Proposed mechanism of action:

At a microscopic and cellular level, shock waves cause interstitial and extracellular biological responses and tissue regeneration. Shockwaves exert a mechanical pressure and tension force on the targeted tissue. This has been shown to create an increase in cell membrane permeability and therefore increasing circulation at a microscopic level and thus metabolism within the effected tissues. Alterations of cell activity through cavitation and acoustic micro-streaming occur. Cavitation bubbles are simply small empty cavities created behind an energy front. They tend to expand to a to a maximum size, then collapse, much like a bubble popping. The two primary effects that ESWT has on tendon tissue can be summarised as

1) Effects on pain. It achieves this through hyperstimulation of pain fibres, dispersion of substance P (an important pain signaller) and destruction of small pain fibres (Type C)

2) Stimulation of tendon cell metabolism to stimulate fibroblasts to lay down more normal collagen and matrix within the tendon, thus initiating a repair process.

Who is ESWT for?

ESWT may be considered as a therapeutic option for any patient whose pain has not resolved with conservative treatment over a period of a couple of months. Many therapies such as non-steroidal anti-inflammatories, steroid injections, physical therapies, massage and acupuncture can help during the acute phase of an injury. However, they are much less effective in improving outcomes when tendinopathy becomes chronic. ESWT should not be used in patients with active infection in the area, pregnancy or in adolescents. Other cautions can include those with diabetes, nerve injury or bleeding problems.

Potential side effects are rare and tend to be transient. They include bruising, skin breakdown, temporary increase in pain and very rarely tendon tear/rupture which is reported at <1:5000 treatments.

What conditions can be treated?

• Plantar Fasciitis

• Achilles tendinopathy

• Calcific tendinosis of the shoulder

• Lateral epicondylitis

Hamstring tendinopathy

• Patella tendinopathy

Greater trochanteric pain syndrome

• There is also evidence to show that ESWT encourages bone healing in some fractures such as metatarsals.

How effective is ESWT?

The answer to this question depends upon which study you read, what methods were used in the study and how “success” is measured in the study. However, there is a growing evidence base for its effectiveness in what are renowned to be stubborn conditions to treat.

At present there is no consensus as to the definition of ‘high and ‘low’ energy but a number of studies are currently looking at what is the optimal dose, number of treatments and method. ESWT has been deemed a safe procedure by NICE (National Institute for Health and Clinical Excellence) and is now part of the treatment pathway for musculoskeletal injuries.

What does treatment involve?

One of the Sports Medicine/Orthopaedic team will assess the tendon and likely undertake either ultrasound or MRI to confirm the diagnosis. Ultrasound is rapidly becoming the investigation of choice given its superior resolution.

A standard course of treatment involves 3 treatment sessions that last around 15 minutes including assessment, treatment and advice post treatment. Currently all major insurance companies, except AXA (currently under review), fund ESWT treatment.

Patient info

Find out important information before your treatment.

The post Shockwave Therapy appeared first on London Sports Orthopaedics.

What are the alternatives to surgery?

Surgery is not always required. Treatment alternatives include orthotics (insoles to relieve pressure), change of footwear or avoidance of pain inducing activity and also injections of cortisone in and around the painful nerve.

It is also important that one has established confidently that the thickened nerve or neuroma really is the cause of the pain. This is because studies have shown that nearly half of the population may have a nerve that is enlarged on imaging scans but is not causing any symptoms.

What does Surgery Involve?

The operation is performed as a day surgical procedure. It can be done under local anaesthetic although if you are fit and well we do prefer a short general anaesthetic  for the procedure. The operation takes between 20-30 mins.

A thigh tourniquet is often used to stop blood obscuring the field of vision. You may notice some bruising or discomfort around the thigh for the next day or two after the operation as a consequence.

The painful space is premarked. This is commonly the “third space” ; the space between the 3rd and 4th toes. A longitudinal incision is made and the soft tissues are dissected and released to exposed the painful nerve. The branches to the corresponding two toes and the main trunk of the nerve together with any surrounding bursa or scar tissue is also removed.

Intraoperative photos showing the exposure and incision required to explore the webspace for a neuroma.

This is usually sent to the lab to confirm the diagnosis.

Example of a neuroma after excision.

The wound is then closed with absorbable sutures and a bulky dressing used.

What are the risks of Surgery?

INFECTION-

This can occasionally (rate 1-2%) occurs as with any operation. Antibiotic therapy or occasionally surgery to wash and clean the wound may be necessary.

NUMBNESS or NERVE INJURY-

This is an expected outcome of the surgery as the nerve that is supplying sensation to the toes is being removed. In practice the area of numbness is small and not of any consequence. Occasionally however the whole toe can go numb.

LACK OF BENEFIT or RECURRENCE –

In a proportion of patients the pain may not improve or may return after a period. This may be cause the initial pain pathology was not the nerve or that the nerve has re-grown. Fortunately this happens in around 5% or less if the correct diagnosis has been made.

THROMBOSIS- 

COMPLEX REGIONAL PAIN SYNDROME (CRPS)-

This is a rare complication that can result in post op pain and skin colour changes in the whole of the foot and sometimes the entire lower leg. It occurs in less than 0.5% but can result in a poor outcome and prolonged recovery.

What happens after the surgery?

WEEKS 0-2
You will have post operative bandaging on your foot but will be able to walk fully weight-bearing in a post operative sandal. Although crutches maybe used they are not necessarily needed. In this time it is important to keep the leg elevated above heart level as frequently as possible although you should not be confined to bed.
You can go to work after a few days if your work is sedentary and desk based and your commute is not difficult.

WEEKS 2-6
You will be seen at the two week mark for removal of the bandaging and a wound inspection. At this stage it is likely that you will be able to graduate to normal shoes although a pair of trainers or comfortable and wide fitting shoes are advised.
There would be residual pain and swelling that would be ongoing but gradually improving.

WEEKS 6-12
The postoperative pain and swelling will slowly resolve in this period and you are able to return to most of your day to day activities although return to sports or high impact activities may only be possible towards the end of this period.

When can I start my routine?

WORK- we recommend between a few days to two weeks off work depending on how physical your work is and what your commute to work is like.

SPORTS- most sports can commence by 3 month post op although some low impact activities such as cycling may be possible as early as 6 weeks.

SHOWER- you can get you foot wet after the two week visit when the bandaging is removed and full wound healing confirmed. Before this you need to shower with protective covering to waterproof the dressings and prevent it from getting wet.

Further Information

We recommend the following links for further information on the surgery:

Patient information leaflet from Guy’s and St Thomas’ Hospitals NHS Trust

Information from NHS Choices website

The post Morton’s Neuroma Surgery appeared first on London Sports Orthopaedics.

What are the alternatives to surgery?

The main alternative to surgery is to wear shoes that have wide and tall toe box. There are also various splints on the market that can help a great deal.

What does the surgery involve?

There are various surgical techniques used depending on the particular problem and your surgeon will discuss these with you. Some of these are outlined below.

Extensor tendon lengthening –

the tendon and soft tissue on the back of the foot maybe tight and short elevation your toe. This can be released surgically and the tendon lengthened.

Flexor tenotomy-

sometimes the problem is a tight tendon underneath the toe. This can be released through a small cut on the undersurface of the affected toe.

Inter-phalangeal joint fusion–

this is when the bone in the knuckle of the affected toe joint is excised to allow the toe to be straightened. It is done through a small cut on the back of the affected toe and the joint is then held with a wire or sometimes an implant until it is fused.

Weil’s Osteotomy-

this is a procedure where the main foot bone joining the toe is broken (osteotomy) and shortened. This is needed if you have a dislocated toe or if you have pain in the ball of the foot. A longer incision or cut is required over the foot near the involved toe. The bone is then fixed with a small screw.

What are the main risks of surgery?

Infection

Floppy or short toe – on occasions the toe may be too short and the tendons therefore relatively long. This may result in a toe that feels loose and floppy and you may not have enough control over. In mild instances this will not cause any problems however if it is causing symptoms the. Revisions surgery may be needed.

Elevated toe-

on occasions and especially if a Weil’s osteotomy is performed the toe will have a tendency to rise above the ground. This can often be controlled with stretching exercises but occasionally may need revision surgery to correct.

Malunion or non-union –

when an interphalangeal joint fusion is performed the toe may heal with some angulation or may not heal at all. If the healing is with fibrous tissue or the angulation is mild then nothing further is needed otherwise revisions surgery may be indicated.

Numbness-

it is common for the toe to feel “numb” or “odd”. Completely numb toes are rare but may occur due to injury to the nerves.

Swelling-

your toe will be swollen for sometime after the surgery. This may take 6 months before resolving. On occasions it maybe larger than its neighbouring toes indefinitely. This is of no consequence and tolerated well.

Vascular (blood flow) compromise –

very rarely the blood supply to the toe may be interrupted which may in turn lead to necrosis and loss of the toe. This is extremely rare and happens in less than 1 in 5000 cases. This risks may be higher if the toe is very short, dislocated or severely deformed.

What Happens after surgery?

Weeks 0-2

Following the surgery you will have bulky bandaging on your foot. If pins have been used you may see the end of the wire from the tip of your toe. You will see the physiotherapist who will show you how to use crutches. You are able to bear weight fully using a flat sandal.
You can inspect the toes through the dressing to ensure they are pink and healthy. Also make sure the pin is kept dry and clean.
You should continue will regular elevation of your foot and take your painkillers as prescribed.

Weeks 2-6

You will be seen in the clinic at around 2 weeks post op for a wound inspection. The dressing is changed. If there are no wires or they are small then it may be possible to go into your usual shoes. Do bring these with you to your appointment. You may however be put back in the flat sandal. Continue with elevation and weight bearing in this period.

Week 6 onwards

At your sixth week appointment the K-wore is removed. Normal activities can now resume although the toes may remain swollen for 3-6 months and sometimes longer. Impact active can be slowly introduced over the next 6 weeks.

The post Hammer Toe Correction appeared first on London Sports Orthopaedics.

What will surgery involve?

In this operation a small cut on the top of your Big toe is made taking care to protect the big toe tendon. The joint is then inspected. The bone spur on the back of the joint is resected with a saw. The cartilage of the main joint can also be cleaned out. Any other bone spurs from the joint will be removed at the same time and any loose cartilage or bone fragments washed out.

The wound is closed with dis-solvable sutures and dressing applied.

You would have had local aneasthetic block to the foot prior to the surgery. This means that when you wake up the foot should be reasonably comfortable and pain free.

What are the benefits of the surgery?

1. Increase motion – by removing the bone spurs the range of dorsiflexion (banding up) of the toe increases although it may not return to a normal range and some restriction will persist depending on the degree of the disease.
2. Reduce pain from impingement: When the toe moves up the bone spurs may impinge on each other causing pain. this can be reduced following the surgery.
3. Reduce friction in shoes: If the bone spur is very large it can cause friction in shoes causing pain. this can be alleviated after surgery.

What are the risks of surgery?

1. Swelling : this is common and will affect almost everyone. This will reduce gradually but it may take more than six months for the swelling to go down completely. It is important to elevate your foot in the early stages.
2. Infection: Wound or deep infection is uncommon after this surgery and occurs in less than 1-2 in 100. The risks can be higher in those with diabetes or in smokers. If infection occurs you may need further surgery to remove the hardware and may require prolonged intra-venous antibiotics. If you feel unwell, have a fever, there is oozing from the surgical incisions; or your leg feels hot and is red; then you need to seek medical attention as soon as possible.
3. Tendon injury: The tendons to the big toe are at risk of injury during the procedure. In particular the extensor tendon (EHL) that helps turn up the end of the big toe. The occurrence is however extremely rare.
4. Nerve injury or numbness: Sensory nerves around the big toe can occasionally be bruised or damaged during the surgery. This can give you an area of numbness on the back or one side of the big toe. In most instances this resolves over a few weeks however on occasions it may be permanent. These nerves are very small and the area of numbness is normally also small and generally is of no consequence. On occasions a regrowth of the nerve within the scar can become sensitive and this may need further minor surgery to excise.
5. Paradoxical deterioration of pain: On occasions gaining more motion in an arthritic joint may cause it to hurt more. This may mean that a fusion operation is necessary.

What happens on the day of surgery?

The surgery is performed as a day surgical procedure and you are often able to go home on the same day. Occasionally if the procedure takes place late in the afternoon or early evening then it may be advisable for you to stay for one night.

We perform the surgery under a general anaesthetic and you will meet and discuss your anaesthetic needs or concerns with our anaesthetist prior to surgery.

The surgery can take between 20-30 mins depending on the complexity. At the start of the procedure we will infiltrate a local anaesthetic “block” around the ankle. This will make the foot numb and help with post surgery pain. This lasts a few hours after the operation. so don’t worry if you cannot feel your toes when you wake up.

The incision is closed with dissolvable stitches in most but not all cases. You are likely to ‘wake up’ with needles in your arm for the anaesthetic agents (cannula) and a big bandage around the foot.

The surgery is done using a tourniquet around the thigh. This is to prevent blood getting into the operative field. This does means that occasionally your thigh might feel bruised and a little sore after the surgery. This is normal and usually settles in a day or two.

What happens after the surgery?

You will be transferred back to the ward where you will be seen by one of our  physiotherapists. You will be shown how to use crutches and will be allowed to fully weight bear on the operated foot wearing a sandal.  Once you are safely moving around and your pain is controlled you are discharged home. It is a good idea to have a friend or relative with you as an escort and to help during the first night at home. The pain is usually controlled because of the local anaesthetic in your ankle. Do take painkillers before this wears off to pre-empt the pain.

Weeks 0-2

Take it easy – It is best to avoid too many work or social activities and have time to rest and elevate the foot. You can use ice packs to control the pain and swelling.

The bandaging should be left undisturbed for the first 2-3 days and then reduced to the adhesive dressing over the cut. At this stage you may be able to convert to a pair of wide fitting shoes.  The wound should be kept dry for the first 2 weeks.

It is a good idea to do gentle exercises of the ankle and try and get around to allow circulation in your leg but need to spend regular periods elevating your foot. 

You will be reviewed by Mr Abbasian at around 2 weeks to check the wound and remove any stitches.

Weeks 2-6

You will be able to continue with a wide fitting shoe. Exercises of the big toe can commence. 

Months 2-4

Swelling, especially with use and the end of the day may continue during this time. You can now resume most of your usual activities including sports but these need to be introduced gradually. 

Months 4-6

 Expect ongoing swelling after heavy use.

The post Cheilectomy for big toe arthritis appeared first on London Sports Orthopaedics.

Bunion Surgery

Bunion Surgery

Bunions, are those bony bumps that often form at the base of the big toe, and can be a source of discomfort and pain for many individuals. While non-invasive treatments such as orthotics and lifestyle adjustments may provide relief, some cases may require more advanced intervention. Bunion surgery, also known as bunionectomy, is a viable option for those seeking a long-term solution to this common foot ailment. In this comprehensive guide, we will delve into what bunion surgery entails, what happens during the procedure, the associated risks and benefits, and what to expect during the recovery process.

Understanding Bunions:

Before we explore the surgical aspect, let’s briefly understand what bunions are and why they develop. Bunions are characterised by a misalignment of the big toe joint, causing the big toe to angle towards the second toe. This deviation leads to the formation of a bony lump on the joint, often resulting in pain, swelling, and difficulty in finding comfortable footwear.

Various factors contribute to the development of bunions, including genetics, improper footwear, and foot structure abnormalities. Over time, the constant pressure on the big toe joint can lead to inflammation, making everyday activities such as walking or standing painful.

Foot, toes, bunion

When is Bunion Surgery Recommended?

Bunion surgery is typically considered when conservative measures fail to provide adequate relief, and the bunion significantly impacts one’s quality of life. Your orthopaedic surgeon will assess the severity of the bunion, considering factors like pain intensity, restricted mobility, and the impact on daily activities. The decision to undergo surgery is a collaborative one, involving thorough discussions with your healthcare provider.

The Bunion Surgery Procedure:

Bunion surgery involves the removal of the bony prominence and realignment of the affected joint to alleviate pain and improve function. There are different surgical techniques, and the choice depends on the severity of the bunion and other individual factors.

One common procedure is the osteotomy, where the surgeon cuts and realigns the bone to correct the deformity. Another method involves removing a portion of the bone or fusing the joint. Your surgeon will determine the most suitable technique based on the specifics of your case.

The surgery is typically performed under local or general anaesthesia, and the duration varies depending on the complexity of the procedure. Patients are usually able to return home on the same day, although some cases may require an overnight stay.

Risks and Benefits:

Like any surgical procedure, bunion surgery carries certain risks. These may include infection, nerve damage, stiffness, or recurrence of the bunion. However, it’s important to note that serious complications are rare, and the majority of patients experience significant relief from pain and improved foot function.

Benefits of bunion surgery include pain reduction, improved joint alignment, and enhanced mobility. Many patients report increased satisfaction with their appearance and the ability to engage in activities that were previously limited due to bunion-related discomfort.

Recovery Process:

Understanding the recovery process is crucial for patients considering bunion surgery. The initial days post-surgery involve rest and elevation to minimise swelling. Your surgeon may recommend the use of crutches or a special shoe to avoid putting excessive pressure on the operated foot.

Physical therapy and prescribed exercises play a vital role in restoring strength and flexibility to the foot. Gradual weight-bearing is introduced, and patients are advised to follow a customised rehabilitation plan. The complete recovery timeline varies among individuals but generally spans several weeks to months.

It’s important to adhere to postoperative care instructions, attend follow-up appointments, and communicate any concerns with your healthcare team. Maintaining a healthy lifestyle, including proper footwear choices and foot care, is essential to prevent the recurrence of bunions.

Conclusion:

Bunion surgery is a viable option for individuals seeking lasting relief from the discomfort and pain associated with bunions. Understanding the procedure, risks, and benefits is crucial in making an informed decision about your foot health. Remember, open communication with your healthcare provider is key throughout the entire process. While the recovery period may require patience and commitment, many patients find that the benefits of bunion surgery significantly improve their overall quality of life, allowing them to walk confidently and comfortably once again.

The post Bunion Surgery appeared first on London Sports Orthopaedics.

What alternatives do I have instead of this surgery?

Surgery to stabilise the ligaments is not always needed after an ankle sprain. In fact most people manage to rehabilitate with Physiotherapy.
Some people who are very hypermobile or have ligament laxity or those with a high arch foot may recover slower. Insoles and ankle braces can be helpful in some cases.

Patients with a high arch will particularly benefit from orthotics to stabilise the ankle.

What is done during the operation?

This is normally a day surgical procedure performed under general aneasthetic. The incision is about 5 cm long and it is curved on the outside of your ankle. There are various repair techniques but we use two small 3mm metal anchors to repair the injured ligaments back onto the fibula bone.
The surgery takes around 45 min. The surgical incision is closed with absorbable sutures.
During surgery a tourniquet is wrapped around your upper thigh to stop blood obscuring the operative filed. You may sometimes feel some soreness around your thigh for a day or two post op as a result.
After the operation you will be placed in a below the knee plaster backslab. This is a half plaster with bandaging around. You will not be allowed to weightbear and will be given crutches to use.

What are the risks of this operation?

Infection – a small risk of infection exist at a rate of around 1 %. This is higher in diabetics or those who smoke. Most cases can be treated with antiobiotica alone. More severe cases may need surgery to remove the suture and suture anchors and perform a clear out. Often multiple operation may be needed to eradicate the infection and achieve skin cover.

Bleeding– excessive bleeding may lead to formation of congealed blood under the skin (Haematoma) this may need surgery to evacuate in rare cases.

Nerve injury or numbness– sensory nerves to the foot cross the outer ankle. Whilst care is taken to avoid injury occasionally they can be bruised or cut. This will not affect walking ability but may cause a patch of numbness on the back or outside of the foot. Sometimes a small regrowth of the nerve may lead to a painful nodule in the scar (neuroma), this may need to be surgically excised.

Thrombosis – Blood clots in the calf (Deep vein Thrombosis) can occur after lower limb surgery. These can break off and go to the lungs causing pulmonary embolism (PE). We assess individual risks of thrombosis and balance agains the side effects of blood thinning injections. You may therefore be offered injections for the first two weeks after surgery.

Complex Regional Pain Syndrome (CRPS)– this is a rare complication that can result in post op pain and skin colour changes in the whole of the foot and sometimes the entire lower leg. It occurs in less than 0.5% but can result in a poor outcome and prolonged recovery.

Recurrence or lack of benefit – the surgery is successful in over 90-95% of patients in eliminating their ankle instability. Those will lax ligaments or high arches are at increased risk of treatment failure. If recurrence occurs then revision surgery may be indicated. This may use artificial ligaments or donor tendon grafts and may also need surgery on the bones to lower the arch or realign the heel.

What is the post operative course?

Weeks 0-2

You will be in a plaster backslab and non-weightbearing with crutches.
In this time you can take the painkiller prescribed and elevate your leg as often as possible. Unless you can work from home it is recommended that you stay off work in this time.
It is important that you move around to reduce the risk of blood clots and also to exercise the rest of your muscles but don’t have your operated leg down for more than 20 mins at a time.
You will be given a follow up appointment at 2 weeks post op for cast removal and wound inspection at which point most patients will be given a “moon boot”. You can then start to weightbear on the operated foot.

Weeks 2-6

In this period you are able to walk with full weightbearing. You may wish to discard the crutches as you gain confidence.
It is also a good idea to start some gentle rehabilitation with exercises of the ankle out of the boot but taking care to avoid turning the ankle in or out.
You can start work and will manage most daily activities.
You are also able to have a shower or bath if careful and out of the boot.

Weeks 6-12
Physiotherapy will commence and you will discard the boot at the beginning of this period.
Any impact activity or sports should be avoided but gentle in-line exercises such as cycling or swimming can commence.

Week 12 onward

You can gradually begging sports. Initially in line sports such as jogging or cycling but eventually sports involving cutting and turning such as football, hockey or netball.
I do recommend that you wear a sports ankle support such as the AirCast A60 during any such sports for the first year after surgery.

Sick Leave
In general up to 2 weeks off work is required for sedentary employment longer periods may be necessary for more physical work.

Driving
You will be able to return to driving following the 6 weeks review, based on satisfactory progress.

These notes are intended as a guide and some of the details may vary according to your individual surgery or because of special instructions from your surgeon.

Further information

Patient information leaflet from Guy’s and St. Thomas’ Hospitals NHS Trust

The post Ankle Ligament Reconstruction (Brostrom Operation) appeared first on London Sports Orthopaedics.

Ankle fusion is a reliable operation with good results in eliminating pain from arthritis. 

What are my alternatives?

Non surgical options include injections and braces which can be effective in the early stages of arthritis.

By the time an ankle fusion is indicated the so called ‘joint preserving’ options such as injections or keyhole clean up surgery will probably have been tried and would not be indicated.

The main alternative to an ankle fusion therefore is a total ankle replacement. You can find further information on Ankle replacement surgery on this website.

On occasions bone realignment surgery may also be indicated. This may be the case if there is significant mal-alignment and the ankle joint is preserved.  You should discuss your individual options with your surgeon before deciding on which operation you should have. 

What is an ankle fusion?

An ankle fusion is a recognised and reliable surgical treatment for symptomatic ankle arthritis. The aim is to “freeze” the ankle so no movement remains and in doing so relive the pain from the arthritis.

In an arthroscopic ankle fusion a keyhole approach is made to the front of the ankle and the joint surfaces are prepared for fusion. This means that any bone spurs are shaved away, the remaining cartilage covering the joint is cleared down to the underlying bone which is then breached so that bleeding surfaces are reached. When this process is complete screws are put across the joint through separate small 5-10 mm incisions on the inside of the lower leg whilst ensuring that the foot is in a flat 90 degree position. 

X-ray of an ankle fusion using the described technique

The operations usually takes around 90 mins and you will have four or five small (5-10mm) incisions which are closed with absorbable sutures. A below the knee half plaster is then used.

What are the risks of this surgery?

Infection

 A small risk of infection exist at a rate of around 1 %. This is higher in diabetics or those who smoke. Some cases can be treated with antibiotics alone. More severe cases may need surgery to remove the screws and perform a clear out. Often multiple operation may be needed to eradicate the infection and the fusion operations may have to be repeated occasionally using external fixation frames and plastic surgery to achieve skin cover. Extremely rare cases may end in a below the knee amputation. 

Bleeding

 Excessive bleeding may lead to formation of congealed blood under the skin (Haematoma) this may need surgery to evacuate in rare cases. 

Nerve injury or Numbness

Sensory nerves to the foot cross the ankle. Whilst care is taken to avoid injury occasionally they can be bruised or cut. This will not affect walking ability but may cause a patch of numbness on the back or outside of the foot. Sometimes a small regrowth of the nerve may lead to a painful nodule in the scar (neuroma), this may need to be surgically excised. 

Blood vessel injury 

One of the blood vessels that supply the foot runs in front of the ankle and is at risk of injury. The rate is less than 1%. 

Thrombosis 

Blood clots in the calf (Deep vein Thrombosis) can occur after lower limb surgery. These can break off and go to the lungs causing pulmonary embolism (PE). We assess individual risks of thrombosis and balance against the side effects of blood thinning injections. You are likely to be offered these injections for the time you are in plaster. Usually for around six weeks. 

Complex Regional Pain Syndrome (CRPS)

This is a rare complication that can result in post operative pain and skin colour changes in the whole of the foot and sometimes the entire lower leg. It occurs in less than 0.5% but can result in a poor outcome and prolonged recovery. 

Non Union 

This is when the fusion fails to happen and the ankle joint will have motion which can remain painful and may result in the screws breaking. If this happens then you may need the procedure repeated to ensure a solid fusion occurs. You may find that bone graft is used or an open approach adopted in the repeat of the operation. 

Mal-Union

Occasionally the foot is placed in a sub-optimal position. The aim is to fuse the ankle in a position that results in the foot being square to the ground. If this isn’t achieved then you may find it difficult to walk. In most mild deformity a shoe insert is likely to solve the problem. More severe cases may need repeat surgery. 

Longer-term Arthritis in other foot joints

In the long-term, stress placed on the surrounding joints may lead to wear and tear and arthritis in those joints as they will be working harder to compensate for a stiff ankle. This may lead to pain in those joints. This occurs after 10 or 15 years and if severe may need further surgical treatment.

How stiff will my ankle be? What can I do?

This is the question most people will ask. By the time the ankle needs fusing a significant amount of up and down motion has been lost from your ankle. Any remaining motion is painful.

There are many other joints in your foot that can compensate and take on the up and down motion. In fact, most day to day activity can be performed with a fused ankle, including higher impact exercises such as jumping or running although sprinting may be difficult.

Most patients will walk without an an obvious limp and will be able to drive.

Any task that requires you to maximally bend the ankle may need to be adapted. One such task is going down stairs.

This article in the daily mail demonstrates how active individuals are following this surgery.

Below is a patient with a fused ankle who has been asked to move his ankle up and then down. The movement is generated from the neighboring joints and demonstrate the range of movement that is still available after an ankle fusion.

Ankle in the ‘up’ or maximal dorsi-flexion position

Ankle in the ‘down’ or maximal plantar-flexion position

What happens after surgery?

Weeks 0-2

In this time you will be in the post operative plaster back-slab. You must not weight-bear on the operated leg. Take time to elevate and control the swelling and take the prescribed painkillers one the local aneasthetic block has worn off (usually by around 24 hours post op). 

You should also try and get around in crutches regularly to make sure the rest of your bones and joints don’t become weak and wasted. It will also help blood flowing around and reduces the risk of thrombosis. 

At the end of this period you will have an appointment to see your surgeon who will change the cast to a full plaster and inspects the wounds. 

Weeks 2-6

Following your 2 week appointment you will remain non-weight-bearing on your crutches for a further 4 weeks. 

You must continue with regular elevation and control the swelling. The pain should be more tolerable by now and you may need fewer painkillers. 

Weeks 6-12 

You will attend for a check X-ray at the 6 week mark and at this stage if good healing is seen you will be taken out of the cast. Occasionally you may be taken out completely into your normal footwear but often a walking boot is provided to help you transition. 

Weeks 12 plus

At this stage an X-ray is repeated and full healing should be demonstrated. You will be in your normal footwear and getting back to normal day to day activity perhaps with a physiotherapist helping you. Return to higher impact activities is normally possible from around 6 months post op.

Swelling may persist for up to 12 months from the operation.

Further information

Below you can find links to recommended further information on the internet.

Patient information leaflet provided by Guy’s and St. Thomas’ NHS Trust.

Information provided by the American Foot and Ankle Society

The post Ankle Fusion (Arthrodesis) appeared first on London Sports Orthopaedics.

What does surgery involve?

An ankle arthroscopy is a keyhole operation to gain access to the inside of your ankle joint and to treat the abnormality or injury that is causing your symptoms. The procedure is normally done through 2 or three small incisions (5-10mm) in front of your ankle. This is also known as ‘anterior ankle arthroscopy’. Less commonly you may need access to the back of your ankle and therefore the arthroscopy may need to be performed through the back of the ankle where 2 small incisions are placed either side of your achilles tendon, this is known as a ‘posterior ankle arthroscopy’.

In both procedures one of the incisions is used to introduce a small camera (3-5mm in diameter) to gain vision whilst the other incision(s) are used to introduce the instruments needed to perform the procedure.

Depending on the pathology, various treatments can be performed. Soft tissue scarring, inflammation, bony spurs or loose bodies can be removed and ‘shaved’ away with small motorised shavers or burrs. Cartilage defects can also be treated by making holes in the exposed bone to encourage a special ‘scar’ cartilage growth. This technique is referred to as ‘microfracture’.

The exact procedure is often planned and discussed with you prior to surgery by your surgeon after careful assessment of your symptoms and your MRI scans is made.

What happens on the day of surgery?

The surgery is performed as a day surgical procedure and you are often able to go home on the same day. Occasionally if the procedure takes place late in the afternoon or early evening then it may be advisable for you to stay for one night.

We perform the Ankle arthroscopy under a general anaesthetic and you will meet and discuss your anaesthetic needs or concerns with our anaesthetist prior to surgery.

The surgery can take between 20-45 mins depending on the complexity. At the end of the procedure your surgeon will infiltrate local anaesthetic around the ankle. This will make the incisions numb and help with post surgery pain. This lasts a few hours after the operation. The incisions are closed with one or two stitches. You are likely to ‘wake up’ with needles in your arm for the anaesthetic agents (cannula) and a big bandage around the ankle.

The surgery is done using a tourniquet around the thigh. This is to prevent blood getting into the operative field. This does means that occasionally your thigh might feel bruised and a little sore after the surgery. This is normal and usually settles in a day or two.

What happens after the surgery?

You will be transferred back to the ward where you will be seen by one of our physiotherapists. You will be shown how to use crutches and will usually be allowed to fully weight bear on the operated ankle. If you have had a ‘microfracture procedure’ then your weight bearing may be restricted for a few weeks. Specific instructions will be given to you in these instances. Once you are safely moving around and your pain is controlled you are discharged home. It is a good idea to have a friend or relative with you as an escort and to help during the first night at home. The pain is usually controlled because of the local anaesthetic in your ankle. Do take painkillers before this wears off to pre-empt the pain.

Weeks 0-2

Take it easy – It is best to avoid too many work or social activities and have time to rest and elevate the foot. You can use ice packs to control the pain and swelling.The bandaging should be left undisturbed for the first 48 hours. You can then reduce this down to the sticky plaster dressing (mepore or opsite dressings).The wound should be kept dry for the first 2 weeks. You can however take a shower from day 2 as long as the incisions are covered with a waterproof dressing. It is best to avoid baths in this time. It is a good idea to do gentle exercises of the toes and the ankle. You can use a towel or a scarf to pull your foot up and stretch the heel cord. You will be reviewed by your surgeon at around 2 weeks to check the wound and remove any stitches.

Weeks 2-6

You will be able to walk unaided and resume most day to day tasks. Physiotherapy and ankle exercises should commence at this stage. We will review you at the 6 week mark to ensure there is satisfactory progress. If you have had ‘microfracture’ then you may continue to use crutches at the stage and limit weight bearing on your operated leg.

Months 2-6

Swelling, especially with use and the end of the day may continue during this time. You can now resume most of your usual activity. We recommend that high impact activity such as jogging should be introduced slowly and in increments of no more that 10-15% per week.

What are the risks of surgery?

As with any surgery, an ankle arthroscopy can have risks. Fortunately these occur rarely in this type of surgery but are important for you to be aware of. Your surgeon will discuss these further with you during the consent process. Below we have listed some of the complications associated with this type of surgery.

Nerve Injury or Numbness

Sensory nerves around the ankle and in particular the superficial peroneal nerve (SPN) can occasionally be bruised or damaged during an ankle arthroscopy. The can give you an area of numbness on the back of the foot. In most instances this resolves over a few weeks however on occasions it may be permanent. We take great care in identifying and marking the nerves during surgery and the rates of nerve injury is thus very low in our practice.

Infection

Wound or deep ankle joint infection is uncommon after ankle arthroscopy and occurs in less than 1-2 in 1000. The risks can be higher in those with diabetes or in smokers. If infection occurs you may need further surgery to clear out the joint and may require prolonged intra-venous antibiotics. If you feel unwell, have a fever, there is oozing from the surgical incisions; or your leg feels hot and is red; then you need to seek medical attention as soon as possible.

Blood vessel injury or Haematoma formation

Blood can collect within the ankle joint or in the cavity in front of the ankle and this in rare occasions may need further surgery to remove. One of the main blood vessels to the foot is also very close to the operation site. A theoretical risk of injury to this vessel exists but rates of injury are extremely rare.

Thrombosis

A clot in the calf veins, ‘deep vein thrombosis or DVT’ may rarely occur after an ankle arthroscopy. Occasionally the clot can break off and travel to the lungs (Pulmonary embolism). The risk of thrombosis varies from person to person. We assess your individual thrombosis risk pre-surgery and will provide you with blood thinning injections if your individual risk is thought to be high. Due to the very rare occurrence of DVT in those with a low individual risk, these medications are not routine for this procedure. We thus avoid their routine prescription, as they themselves have serious risks and side effects.

Further information

Below you can find links to recommended further information on this topic:

Patient information leaflet provided by Guy’s and St Thomas’ Hospitals NHS Trust

Information from NHS choices

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What does surgery involve?

Surgery for insertional achilles tendinopathy is a last resort procedure when all other treatment modalities have failed.

This is normally performed as a day surgical procedure although on occasions you may need to stay overnight. The procedure is performed under general anaesthetic and with a tourniquet around your thigh to stop blood obscuring vision at the surgery site.

The surgical incision is normally in the midline at the back of your heel and the achilles tendon. Occasionally if only the Haglund process is being removed this can be done through an incision on the side or through keyhole (minimally invasive) techniques.

The aim of the operation is to partially detach the tendon and remove any diseased tendon or calcific deposits that are often found in this condition. The fluid sac in front of the bone (retrocalcaneal bursa) is also removed. Once a thorough “clean up” of the area is performed the bony bump on the back of the heel bone is removed with a saw. Finally the tendon is reattached back to the bone using a very strong synthetic material and small bone screws.  This is known as the Achilles SpeedBridge technique.

Click here to watch an animation of the surgery.

The tendon and the skin incision are then repaired with absorbable sutures to the skin and your foot is placed in a below knee plaster backslab.

What happens after the surgery?

After surgery you will be returned to the ward. You would have had a local anaesthetic block during your operation to help with pain control and may feel some numbness around the foot and the heel.

Occasionally your thigh may feel a little sore or red from the tourniquet. This is normal and will resolve in 24-48 hours.

What is the post operative rehab?

Week 0-2

During this time you will be in a plaster backslab (a half plaster that is put on in the operating theatre) the foot may be positioned with the toes pointing down if we feel extra protection of the repair is needed.

You will need to remain Non-Weight Bearing  with the aid of crutched and try and elevate your foot above your heart level for as much of possible. We recommend doing this for 40 min in every hour although it is important for you to spend the remaining 20 mins moving around to help with blood circulation.

We would have also prescribed heparin injections which you would need to continue taking everyday.

Weeks 2-6

Your first post op appointment with Mr Abbasian will be at around 2 weeks. The backslab plaster is removed. At this point you may be given a walking boot.

Occasionally if there is concern about the tendon healing and repair strength you may be kept in a full plaster for longer.

The walker boot will remain in situ for the rest of this period.

Weeks 6-12

You will start graduating into your normal shoes although it is a good idea to use a pair of comfortable trainers at this stage. There would be swelling and discomfort which is normal. Competitive sports or any high impact activity should be avoided.

Months 3-6

This is when a gradual return to day to day activity and then followed by sports is started. You will be guided by your physiotherapist but we do not recommend sports that involve jumping or explosive push off to be done before the 6-month mark although in some cases earlier return is possible.

Months 6-12

Gradually improve to be able to do most sports and activities. Return to high level, high impact sports such as endurance running may not be possible after surgery such as this for over one year although most of our patients are able to participate in sports on a social and non-competitive basis.

What are the risks of the procedure?

As with any surgical procedure there are a number of complications that you would need to be aware of.

1. Wound breakdown or Infection  The blood supply to the skin around the incision can be compromised at the time of the surgery and very occasionally the skin incision may not heal well or breakdown. Sometimes this can be complication with a superimposed infection. The risks are higher if you are a smoker or a diabetic. Frequently we can manage this with a course of antibiotic and dressing changes but occasionally revision surgery to clear the infection and achieve skin cover may become necessary.
2. Achilles tendon rupture It is possible for the reattached tendon to rupture and ‘come off’ the bone if the repair fails. With modern techniques this is less likely to happen.
3. Nerve Injury Small nerves around the incision are commonly bruised and you may feel that the immediate area around the incision has unusual sensation. Larger nerves may rarely be injured. The Sural nerve is close to the surgery site and provides sensation to the outer aspect of the foot. A risk to this nerve exists and this can very rarely occur.
4. Thrombosis A clot in the calf veins, ‘deep vein thrombosis or DVT’ may occur after this procedure as you are non-weight bearing and in a plaster. Occasionally the clot can break off and travel to the lungs (Pulmonary embolism). The risk of thrombosis varies from person to person. We assess your individual thrombosis risk pre-surgery and will usually provide you with blood thinning injections after this operation until your mobility returns to normal. You may still suffer from thrombosis even on blood thinning injections but the risk is reduced significantly.

How successful is the operation?

The published success rates reported are in the region of 70%. However because of concerns regarding the strength of repair of the Achilles insertion it was not possible to fully and safely detach the tendon to remove the diseased area. With newer techniques a more thorough removal of diseased tissue is possible and we have noticed a significant improvement in outcome in terms of pain relief.

It must be noted that this is a surgery that we consider only in patients who have failed all other treatment and are in significant pain. Surgery aims to improve the symptoms and although the symptoms are generally much improved some patients may have residual pain and swelling although a significant number will be pain free.

Pre-op Haglund deformity and bone spur at the insertion of the Achilles tendon

Post op – removal of pain generating deformity confirmed.

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What does big toe fusion surgery involve?

During the surgery your surgeon will make a small incision around 5cm long on the back of your big toe to expose the arthritic joint. 

  The joint is cleared from any bone spurs that often grow around the big toe joint. The remaining joint cartilage is then removed to expose the undersurface of the joint. This surface is then perforated and thus “prepared” for a fusion. The aim is to encourage  bleeding and stem cells at the end of the bones to facilitate healing or union. Just like when a fracture or break heals.

After the surfaces are ready they are held in a functional position for the big toe and fixed rigidly using small plates (see picture) and screws. The joint will then heal into one solid bone.

Location of the incision is marked on the skin.

Intra-operative photo showing the fixation plate in situ.

What are the risks of the surgery?

As with any surgery, a 1st MTPJ fusion can have risks. Fortunately these occur rarely in this type of surgery but are important for you to be aware of. Your surgeon will discuss these further with you during the consent process. Below we have listed some of the complications associated with this type of surgery.

Nerve Injury or Numbness

Sensory nerves around the big toe can occasionally be bruised or damaged during the surgery. This can give you an area of numbness on the back or one side of the big toe. In most instances this resolves over a few weeks however on occasions it may be permanent. These nerves are very small and the area of numbness is normally also small and generally is of no consequence. On occasions a regrowth of the nerve within the scar can become sensitive and this may need further minor surgery to excise.

Infection

Wound or deep infection is uncommon after this surgery and occurs in less than 1-2 in 100. The risks can be higher in those with diabetes or in smokers. If infection occurs you may need further surgery to remove the hardware and may require prolonged intra-venous antibiotics. If you feel unwell, have a fever, there is oozing from the surgical incisions; or your leg feels hot and is red; then you need to seek medical attention as soon as possible.

Thrombosis

A clot in the calf veins, ‘deep vein thrombosis or DVT’ may rarely occur after foot surgery. Occasionally the clot can break off and travel to the lungs (Pulmonary embolism).

The risk of thrombosis varies from person to person. We assess your individual thrombosis risk pre-surgery and will provide you with blood thinning injections if your individual risk is thought to be high. Due to the very rare occurrence of DVT in those with a low individual risk, these medications are not routine for this procedure. We thus avoid their routine prescription, as they themselves have serious risks and side effects.

Tendon injury

The tendons to the big toe are at risk of injury during the procedure. In particular the extensor tendon (EHL) that helps turn up the end of the big toe. If this occurs it is usually repaired at the time and no functional deficits is likely to result.

Malunion

This means healing in the wrong position. We aim to put the joint in the most functional position. This generally means that the toe is put nearly straight and flat to the ground but with a slight bend inwards (valgus) and upwards (dorsiflexed). This has been shown to be the best position to allow good function. On occasions the position may not be achieved. If the toe is bent too inwards or outwards it may rub against shoes or the other toes and become symptomatic. Fortunately, malunions are very rare in our practice, as we take utmost care to achieve the perfect position. If they occur and the symptoms are not acceptable then secondary surgery to “change” the position may become necessary.

Non-union

This means a lack of healing. A 5% rate has been listed in the literature. Various factors can lead to the fusion ‘not taking’ and for healing to not complete. Smoking is a big risk factor and smokers’ risk of non-union is much higher than the above figure. We therefore advise against having this operation unless you have been a non-smoker for at least 3 months. In the presence of a symptomatic non-union then revision surgery to get the joint fused may be necessary.

Painful Hardware

The plates and screws used in our practice are incredibly low profile and thin and are of the latest generation. The rates of symptoms from the hardware is therefore very low in our practice. Should the hardware be palpable and rub against shoes then it may be necessary to remove them after the fusion is complete. This is a relatively minor procedure with a rapid recovery.

An example of a modern low profile plate.

What happens on the day of the surgery?

The surgery is performed as a day surgical procedure and you are often able to go home on the same day. Occasionally if the procedure takes place late in the afternoon or early evening then it may be advisable for you to stay for one night.

We perform the surgery under a general anaesthetic and you will meet and discuss your anaesthetic needs or concerns with our anaesthetist prior to surgery.

The surgery can take between 45-60 mins depending on the complexity. At the start of the procedure we will infiltrate a local anaesthetic “block” around the ankle. This will make the foot numb and help with post surgery pain. This lasts a few hours after the operation. so don’t worry if you cannot feel your toes when you wake up.

The incision is closed with dissolvable stitches in most but not all cases. You are likely to ‘wake up’ with needles in your arm for the anaesthetic agents (cannula) and a big bandage around the foot.

The surgery is done using a tourniquet around the thigh. This is to prevent blood getting into the operative field. This does means that occasionally your thigh might feel bruised and a little sore after the surgery. This is normal and usually settles in a day or two.

What happens after the surgery?

You will be transferred back to the ward where you will be seen by one of our  physiotherapists. You will be shown how to use crutches and will usually be allowed to fully weight bear on the operated foot wearing a special shoe (see pictures). You will be allowed to weight bear on the heel with a foot-flat-gait and will be asked to avoid ‘toeing off’ on the front of the foot. Once you are safely moving around and your pain is controlled you are discharged home. It is a good idea to have a friend or relative with you as an escort and to help during the first night at home. The pain is usually controlled because of the local anaesthetic in your ankle. Do take painkillers before this wears off to pre-empt the pain.

Weeks 0-2

Take it easy – It is best to avoid too many work or social activities and have time to rest and elevate the foot. You can use ice packs to control the pain and swelling.

The bandaging should be left undisturbed in this time. The wound should be kept dry for the first 2 weeks.

It is a good idea to do gentle exercises of the ankle and try and get around to allow circulation in your leg but need to spend regular periods elevating your foot. We recommend 30-40 minutes of elevation in every hour.

You will be reviewed by your surgeon at around 2 weeks to check the wound and remove any stitches.

Weeks 2-6

You will be able to continue with heel weight bearing in the post op shoe. The time spent with the foot elevated can be relaxed, however, you must still avoid long journeys and prolonged periods with your foot down.

You will be assessed by your surgeon at six weeks with X-rays to assess the fusion and confirm that it is healing.

Months 2-4

Swelling, especially with use and the end of the day may continue during this time. You can now resume most of your usual day to day activity. We recommend that high impact activity such as jogging should be avoided in this time although some low impact activity such as swimming can start.

Months 4-6

In this period a gradual return to exercise is possible but usually under the supervision of a physiotherapist and in small increments. Expect ongoing swelling after use.

When can I start my routine?

Work

This depends on the type of work you do and the complexity of your ankle arthroscopy. As a general rule however, sedentary and desk based jobs can commence within 7-14 days. Following the 2 week visit most office based jobs can commence however we do recommend that long commutes on public transport are avoided and alternative transport used or working from home chosen. If your work is more physical or requires prolonged walking or standing then it is best to delay for 6 weeks.

Driving

This depends on how painful and swollen the foot is. You should feel safe and in control of the car before you consider driving. As a general rule we always say that you must be able to perform an emergency stop without undue pain in your ankle.

The Drivers Vehicle Licensing Agency (DVLA) regards it as your responsibility to judge when you can safely control a car. Motor insurance companies vary in their policies, It is best to discuss your circumstances with your insurance company. If you drive an automatic car and the surgery is in your left foot then you can start driving as soon as a few days after the surgery. If not then driving should not be contemplated for the first 6 weeks when the post operative shoe is on.

Shower or Bath

We recommend no baths (this applies to hot tubs or swimming pools too!) for the first 6 weeks. A shower can be used from 24 hours using waterproof coverings to protect the bandaging.

Sports

This is very variable and depends on the condition of your ankle and on the particular sport. However most sports should be avoided for the first 2 months and only very low impact sports during the 2-4 month period. Higher impact activity is gradually introduced from 4 months and most actives are resumed by 6 months.

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