Foot and Ankle

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Ankle arthroscopy is a minimally invasive procedure that allows surgeons to diagnose and treat various ankle problems. This keyhole surgery is commonly used to address conditions such as:

- Ankle bone spurs (osteophytes)

- Loose bodies (bone or cartilage fragments)

- Arthritis

- Cartilage or bone injuries (osteochondral lesions)

- Scarring or ligament damage

- Impingement in the front (anterior) or back (posterior) of the ankle

- Small fractures

- Ligament repair or reconstruction in combination with other procedures

The surgery is typically performed as a day case under general anaesthesia, with local anaesthesia injected into the incisions to minimise pain post-surgery. Surgeons make two or three small incisions for the telescopes and instruments to examine the joint and treat any issues.

The procedure generally takes between 45 minutes to one hour.

Recovery

After surgery, patients usually go home a few hours later once they have fully recovered from anaesthesia. It's important to arrange for someone to drive you home.

Initially, you will need crutches for a few days until you can comfortably walk without them. Typically, you can bear weight as tolerated, but in some cases, your surgeon may advise non-weight bearing, especially after a microfracture procedure.

Rest and elevate your foot strictly for the first 36-48 hours, and then continue to keep it mostly rested and elevated for the first week. Applying ice for 20 minutes two to three times daily for the first 3-5 days can help reduce swelling and pain.

You may remove the soft bandage after 48 hours and replace it with an elastic tubigrip for swelling control. Leave the stick-on dressings in place until your follow-up appointment. If the dressings fall off, replace them with bandages.

Move your foot and ankle in different directions to prevent stiffness and blood clots. Physiotherapy can begin 10 days post-op, and stationary bike exercise is typically safe after 5-7 days.

Avoid driving if the right foot was operated on for one week or until you can walk comfortably without crutches.

Time Off Work

Desk work: 4-7 days

Light duties: 1-2 weeks

Standing/heavy work: 3-5 weeks

Sports: 6-12 weeks

Full recovery: 3-4 months

Following post-operative instructions carefully and attending follow-up appointments will help ensure a smooth recovery.

Ankle sprains are one of the most common sports injuries, often healing with appropriate rest and physical therapy. However, persistent ankle instability occurs when the ankle repeatedly gives way during physical activity or daily life. This can lead to recurrent sprains, joint pain, swelling, and damage to the ankle ligaments. Repeated instability episodes can cause harm to the joint cartilage, development of bone spurs (osteophytes), and eventually arthritis.

Non-Surgical Treatment

Initial treatment for ankle sprains involves rest, ice, compression, and elevation (RICE), along with painkillers and anti-inflammatory medications as needed. Physiotherapy plays a key role in regaining range of motion, strength, balance, and proprioception (joint position sense). An ankle brace may benefit those who continue to experience issues during physical activities. For some patients, a targeted PRP (platelet-rich plasma) injection may provide relief from inflammation and support ongoing physiotherapy.

Surgical Treatment

When non-operative methods fail and instability persists, surgery may be recommended. The procedure typically involves assessing the ankle ligaments and possibly performing an MRI to evaluate the joint and surrounding structures. The surgical process includes repairing and reinforcing the torn ligaments (modified Bröstrum-Gould repair), and inspecting and repairing the tendons behind the ankle if necessary. Additionally, arthroscopy is performed to examine the joint, remove inflammatory and scar tissue, and trim bony spurs. Post-surgery, a half plaster cast is applied to protect the repairs.

Post-Surgery Recovery

Rehabilitation and physiotherapy are crucial to a successful recovery from surgery and a return to normal activities. For the first two weeks, the focus is on reducing swelling and allowing wounds to heal while using crutches and maintaining non-weight bearing status. After two weeks, patients may begin wearing a lace-up ankle brace, gradually increasing weight bearing and range of motion. After six weeks, the brace can be removed for daily activities, and an intensive strengthening and balance program can start. The brace should be worn during sports for around three to six months after surgery. The ankle may remain stiffer than the unaffected side, but this is typically not a major concern.

Recovery Times

- Hospital Stay: 1 night

- Rest and Elevation: 7-10 days

- Plaster cast and crutches (non-weight bearing): 2 weeks

- Lace-up brace or cam walker (partial weight bearing for 2 weeks, full weight bearing for 2 weeks): 4 weeks

- Lace-up brace for training: 6 weeks

- Ankle strapping for competition: 12+ weeks

Time Off Work

- Desk work: 2-3 weeks

- Standing work: 6 weeks

- Heavy physical work: 12 weeks

After surgery, you will receive a recovery protocol to follow with your physiotherapist for a smooth healing process.

Foot and ankle surgery is a specialised field within orthopaedics that requires attention to individual patient needs and goals. While the surgery itself can be complex, a successful outcome relies heavily on patient cooperation with post-operative care, including following instructions, performing exercises, and modifying activities during the healing process. Achieving optimal results requires patience and persistence from the patient. 

Preparing for Surgery

On the morning of your surgery, shower and wash your feet and toes thoroughly with soap and water. Fast as instructed. If you use insulin or diabetes medication, follow the specific instructions provided. Blood thinners such as aspirin should be stopped one week before surgery. Take your regular medications, such as blood pressure tablets, with a small sip of water. Arrive at the hospital at the appointed time for check-in and pre-surgery preparation. Don't forget to bring your X-rays or scans for your surgeon to review.

Pain Management

During surgery, you may receive a local anaesthetic block for numbness and pain relief lasting 12-18 hours post-operatively. This should allow for a comfortable recovery and a smooth transition to oral pain medication. Taking painkillers regularly for the first 1-2 weeks, as prescribed, will help manage discomfort. After the initial 2-3 days, over-the-counter medications like Panadol or Panadeine may suffice. Take painkillers before your first post-op visit to minimise discomfort during plaster or suture removal.

Post-Operative Care and Recovery

Keep your bandages intact until your first post-operative visit, except in specific cases like ankle scopes and plantar fascia release. Protect your bandages from getting wet by using a plastic bag when showering. Rest and elevate your foot for the first 10 days to minimise swelling and aid healing. Apply ice for 20 minutes, 2-3 times per day for the first 3-5 days to help reduce swelling and pain. Follow the specific movement and stretching instructions provided by your surgeon to improve circulation and muscle recovery.

Follow-Up and Healing

Your initial post-op appointment will be two weeks after surgery for stitch removal and wound healing assessment. Further follow-ups are typically scheduled at four to six weeks and then every few months, depending on the type of surgery and progress. Be prepared for possible swelling, which may last up to a year for certain procedures. Physically demanding work may require up to six weeks of recovery time before you can safely resume.

Recovery Time

Recovery timelines vary, but it generally takes 3 months to feel around 75% recovered, 6 months for 90%, and up to a year for full recovery.

Exercise and Activity

Exercise is important, but too much too soon can be harmful. Follow your surgeon's guidance on resuming physical activities to avoid compromising your recovery process. Work with your trainers and healthcare providers to ensure a smooth return to sports and other physical activities.

By adhering to these post-operative care instructions and maintaining open communication with your healthcare providers, you can maximise the benefits of your foot and ankle surgery and facilitate a successful recovery.

Hallux rigidus (HR) refers to stiffness in the joint at the base of the great toe (metatarsophalangeal joint or MTPJ). This condition is usually caused by arthritis or wear and tear of the smooth cartilage lining the joint. HR can also be due to a previous injury or part of a broader medical condition like gout. Sometimes, the cause may be unknown, particularly as people age.

Symptoms and Non-Surgical Treatment

HR manifests as stiffness and pain in the great toe MTPJ, which can limit walking distance and affect work and leisure activities. Bony spurs (osteophytes) may form around the joint, causing discomfort from tight-fitting shoes. To relieve pain and minimise movement through the great toe MTPJ, lifestyle modifications like weight loss, using walking aids, and avoiding high-impact activities can be beneficial. Painkillers, proper footwear, orthotics, and cortisone injections may also offer relief.

Surgical Options

When non-operative treatments are insufficient, surgery may be necessary to relieve pain and enhance quality of life. The main options include motion-preserving procedures like joint debridement with osteotomy or joint fusion (arthrodesis). The choice of treatment depends on factors such as the severity of arthritis, patient age, functional demands, and whether adjacent joints are also affected. The decision is made jointly between the surgeon and the patient.

Surgical Procedures and Recovery

For mild HR, the upper part of the joint may be trimmed and washed out (debridement), sometimes combined with realignment of the bone at the base of the great toe (Moberg osteotomy). This procedure can be done minimally invasively for a quicker recovery. In advanced cases, debridement might be paired with resection of part of the proximal phalanx and the insertion of surrounding soft tissue (Hamilton-Thompson Interposition Arthroplasty) for long-lasting relief and improved movement.

For advanced arthritis, MTPJ arthrodesis (joint fusion) is the gold standard. This involves removing remaining cartilage and fusing the bones together with screws or a combination of screws and a plate. Most patients experience significant pain relief, but the joint remains stiff, limiting high-heel wear and running. There's a small risk of developing arthritis in the next joint, but this is uncommon.

Recovery Times

After surgery, patients can expect a hospital stay of one night, followed by rest and elevation for 10 days. The use of crutches or a frame may be necessary for 1-2 weeks, with foot swelling potentially lasting up to 12 weeks. Returning to normal footwear takes about 6-12 weeks, while fashionable shoes might take up to 6 months. Recovery times for seated work are 3-4 weeks, standing work 6-8 weeks, and for full pain relief and function improvement, it can take up to a year.

This overview provides a general understanding of the surgical management of hallux rigidus. For more specific questions or concerns, please consult your surgeon.

Hallux Valgus is a common foot deformity that often results from a muscle imbalance, which can be hereditary. While improper footwear can exacerbate the condition, it isn't usually the primary cause. Bunions tend to worsen with age and can lead to pain and deformity over time. They may also cause damage to other areas of your feet due to their size and impact on foot biomechanics. Treatment is typically recommended when bunions cause significant pain or make finding comfortable footwear challenging.

Surgery

The surgical treatment your surgeon uses for bunion correction is called the Scarf and Akin osteotomy. Over the years, various operations have been attempted with differing degrees of success. Many have failed due to high recurrence rates, excessive joint stiffness, or by causing issues in other parts of the foot. The Scarf/Akin osteotomy addresses many of these problems by restoring proper foot mechanics, allowing early return of joint motion, and maintaining low recurrence rates.

The procedure involves five steps carried out through two incisions. Initially, the tight ligaments and muscles on the opposite side of the bunion are released, followed by shaving down the bunion. Next, the metatarsal bone is cut and adjusted to narrow the foot and realign the joint, known as the Scarf osteotomy. Two small screws are used to secure the bone in place. Then, a wedge of bone is removed from the phalanx bone to straighten the big toe in a procedure known as the Akin osteotomy. A small staple or screw holds the bone in place. Finally, the joint capsule is tightened, and the skin is closed. Metalwork typically remains in place and doesn't need removal.

A minimally invasive technique is now available for some patients, using smaller incisions (about 3-5mm in length) for a slightly quicker recovery and better cosmetic results. Long-term outcomes are similar to the traditional open technique since the underlying bony procedures are the same.

Post-Surgery

You can bear weight immediately after surgery in a post-operative stiff-soled shoe, without needing a plaster cast. The way your foot is bandaged helps keep the big toe in place, while the post-operative shoe protects the toe during walking, serving the function of a plaster cast for 4 to 6 weeks. Like all foot surgeries, swelling is a main concern and may increase over the first 6 weeks before decreasing over the following 6 weeks. Your final result will begin to manifest 3 months after surgery. Over the next 12 months, your body will continue making subtle adjustments due to the significant changes in foot mechanics.

Managing pain after foot surgery is essential. The operation is performed under general anaesthesia, with a nerve block also usually administered, providing numbness for 12-18 hours. You should wake up with minimal pain, and injectable pain relief is now rare. When the block wears off, you can take simple oral pain relief. Start taking your oral pain relief before the block wears off to manage pain effectively.

Recovery Times

Hospital stay: 1 night

Rest and elevation: 10 days

Crutches/Frame: 1-2 weeks

Foot swelling: 12 weeks

Shoes

Hospital: Up to 6 weeks

Wide: 6-12 weeks

Normal: 12 weeks

Fashionable: Up to 6 months

Time off Work

Seated: 3-4 weeks

Standing: 6-8 weeks

Lifting/Carrying: 8-12 weeks

Lesser toe deformities can lead to discomfort in various ways. 'Hammer' or 'claw' toes are the most common types of toe deformities that may require surgical intervention. These deformities often result in issues such as prominent knuckle joints (PIP joints) rubbing against footwear and causing corns or ulcers. Additionally, inflammation in the main joint (MTP joint) at the base of the toe, or damage and stretching of the ligament under the toe and ball of the foot, may cause pain. Sometimes, toe deformities can lead to extra pressure under the ball of the foot, creating pain or a sensation of walking on a pebble.

Causes of 'Hammer' Toe Deformities

These issues can arise from various factors:

- Genetic predisposition

- Tight footwear

- Presence of a bunion

- Neurological conditions

- Rheumatoid or other types of arthritis

- Anatomical features such as a long second toe

- Overuse and ligament damage

Non Surgical 

Non-surgical treatments should always be considered first before opting for surgery. Possible non-surgical interventions include:

- Wearing appropriate footwear with a wide and deep toebox

- Using orthotics or insoles for pain relief under the ball of your foot

- Taping or strapping the toe for early hammer toes or ligament damage

- Using silicone sleeves or soft padding over the toe, available from pharmacists or podiatrists/orthotists

If these measures are ineffective or unsatisfactory, surgery may be considered to straighten the toe.

Surgical

Surgical treatment for lesser toe deformities may involve various small procedures depending on the degree of deformity and the specific issue.

Typically, the bent knuckle in the middle of the toe (the PIP joint) may need to be straightened and possibly fused. This may require a pin in the toe, which is left just 5mm out of the toe and removed after 4-6 weeks. Removing the pin is straightforward and takes just a few seconds, with no need for anesthetic. Sometimes, internal or dissolvable pins can be used instead of an external pin.

Other procedures may include lengthening tight tendons or shortening the metatarsal head (knuckle bone at the base of the toe joint) known as a 'Weil osteotomy.'

Surgery is typically performed as an outpatient procedure, unless combined with bunion or other surgeries that may necessitate an overnight stay.

Weight bearing is allowed in a post-operative sandal, and elevation is essential for at least the first 5-7 days. Recovery usually occurs within 4-5 weeks once the bones start healing. Swelling may persist for up to 3 months but should gradually subside.

Some stiffness in the toe is expected, as the toe cannot be made completely perfect once previous damage has occurred. However, the toe should be straighter and more comfortable.