Surprisingly, many patients do not associate the word surgery with the word podiatry. There seems to be a misconception of sorts that podiatrists treat conditions of the foot and ankle only with non-invasive or minimally invasive methods, such as orthotic footwear, trimming of callouses, applying paddings, injections of cortisone, or regenerative medicine therapy.
While more conservative methods of treatment are always the first line of defense when it comes to managing a condition sometimes surgery becomes the only option to effectively correct the problem.
Here are four conditions in which surgery is a viable option for treatment:
Bunions are bony bumps that form at the base of the big toe, typically forcing the big toe to point toward the second toe. When other treatments have failed for relieving pain such as wearing wider, boxy shoes or bunion cushions a bunionectomy may be in order.
There are four approaches to a bunionectomy:
- Osteotomy: The bones around the big toe joint are precisely cut, and the toe is realigned into its normal position
- Exostectomy: Removal of the bunion from the joint with or without a realigning of the toe by balancing the soft tissues.
- Arthrodesis: Fusing the damaged joint with metal plates or screws to fix the deformity
- Arthroplasty: Removing the joint and replacing it with a state-of-the-art implant or allowing fibrocartilage to naturally replace the joint. During the arthroplasty, the bunion is usually realigned as well.
Flatfeet (the plural or flatfoot) is a condition in which the arches on the inside of the feet become flattened, making it painful to walk, run, and participate in daily activities. Flatfeet may be the result of stress, age, accidents, and injury. It may also be the case that the patient never developed arches during childhood, usually due to genetics.
When a patient has painful flat feet, a podiatrist may first recommend stretching exercises, orthotic inserts, or wearing more supportive shoes. If pain persists, a combination of procedures to improve the alignment of the foot may be performed to correct the problem.
Surgical techniques include:
- Double or triple arthrodesis: Fusion of the joints to give the foot stability and correct arthritis that may have formed within the joints (double or triple refers to the number of joints that are fused)
- Lateral column lengthening: A portion of the heel bone is cut, and a wedge is inserted into the opening to lengthen the bone and rotate the foot back from an outward-facing position
- Medial calcaneal osteotomy: The heel is realigned and fixed in place using metal plates or screws
- Arthroereisis: A removable implant is inserted into the foot to elevate the talus on the calcaneus (heel bone) preventing outward protrusion of the ankle and flattening of the arch.
A hammertoe is an abnormal bend in the toe that usually occurs in the second or third and fourth or fifth toes. The abnormal bend is the result of an imbalance within the muscles, ligaments or tendons that hold the toe in the right position.
If the toe is flexible, it may be recommended that footwear with more room be worn. Splints can be prescribed as well as certain exercises performed to stretch out the problematic tissue. Should that not correct the problem, surgical procedures may be suggested depending on the flexibility of the toe.
For a flexible hammertoe, a procedure in which the tendons are rerouted from the bottom of the toe to the top to pull the joint into a straight position may be performed. It is also possible that a tenotomy (a release of the tendon), performed through a small incision will fix a flexible hammertoe.
For a rigid or semi-rigid hammertoe, there are two surgical options:
- Joint resection: The end of the “knuckle” bone is removed to allow the toe to straighten and pins are sometimes temporarily inserted to keep the toe in place.
- Fusion surgery: The ends of the bone are cut and pins, screws or other implants are inserted temporarily or permanently until the bone ends heal and fuse together.
Heel spurs are bony projections that form along the weight-bearing edges of the heel bone, where the plantar fascia attaches to the calcaneus. Heel spurs usually develop as a result of flattening of the arch leading to tension on the heel.
It is not usually the spurs that cause pain and discomfort, but they are a sign of a mechanical problem with the foot. The pain arises from the attachment area of the plantar fascia. Usually over-the-counter and prescription medication, injections of cortisone, physical therapy, extracorporeal shockwave therapy (EPAT) or change in footwear as well as utilization of inserts are effective in relieving the pain of heel spur syndrome. However, heel spurs syndrome that will not resolve with conservative care may require surgical intervention.
Surgical techniques include:
- Plantar fascia release: Cutting a section of the ligament that connects the heel bone to the toes to release tension and restore mobility usually done with the guidance of an endoscope a thin, flexible tube with a camera at its tip that is slipped through a small incision in the heel. The surgeon utilizes tiny tools to cut the Removal of the spur itself is not necessary unless it is fractured, angled towards the ground or present on the back of the heel and interfering with shoes.
- Spur removal: Guided by an endoscope a thin, flexible tube with a camera at its tip that is slipped through a small incision in the heel, the surgeon utilizes tiny tools to remove the spur itself
While there are many innovative surgical solutions for these and other foot and ankle conditions, treatment is always dependent on the patient’s specific diagnosis and recommended treatment plan.
References: [1,2] American College of Foot and Ankle surgeons, https://www.foothealthfacts.org/what-is-a-foot-and-ankle-surgeon