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Foot Surgery
 

Dr. Ian H. Beiser's Podiatry Page

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Dr. Beiser is a podiatrist serving patients in the Washington, DC, area

He is a partner in Foot and Ankle Specialists of the Mid-Atlantic, LLC,  a diverse group of foot and ankle specialists, dedicated to providing advanced and comprehensive foot and ankle care

1145 19th St., NW  Suite #203
Washington, DC 20036
(202) 833-9109

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Contents

Office Information
Credentials
Board Certification
Foot Information
    Foot Problems
    Normal Foot
    Diabetic Foot
    Heel Pain
    Bunions
    Other conditions
    Foot Surgery
      Absorbables
    Fungal Nails
    Orthotics

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Foot Surgery

Introduction
The podiatric surgeon is taught to approach foot surgery by keeping the knowledge of normal foot function and biomechanics in mind. Because of the weightbearing nature of the foot, surgical procedures must be designed to be as stable as possible to withstand the forces of everyday standing and walking. Care is taken to understand the cause of the problem so as to provide a long-lasting cure, when possible. Greater than 99% of podiatric surgery is done in an outpatient setting such as a hospital outpatient department, a freestanding surgery center or in the podiatry office. Most procedures allow for immediate walking with a surgical sandal. Some procedures may require the use of a cane, crutches, or a cast. Specific surgical treatments for many common (and some less common) foot conditions will be discussed.

Please select a topic from the list below or click here to start in the beginning

Foot Deformities and Biomechanical Problems
        Flat Feet (Pes Planus)
        High Arched Feet (Pes Cavus)
        Morton's Neuroma
        Tarsal Tunnel Syndrome
        Bunions (Hallux Abducto Valgus)
        Hammertoes
    Sports Medicine  and  Traumatic Injuries
        Heel Pain and Plantar fasciitis
        Fractures
        Tendonitis
        Sprains
    Conditions Related to Systemic Diseases
        Diabetes  
           
 Diabetic Foot Surgery Considerations
            Deep Space infections

            Circulation Problems (Peripheral Vascular Disease, PVD)
            Charcot Joint ( Diabetic Neurotrophic Osteoarthropathy)
        Arthritis    
            Osteoarthritis
            Rheumatoid Arthritis
            Gout
    Conditions of the Toenails
        Fungal Toenails (Onychomycosis)
        Ingrown Toenails (Onychocryptosis)
    Conditions of the Skin
        Calluses and Plantar Keratoses
        Corns (Heloma Durum)
        Soft Corns (Heloma Molle)
        Warts
        Ulcers
 

Surgical Procedures and Considerations
Foot Deformities and Biomechanical Problems

    Flat Feet (Pes Planus)

Surgery for flat feet is generally reserved for the most symptomatic cases. Orthotics are often the first line course of treatment. Many people have what are referred to as "Flat Feet" but are relatively asymptomatic. Flat feet may result in significant foot pain and deformity because of excessive pronation which causes joint instability. Flat foot procedures are designed to provide for a more stable foot which pronates less. Most flat foot surgery is performed on patients in the adolescent age group. There are a large variety of specific surgical procedures that may be used. They may be grouped according to the region of the foot that is treated. Often, 2 or 3 procedures may be performed together from the different groups.

Rearfoot osteotomies
These are procedures which are designed to change the position of the heel into an inverted or supinated position (the opposite of everted and pronated which are found in flat feet.) An osteotomy is a surgical cut in the bone. Often, a wedge of bone is removed to change the angle of the heel bone (calcaneus).  Other procedures are transpositional and involve sliding of one part of the bone along the other part of the bone. (E.g. the Koutsogianis procedure). Other procedures involve adding a bone graft and opening the wedge to change the angle of the calcaneus.( E.g. the Evans Procedure). These osteotomies are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for several weeks.

Medial column stabilizations
These procedures involve fusing two or more of the bones along the medial side (inner side) of the foot. Common fusion sites are the navicular and medial cuneiform.  These bones have often dropped in a flat foot and fusing them provides more stability. These osteotomies are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for several weeks.

Tendon transfers
Sometimes the insertion sites of tendons are detached and then reattached to bones at different locations. The result is a dynamic stabilization. Repositioning of the tendons allows the muscles that pull them to exert their force in a more beneficial way to help support the arch. The Young tenosuspension procedure reattaches the Tibialis Anterior tendon to a better position beneath the medial arch where it can pull up on the arch to support it.

Tendon lengthening
Often, the Achilles tendon is tight and is a major deforming force contributing to flat foot conditions. A condition associated with a tight Achilles tendon is known as equinus. An Achilles tendon lengthening procedure is often effective at reducing this deforming force. The calf is made up of 2 gastrocnemius muscle bellies as well as the soleus muscle. The Achilles tendon attaches to all three. An Achilles tendon lengthening lengthens the whole group together. Sometimes, the gastrocnemius muscles are tight while the soleus is not. In this case, a gastrocnemius recession can be performed to lengthen only the gastrocnemius while leaving the soleus alone.

Arthroeresis
These are procedures in which a peg made of plastic or titanium is placed in front of a bone to limit its motion. A common location for placement of such a device is the Sinus Tarsi which is a cone-shaped space between the talus and calcaneus bones. The peg helps to limit pronation. This is often just a temporary measure with the peg left in for a few years and then removed.

Arthrodeses
An arthrodesis is a fusion of two bones. In addition to the medial column stabilization fusions discussed above, rearfoot bones may also be fused. Rearfoot fusions are generally reserved for the most severely deformed, arthritic and painful feet . A Triple Arthrodesis is a fusion of the Talo-calcaneal, Talo-navicular and Calcaneo-cuboid joints. This is one of the most complex foot surgeries performed since all three joints must be aligned and fused properly to achieve a satisfactory result. In addition, because motion in the rearfoot is eliminated, the ankle joint and other joints in the foot may be forced into compensating to provide additional motion which could result in future symptoms in those places. These fusions are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for two or three months.
More on Flat Feet-  Common Foot Problems page


  High Arched Feet (Pes Cavus)

Surgery for high arched (cavus) feet is generally reserved for the most symptomatic cases. Cavus feet may result in significant foot pain and deformity. These feet are often rigid and will not flatten at all. The lack of shock absorption associated with these rigid feet may result in symptoms of the knees, hips and back as well as the foot. In addition to the high arch, the foot is often positioned in an inverted position that may be prone to ankle sprains. This is a common reason for pursuing this type of surgery.   .

Rearfoot osteotomies
These are procedures which are designed to change the position of the heel into an everted or more pronated position (the opposite of inverted and supinated) An osteotomy is a surgical cut in the bone. Often, a wedge of bone is removed to change the angle of the heel bone (calcaneus).  A common procedure is called the Dwyer osteotomy. A pie-shaped wedge of bone is removed from the lateral side (outer side) of the calcaneus and as the bottom portion of the heel bone is closed along the hinge that is created, the heel is rotated into a straighter position. These feet are also prone to chronic ankle sprains. The Dwyer procedure may be performed along with a lateral ankle stabilization procedure to prevent future ankle sprains. These osteotomies are generally held together with special screws, pins or bone staples and require a period of casting and immobilization for several weeks.

1st Metatarsal Osteotomies
There is often a 1st metatarsal deformity associated with the rearfoot deformity. The 1st metatarsal bone is often plantar declinated (positioned so that it sits downward and protrudes at the ball of the foot relative to the other metatarsal bone). To correct this, a wedge of bone may be removed from the top of the 1st metatarsal to correct its position. This may also be held together with special screws, pins or bone staples and require a period of casting and immobilization for several weeks.

Midfoot osteotomies
These are procedures in which wedges of bone are removed across the entire middle of the foot to reduce the high arch. These procedures  are not performed as commonly as the other procedures. They require extensive rehabilitation postoperatively.

Tendon transfers
Sometimes the insertion sites of tendons are detached and then reattached to bones at different locations. The result is a dynamic stabilization. Repositioning of the tendons allows the muscles that pull them to exert their force in a more beneficial way to help support the arch. The Jones tenosuspension procedure reattaches the Extensor Hallucis longus tendon to the 1st metatarsal where it can pull up on  it. Another procedure is the SPLATT (Split Tibialis Anterior Tendon Transfer) which redirects part of the tendon to the lateral (outer) side of the foot so that the tendon may help to evert rather than invert the foot.
More on Cavus Feet- Common Foot Problems page

Morton's Neuroma

Excision of a neuroma is a fairly straightforward and simple procedure. These are commonly approached from the top of the foot with an incision  usually measuring less than 1 1/2 inches just behind the space between the 3rd and 4th toes (or sometimes between the 2nd and 3rd toes). The enlarged nerve is identified and separated from the surrounding structures. A section of the nerve is removed and the wound is closed with a few stitches. There are no muscles controlled by the nerve so most people can live comfortably without it. There is often a small area of numbness between the 2 toes but it is usually not something that is noticeable unless it is specifically tested. There is a chance that the neuroma could reoccur or that the 'stump' of the remaining nerve could be painful but most people do well following the procedure. Most people are able to walk immediately following the surgery. Patients commonly wear a surgical shoe for about 3 weeks. Some surgeons may prefer to approach the nerve through an incision on the bottom of the foot but this may require a period of non-weightbearing after the surgery.


Tarsal Tunnel Syndrome
Tarsal tunnel surgery is usually performed to reduce pressure on the Tibial nerve as it travels below the medial malleolus (ankle bone on the inner side of the foot). A curved incision is usually made and after releasing the ligament that sits over the nerve (flexor retinaculum). Occasionally, there may be an abnormal mass (e.g. an enlarged vein, a cyst or a benign tumor) sitting near the nerve. Any abnormal mass is removed to reduce pressure on the nerve. Additionally, if the nerve is being entrapped by a muscle (e.g. Abductor Hallucis) as it leaves the tarsal tunnel, the entrapped area is loosened. Most people are able to bear weight immediately following the surgery. Patients commonly wear a surgical shoe for about 3 weeks.

Bunions (Hallux Abducto Valgus)
          see Bunion page for information about bunion surgery


Hammertoes
The most common procedures used to correct hammertoe deformities and painful corns are the digital "arthroplasty" and the digital "arthrodesis". An arthroplasty consists of the removal of part of the bone within one of the toe joints (proximal or distal interphalangeal joints). This allows the toe to straighten from its deformed, contracted position and allows for removal of the often enlarged, prominent bone that can be felt beneath a corn.. An arthrodesis procedure is similar but instead of removing the bone and leaving a new 'joint' space between the two bones, the two bones are fused together. An arthrodesis creates a rigid toe but there may be less chance of recurrence. In addition to these 2 procedures, it may also be necessary to lengthen the tendon and loosen the joint behind the toe (metatarsophalangeal joint) to completely remove the hammertoes deformity. These procedures are often done under local anesthetic and walking is possible immediately. A surgical sandal is usually worn for about 3 weeks or until swelling has reduced enough to return to regular shoes. There is usually only mild pain after surgery, primarily for the first 2 or 3 days. This is often well controlled with analgesics.

Sports Medicine  and  Traumatic Injuries

          Heel Pain and Plantar Fasciitis
               see Heel Pain page for information about heel surgery

Fractures
Some fractures (broken bones) can be treated with a cast. However, if the fracture is out of place or subject moving, surgery may be necessary to hold the bone together. Often, fractures of toes do not require surgery and are simply splinted. However, fractures of metatarsal bones and ankle bones often require surgery (open reduction with fixation) to stabilize and realign them properly. This can be accomplished with special bone screws, plates and wires. Casting after the surgery is usually required. Bone generally takes about 6 to 8 weeks to heal.


Tendonitis
Sometimes chronic tendonitis or tenosynovitis requires surgery to remove inflammatory tissue or parts of the tendon that have died. Often, there is a structural (bony) deformity that has contributed to the abnormal  tendon condition. If that is the case, the structural deformity should also be addressed to help reduce a recurrent problem. Common tendons requiring surgery are the Tibialis posterior and the peroneal tendons.


Sprains
The most common sprains in the foot are ankle sprains. A sprain is another name for a torn ligament. A ligament connects two bones at a joint and prevents them from moving in the wrong direction. After a sprained ankle has healed, the joint is almost always looser than it was before the injury.  After repeated sprains, the ankle joint can become quite loose, predisposing it to additional sprains. Surgery may be performed to stabilize the ankle. There are many different procedures that can be performed to accomplish this goal. These procedures are known collectively as lateral ankle stabilizations. In these procedures, a piece of a nearby tendon may be used to "re-create"  the lateral ankle ligaments. In addition, there is often a bony deformity that has contributed to the recurrent ankle sprains. Most commonly, this consists of a high arched or cavus foot. A wedge of bone may need to be removed from the heel bone (Dwyer procedure) or the 1st metatarsal bone to bring the foot into a straighter position.


    Conditions Related to Systemic Diseases

        Diabetes
                see Diabetes page  
           
 Diabetic Foot Surgery Considerations
            Deep Space infections

            Circulation Problems (Peripheral Vascular Disease, PVD)
            Charcot Joint ( Diabetic Neurotrophic Osteoarthropathy)


Arthritis
    
Osteoarthritis
The  treatment for osteoarthritis varies depending on the severity of the condition and on which joint or joints are affected. Surgical treatment options often range from a simple exostectomy  to joint arthroplasty or joint fusion. An exostectomy is simply the removal of a bone spur. This may be performed when the primary symptom is a painful prominence around a joint. An arthroplasty is the removal of part of a joint (cartilage and bone, usually from one of the two bones that make up the joint.) Sometimes this is performed along with insertion of an artificial joint or a joint spacer. This is performed when the joint has become stiff and painful as a result of the arthritis . The procedure allows improved motion and function and alleviation of the pain. In other cases, the painful, arthritic joint is fused( an arthrodesis). The fusion alleviates pain which was caused by the grinding of two bones against each other at a joint in which the cartilage has been eroded. Ordinarily, the cartilage serves as a lubricant and allows for smooth, gliding, pain free motion at a joint. Since the normal cartilage cannot be regenerated, fusion of the joint may be a good way to eliminate arthritic symptoms. Fusion may be chosen over arthroplasty when stability of a joint is required. Some joints such as the subtalar joint in the rearfoot are almost never conducive to arthroplasties and require a fusion when surgery is indicated. The post-operative course varies from immediate weightbearing in a surgical shoe with an exostectomy or arthroplasty to non-weightbearing and a cast for more than 8 weeks with certain fusions.


Rheumatoid Arthritis
There are many joints of the foot that may be affected by rheumatoid arthritis that could require surgery. The classic pattern of a rheumatoid foot deformity is a bunion and hallux abducto valgus deformity along with hammertoes and prominent metatarsal bones at the ball of the foot. Often, the hammertoes are dislocated from the metatarsal bones and push down on them, making the ball of the foot quite painful (metatarsalgia.) This is complicated by the fact that the fat pad cushion at the ball of the foot may be severely atrophied (shrunken or absent.) This complex deformity of the entire front half of the foot is often treated with what may be referred to as a Hoffman procedure. In this procedure, all of the metatarsal heads are removed to eliminate the bony prominences at the ball of the foot. In addition, the hammertoes may be treated with either arthroplasties or arthrodeses.The big toe deformity (Hallux Abductovalgus) may be treated with an arthroplasty or arthrodesis (fusion). Occasionally, implants or joint spacers may be inserted.

Gout
In the foot, gout most commonly affects the 1st metatarsophalangeal joint (the joint behind the big toe). Gout results in erosions around the joint. It also results in the deposition of uric acid crystals and chalky deposits called tophi. The cartilage of the joint may become severely eroded. Surgical treatment options are similar to those of osteoarthritis and often include arthroplasty or arthrodesis. An arthroplasty is the removal of part of a joint (cartilage and bone, usually from one of the two bones that make up the joint.) Sometimes this is performed along with insertion of an artificial joint or a joint spacer. This is performed when the joint has become stiff and painful as a result of the arthritis . The procedure allows improved motion and function and alleviation of the pain. In other cases, the painful, arthritic joint is fused( an arthrodesis). The fusion alleviates pain which was caused by the grinding of two bones against each other at a joint in which the cartilage has been eroded. Ordinarily, the cartilage serves as a lubricant and allows for smooth, gliding, pain free motion at a joint. Since the normal cartilage cannot be regenerated, fusion of the joint may be a good way to eliminate arthritic symptoms. Fusion may be chosen over arthroplasty when stability of a joint is required.

Conditions of the Toenails
 
Fungal Toenails (Onychomycosis)
    See Fungal Nails page
Ingrown Toenails (Onychocryptosis)
Once a nail has become ingrown, it usually must be removed to eliminate the pain and inflammation. Soaking and antibiotics alone, without  excision of the nail is usually ineffective.There are basically three ways this could be done:

1. Slant back nail avulsion. This may be done if the nail is not deeply embedded. This may be just a temporary measure and is often done without anesthetic. In this procedure, a nail clipper is used to create a tapered edge of the remaining toenail as the ingrowing portion is removed.

2. Partial nail avulsion. The toe is numbed with local anesthetic and the ingrowing portion of nail is removed by splitting the nail longitudinally at the affected side. The side of the nail takes several months to regrow and may become ingrown again as it grows out, particularly if the nail is deformed.

3.  Partial nail avulsion with matrixectomy. This procedure is identical to the partial nail avulsion with the additional step of destroying the nail matrix so that the corner of the nail does not regrow. A chemical such as phenol or sodium hydroxide is often used to deaden the nail matrix. There is not usually any pain when the anesthetic wears off (although there may be some mild tenderness if a very tight shoe is worn) and most people are able to return to work and regular activities immediately. There is often some mild drainage from the healing area which is normal and not a sign of infection. A Band-Aid is usually all that is needed until the drainage stops completely.    
   

Conditions of the Skin
        Calluses and Plantar Keratoses
Calluses and plantar keratoses are most commonly treated with periodic trimming and by using special insoles or orthotics. Since these conditions are caused by excessive pressure beneath a bony prominence, measures to rebalance the weight beneath the ball of the foot may help to slow down the rate of recurrence. Occasionally, surgery is performed to elevate one or more metatarsal bones to take pressure of a deep intractable keratosis. These procedures are not as predictable and the success rates are not as high as most other foot surgeries. This is due to the fact that it is very difficult to gauge exactly how much to elevate a particular metatarsal bone. If the bone is elevated too much, weight may be transferred to the adjacent metatarsal which develops a similar keratosis referred to as a "transfer lesion". If the bone is not lifted high enough, the keratosis may persist. Most people are able to walk immediately following the surgery. Patients commonly wear a surgical shoe for about 3 to 6 weeks. Sometimes a cast may be utilized for the the first few weeks.

 
        Corns (Heloma Durum)
Since corns are most often the result of an underlying hammertoe deformity, eradication of the condition usually requires removal of the hammertoe. There is no "root" that can be dug out. Simply shaving off the corn results in a recurrence since the prominent bone beneath it is still subject to irritation and pressure. The most common procedures used to correct hammertoe deformities and painful corns are the digital "arthroplasty" and the digital "arthrodesis". An arthroplasty consists of the removal of part of the bone within one of the toe joints (proximal or distal interphalangeal joints). This allows the toe to straighten from its deformed, contracted position and allows for removal of the often enlarged, prominent bone that can be felt beneath a corn. An arthrodesis procedure is similar but instead of removing the bone and leaving a new 'joint' space between the two bones, the two bones are fused together. An arthrodesis creates a rigid toe but there may be less chance of recurrence. In addition to these 2 procedures, it may also be necessary to lengthen the tendon and loosen the joint behind the toe (metatarsophalangeal joint) to completely remove the hammertoes deformity. These procedures are often done under local anesthetic and walking is possible immediately. A surgical sandal is usually worn for about 3 weeks or until swelling has reduced enough to return to regular shoes. There is usually only mild pain after surgery, primarily for the first 2 or 3 days. This is often well controlled with analgesics.


        Soft Corns (Heloma Molle)
Soft corns are like hard corns except  they are caused by pressure between two toes rather than by shoe pressure on a single toe. To permanently remove a soft corn, one or both of the involved toes must be treated. This may be accomplished with an arthroplasty procedure. An arthroplasty consists of the removal of part of the bone within one of the toe joints (proximal or distal interphalangeal joints). This  allows for removal of the often enlarged, prominent bone that can be felt beneath a corn. Sometimes a syndactylization procedure is performed, particularly in the case of recurrent soft corns where prior surgery has been unsuccessful. In this procedure, the skin at the bases of the two toes are sown together to create a partial webbing of the toes where the soft corn previously resided.These procedures are often done under local anesthetic and walking is possible immediately. A surgical sandal is usually worn for about 3 weeks or until swelling has reduced enough to return to regular shoes. There is usually only mild pain after surgery, primarily for the first 2 or 3 days. This is often well controlled with analgesics. 


        Warts
Surgical excision of warts is often limited to cases that have not responded well to  non-surgical measures such as acid treatments. Although the procedure itself is quite simple, there is a risk of developing a painful scar. There may also be recurrence of the warts, even with surgery. Also, if there are very large or multiple warts, excision may not be practical due to the extensive defect in the skin that would need to fill in. This could take several weeks and could be quite tender.  There would also be a greater risk for infection and there may be the need to keep the foot dry ( in other words, no showers) for several weeks. Excision of the wart is usually done in the office under local anesthetic. A small gauze dressing may need to be worn for several days or a few weeks, depending on the extent of the wart involvement.


        Ulcers
Surgery for ulcers consists of an assortment of measures such as debridement, incision and drainage as well as promotion of off-loading by either simple removal of bone or reconstructive foot surgery. See the ulcer management section of the Diabetes page for more information.

 

 

Ian H. Beiser, D.P.M., F.A.C.F.A.S, F.A.S.P.S.

Foot and Ankle Specialists of the Mid-Atlantic, LLC
1145 19th St., NW  Suite #203
Washington, DC 20036
(202) 833-9109

 
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Copyright 2008 Dr. Ian H. Beiser's Podiatry Page
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