surgery

• PRP injection at tender point
• Radiofrequency ablation of planter fascia attachment at heel bone

What’s surgeries are being done for planter fasciitis treatment?

• Release of medial attachment of planter fascia at heel bone
• Gastrocnemius recession at various level are being very popular recently governed by the philosophy that tight gastrocnemius muscle is the causative factor of planter fasciitis.

Even after surgical treatment a long rehabilitation is mandatory for better outcome. One can be mobile with out any aid or support after 4-6 weeks but may need 3-6 months for full recovery

Bunion

When do you need surgery for Bunion/ Hallux valgus?

Surgical treatment of bunion for cosmetic purpose is not encouraged. But if it cause symptoms of suffering by any form like pain, gait disturbance, unable to manage wearing normal foot ware, not able maintain basic hygiene of the foot or become a predisposing factor for ulcer development in diabetic patient.

What are the surgeries recommended or practised for Bunion?

Deformity correction either by cutting and realigning the bones or fusion of joints to realigning the bones. Cutting and realignment of the bones are being done at different level depending on magnitude of deformity, configuration of the joints involving the bones. But this procedures are always associated with different soft tissue release and procedures around the bunion joint to redirect the deforming forces. Fusion is done either at the joint of bunion or at midfoot near the base of the bunion bone. Fusion at bunion joint is being done in case of arthritic changes of the bunion joint. And fusion at base of bunion bone is done in severe deformity and usually associated with flat feet

How is the recovery after surgery? 

Usually after surgery a offloading foot ware is given if the surgery is being done at the level of bunion or a plaster cast given if the surgery is done at the level of mid foot near base of the bunion bone whether it is a realignment bone cutting surgery or a joint fusion surgery.  Both the fore foot offloading foot ware and plaster cast is prescribed for a period of 4-6 weeks. Patient can walk with walking aid support avoiding putting full weight at fore foot. 

Surgeries for fractures

Many of the fractures can be treated with plaster cast or even only rest, elevation, ice and analgesic is enough for recovery. But there are few fractures of foot and ankle which need surgical treatment as a mandatory option to achieve a better outcome. Most of the fractures around base of 5th metatarsal, fracture of the phalanges are treated by this means. Fracture around ankle without joint dislocation, un-displaced fractures of midfoot bone like cuboid, navicular and cuneiform bone are treated with plaster cast. 

Fractures around Ankle which requires surgery

• Fractures involving ankle bones with ligament injury or joint dislocation
• Fracture of talus bone except un-displaced fracture.
• Fracture of heel bone with deviation and distortion of heel alignment and shape, displaced joints surface.
• Avulsed Achilles tendon attachment is an emergency surgical situation because any delay can cause necrosis of whole skin leaving the tendon bare.

Fractures around Midfoot which requires surgery

• Displaced fracture of navicular
• Cuboid Fracture with collapse of shape 
• Fracture dislocation of Lisfranc joints involving cuneiforms and metatarsal bases in any combination. Even a very subtle fracture that many times get missed on usual observation may also need surgical fixation because of the significant morbidity associated with this injury.  

Fractures around fore foot which requires surgery

• Fractures involving metatarsals with major displacement resulting in distortion of there length and parabola 
• Fractures of metatarsals causing significant planter angulation of distal end and generating an abnormal pressure point
• Fractures of metatarsals causing distortion of toe alignment
• Fracture involving joint surface of major medial proximal phalances  

Osteotomy

What is osteotomy?

In this surgery bone is cut in a precise way and the realigned to correct deformity.

In which conditions osteotomies are done?

Followings are the common conditions where osteotomy is being done:

• Osteotomy of distal end of tibia to correct deformity around ankle, either post trauma or congenital
• Calcaneal osteotomy for flat feet and cavus feet
• Mid foot osteotomy for cavus foot
• Osteotomy of 1st metatarsal for hallux valgus
• Osteotomy of metatarsal neck for Freiberg disease, lesser toe deformity

What is technique of osteotomy surgery?

The basic technique is same like osteotomy of other bones: identify the proper indication, precise bone cut, adequate fixation with proper implant. Pre-operative planning is always required to determine where the bone need to be cut and how much correction is required.  

What is the normal recovery pattern of osteotomies?

Normal recovery pattern is like the usual time for a fracture to unite. Depending of the site of osteotomy and strength of fixation plaster cast immobilization or protection in the form of non-weight bearing is required

Arthrodesis or Joint fusion 

What is arthrodesis or Joint fusion?

It is a surgical procedure where the movement of the joint is sacrificed and convert the bones across the joint in to a single bone. 

In which conditions arthrodesis are done?

This is done in painful arthritic joint to relieve pain, unstable joint to provide stability and sometimes in for deformity correction.

What is technique of arthrodesis surgery?

Joint surfaces are exposed and cartilage denuded. Following this the bones across the joint are fixed rigidly with implant; nail, plate or screw. Bone graft may require sometime to augment bony union and/or achieving alignment. 

What is the normal recovery pattern of arthrodesis surgery?

The normal recovery pattern is like a fracture union. It may require non-weightbearing or plaster cast immobilization depending on the stability of the fixation as well as the joint fused.

Foot & Ankle arthroscopy

What is Ankle arthroscopy?

Just like other joint arthroscopy foot & ankle surgeries can also be done with the help of arthroscope. The surgery is similar to knee and shoulder arthroscopy. Most of the equipment are same but some special instruments are required for foot and ankle arthroscopy procedure. 

What are the scopes of Ankle arthroscopy?

The technique and skill of foot & ankle arthroscopy is evolving and new indications are being added. The most common surgeries that are being done with the help of arthroscope are

• OCD reconstruction of talus
• Ankle impingement
• Ankle instability reconstruction
• Ankle and subtalar joint arthrodesis

Other indications

• Tendinosope for diagnosis and debridement of different tendon pathology