Restore Normal Stability
and regain ankle function
Ballarat Orthopaedics & Sports Medicine - Foot & Ankle Surgery Specialists
Foot & Ankle Surgery specialists at Ballarat OSM have advanced training in orthopaedic & foot & ankle surgery.
If surgery is required, Shaun English has fellowship training in foot and ankle surgery. Emergency cases and some straight froward cases are treated by all of the surgeons in the group.
Listed below are the most common foot and ankle conditions. Patient selection for surgery is critical – smokers and diabetics are both extremely high risk patient groups with slower healing, more infections, and poorer results.
Foot and Ankle Surgery Options & Information
Great Toe Arthritis
Stiffness of the great toe, whether or not with a bunion, is probably arthritis and the treatment different to bunions. Non operative treatment involves a stiffer sole shoe so less force passes through the great toe. Shoes or boots with a wider toe box may also help as might NSAIDs before physical activity.
The surgical treatment if required is arthrodesis, i.e. removing the remaining joint surface, exposing cancellous bone, compressing the bones together, and protecting until the arthrodesis is solid. This usually means two weeks of laying around at home with the leg up and crutches from brief periods of mobilisation, until the wound heals. A stiff soled shoe or heel support shoe can then be used for four weeks.
This case shows a destroyed joint that has been now been crossed by two “Memory Staples”. Over the last decade, our group has performed over 300 great toe arthrodesis operations, the majority are done as day surgery. If in combination with a complex forefoot reconstruction or in a frailer patient, inpatient care may be necessary.
Appointments can be made with Shaun English, David Mitchell or Scott Mason
In middle age, lots of people develop arthritis in joints across the top of the foot / roughly where one one lace up a shoe. Many people don’t even know they have it. Some need treatment – a stiff soled shoe, an arch support and some tablets from time to time might be enough.
There are some circumstance where a fusion operation is required to reduce the pain, improve the shape, or improve the ability to walk and function.
We don’t routinely use ultrasound to assess ankle injuries. A plain XR excludes ankle fractures & 5th metatarsal base fractures. If the bruising is typical of a sprain, and XR is normal, physiotherapy is appropriate.
Red flags indicating orthopaedic assessment is required are if: excessive swelling extending above the ankle suggesting a syndesmosis sprain, excessive swelling below the ankle on both sides sometimes represents a subtalar joint injury, or an inability to weight bear the day after injury.
Indications for surgery after normal ankle sprain are ongoing pain or ongoing symptomatic instability, the presence of an ATFL tear on ultrasound is NOT a reason to operate.
Most patients recover well with physiotherapy following ankle sprains, but some have persisting trouble of instability – i.e. rolling their ankle unexpectedly. Whilst taping and footwear may be enough to control the problem, if problematic, surgery is undertaken to repair or reconstruct the ligament on the outer aspect of the ankle.
This is often day surgery, ankle involved two weeks in a plaster cast and then a cam boot and physiotherapy. Return to sport is usually at three to four months depending on rate of recovery.
amera controlled surgery has a number of uses. One use is for what seemed like an ankle sprain but fails to improve. A band of scar tissue sometimes causes pain & swelling.
An alternate finding is a “talar dome fracture” which might be treated by removing the fragment and stimulating the bone to replace the damaged area with scar tissue.
Ankle Arthritis / Ankle Fusion
The ankle joint has two main components, one which goes “up-down” and is useful walking up a ramp, the other going side to side – useful walking across a slope. The up down (tibiotalar joint) joint can become stiff and painful. If boots / brace / tablets don’t achieve enough, ankle fusion may be considered. A fusion operation is where the arthritic joint surfaces are removed, and the underlying “cancellous” bone surfaces compressed together with screws.
The operation is usually done arthroscopically, often as day surgery or with a single night in hospital. A plaster cast is required to protect the fusion, and then a cam boot or “moon boot” until the fusion is solid at three months. Some “up-down” movement of the foot is still possible after the surgery as the next series of joint contribute some movement in that direction.
Almost as common as ankle arthritis is arthritis of the next series of joints below the ankle the do the “in-out” movement that allows one to walk across a slope. The three joints move together, so when arthritic, often all three are involved.
Like other fusion operations, the joint surfaces are removed, and the cancellous bone surfaces are compressed together. Bone graft may be required especially if there is a significant deformity. Like ankle fusion, a plaster cast is used initially, then a cam boot until about three months from surgery.
Bunions (Hallux Valgus)
Bunions refer to a lump usually at the base of the big toe. Apart from the cosmetic problem, they can make it difficult to find appropriate shoes, and cause pain from rubbing against the shoe. Wider shoes and lower heels may be all the treatment required.
Many operations have been described, but the Scarf osteotomy, soft tissue balancing, and sometimes an Akin osteotomy is the classic way to correct the problem. Whilst minimally invasive techniques have been mooted, our experience is that the results aren’t quite as reliable.
Appointments can be made with Shaun English, or Scott Mason.
Hindfoot Reconstruction “Adult Flat Foot”
With inflammation or tears of the tibialis posterior tendon, the foot can become deformed into a very flat foot, with the toes pointing outwards rather than the direction you’re walking. This can cause pain either on the inner or outer aspect of the foot. If non operative treatment doesn’t achieve enough, and smoking or diabetes doesn’t prevent surgery, it may be fixed.
The heel bone is moved across to change the forces, the tendon repaired or reconstructed, and stretched ligaments tightened up. It isn’t a quick recovery – six week in plaster then another six weeks in a cam boot, but it has a very high success rate.
Pain around the back of the heel, either within the achilles tendon, or where it connects to bone may need treatment. Shoe or activity modification may be enough – but we do not want people to become inactive because of this condition. Non insertional tendinopathy usually causes a swelling of the tendon above the level of the ankle, and responds very well to either ABI (autologous blood injection) or PRP (Platelet Rich Plasma).
For the cases further down, where the connection to bone is a problem has some non operative treatments too, but sometimes requires surgery to remove impinging bone and sometimes even to repair the tendon.
Achilles Tendon Rupture
For athletic, healthy patients, our preference has been to operate on achilles ruptures. The surgery is usually done relatively urgently, but not as an emergency.
Patient selection for the surgery is critical – smokers and diabetics, and elderly patients are often better treated non operatively using the Kennedy Fowler protocol.
Rheumatoid Arthritis of Forefoot
Luckily rheumatoid arthritis is better controlled by the rheumatologists now than was possible some decades ago. Typically pain and swelling will effect in particular the base of the toes, which may become deformed.
Shoes and rheumatology treatments may be enough. If not, surgical reconstruction might involve removed the angry joints and fusing the rear toe. It is not as good as a normal foot, but most patients have a significant improvement in their function.
Ankle fractures have obviously occurred throughout time. Traditionally, treatment involved re-aligning the fracture, and then applying a plaster cast. Treatment usually included being in plaster cast for six weeks. This treatment works reasonable well most of the time, and success could reasonably be predicted if there was no pain, and a new x-ray at twelve days shows good alignment. Generally, stiffness had resolved by three months, and full function returned.
Some groups have bad outcomes. Fractures on both sides of the ankle and displaced fractures within the joint routinely have internal fixation – e.g. plates & screws. People with osteoporosis may have an increased risk of the fracture collapsing.
This can cause chronic pain, fractures around the joint can lead to post-traumatic osteoarthritis. Not moving your ankle whilst in plaster makes you prone to blood clots, which can be dangerous. Some patients want a more aggressive approach to their fracture to allow earlier weight bearing, and to be out of their brace in bed, showering, and physiotherapy.