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Forefoot Surgery

Complex forefoot reconstruction

Foot reconstruction is a surgery performed to correct the structures of the foot and restore the natural functionality of the foot that has been lost due to injury or illness.

The foot is formed by several bones, ligaments, joints and muscles, which function collectively to control various movements such as walking and running. The feet are susceptible to various mistreatments in the form of ill-fitting shoes, sports injuries, work-related trauma, or the strain of walking. Various outside forces tend to harm the feet and cause pain and discomfort.

Indications for Foot Reconstruction:

A variety of reconstructive procedures are designed to treat many foot disorders and restore your foot back to its original health and function. Following are the indications:

  • Common foot ailments such as bunions or hammertoes
  • Birth defects such as club feet
  • Postural deformity such as severe flat feet
  • Fractures sustained because of accident/trauma
  • Athletic injuries such as Achilles tendon tears, foot/ankle fractures, ligament injuries and several others
  • Plantar fasciitis, a common cause of heel pain
  • Heel and bone spurs
  • Joint or bone deformities due to arthritis
  • Infections
  • Tumours and lesions
  • Foot problems with metabolic diseases such as diabetes

Foot Reconstruction Surgery:

The primary objectives of foot reconstruction are reduction of pain and restoration of function and appearance. The surgery to be performed depends on several factors such as age, type of foot disorder, and severity and duration of the symptoms. It is often recommended when conservative treatments fail to resolve the symptoms and is a good choice in permanently treating various foot disorders.

With the new advancements in surgical technology, the traditional method of treating foot disorders is replaced by a minimally invasive technique (arthroscopy) which can most often be performed on an outpatient basis.

This procedure is usually performed under general anaesthesia. Several tiny incisions are made by your surgeon to insert an arthroscope and miniature surgical instruments into the joint. The camera attached to the arthroscope displays the internal structures on a monitor and your surgeon uses these pictures to evaluate the joint and direct the small surgical instruments either to repair or remove the damaged bone or tendon depending upon the extent of injury.

At the end of the procedure, the surgical incisions are closed by sutures or protected with skin tapes and a soft dressing pad is applied. Depending upon the surgery, your surgeon will place a cast or a splint to prevent movement of the foot until healing occurs and it regains normal functioning capacity.

Some of the advantages of arthroscopic surgery include:

  • Minimal trauma to the surrounding structures
  • Shorter recovery time with less post-surgical complications
  • Greater range of motion with less post-operative pain
  • Usually performed as an outpatient day surgery

Post-operative Care:

Following are the post-surgical guidelines to be followed after reconstruction:

  • Make sure you get adequate rest. Avoid using the affected foot for a few weeks.
  • Take medications to help alleviate pain and inflammation as prescribed by your doctor.
  • Apply ice bags over a towel to the affected area for about 15-20 minutes to reduce post-operative pain and swelling.
  • Compression dressings (bandage) should be worn to support the foot and reduce swelling.
  • Keep the foot elevated at or above the level of your heart. This helps minimize swelling and discomfort.
  • Crutches or a walker may be used to maintain balance or stability while walking.
  • Start rehabilitation (physical therapy) as recommended by your surgeon to improve range of motion. You should begin appropriate exercises to stretch and strengthen the muscles in your feet.
  • Return to sports once the foot has regained normal strength and function with your surgeon's approval.

The outcome of foot reconstruction surgery is greatly improved when you, your surgeon, and the physical therapist work together as a team.

Weil Osteotomy

Weil Osteotomy or Lesser toe surgery is a commonly used surgical procedure to treat lesser toe deformities. Pressure under the tip of the toe, in the balls of the feet and on the corns on the top of the toes is the cause for pain in patients suffering from deformity. The callous (thick lump of skin) formation and swelling in the joints makes it difficult to walk and wear shoes. The common types of deformities that affect the lesser toes are – claw toe, hammer toe and mallet toe. Early deformities can be treated by strapping or wearing foot wear which has silicone pads. This provides cushioning to prominent and tender areas of the foot, making you feel comfortable while you walk. If the symptoms persist after the non-surgical treatments have been tried, surgery should be considered as the best treatment option.

Pre-surgical Care

The surgeon will first diagnose the extent of the toe deformity by X-ray. After collecting the details of your medical history and the medications that you are taking, the clinical examinations will be carried out. The surgery is either performed as a day-case (no over-night stay in the hospital) or as an inpatient (with an over-night stay). The surgery is carried out under local anaesthesia combined with sedation or occasionally under general anaesthesia.

Surgical Procedure

The type of surgery depends on the problem being addressed. A small incision (cut) is made across the joint and any bony bump is trimmed thoroughly. The bones may be cut and repositioned in place with the help of surgical screws, wires or staples. Your surgeon may release or lengthen the tendons. Sometimes an osteotomy (removal of bone) is necessary to fix the problem. At the end of surgery, the wound is stitched closed and covered with a loose dressing.

Post-surgical Care

After the operation, you are advised to keep the foot above the level of the heart for at least 24 hours to avoid swelling. The soreness and pain will subside with the help of painkillers, but might stay numb initially for 6-12 hours. The wound should be regularly dressed to avoid infection and to facilitate healing. It should be taken care that no pressure is put on the toe while walking for the first 2 weeks. You can resume your regular activities after 2 weeks but it might take 3 months to return to normal. You will be able to drive a vehicle after 6-8 weeks and can return to sports between 3-6 months.

Risk & Complications

As with any surgery, lesser toe surgery involves possible risks and complications. These can include:

  • Recurrence of the deformity (occurs in 1 among 10 people)
  • Swelling, stiffness and numbness
  • Infection and delay in wound healing (might require antibiotics)
  • Nerve damage
  • Scaring
  • Blood clots

In most of the patients, benefits outweigh the risks associated with surgery. This surgical procedure helps to cure the pain and discomfort while walking.

BRT Osteotomy

Osteotomy is a surgical procedure wherein a wedge of bone is removed near the degenerated joint and the remaining bone is trimmed and realigned. The surgery aims to ease pain and restore function to the affected joint.

Hallux Metatarsophalangeal Joint Fusion

The metatarsophalangeal (MTP) joint connects the metatarsal bones (group of long bones in the foot) and bases of the proximal phalanges of the toes.

The MTP joint at the base of the big toe is commonly affected by osteoarthritis or rheumatoid arthritis. In cases of osteoarthritis, the surface of the joint wears out and the adjacent bone thickens and forms osteophytes (bone spurs). This eventually leads to severe pain and stiffness in the affected joint. In cases of rheumatoid arthritis, the bones in the joints are extremely destroyed resulting in swelling and severe pain. These conditions may cause the MTP joint to become predominantly stiff (hallux rigidus) or deformed (hallux valgus).

Hallux arthrodesis is a surgical approach performed to fuse the MTP joint of the big toe to provide pain relief and improve function.

Indications

The affected big toe joint is initially treated with conservative approaches such as medications, physical therapy, steroid injections or exercise. Surgery is recommended if conservative approaches fail to provide pain relief. MTP joint fusion of the big toe or hallux arthrodesis is indicated in the following conditions:

  • Painful joint
  • Severe big toe deformity or stiffness
  • Difficulty in wearing footwear
  • Associated foot disorders such as inflammation, ulceration, outgrowth of bone in the joint region or nerve entrapment

Pre-operative Preparation

Before the surgery, your doctor may conduct a physical examination and analyse details of your medical history. Talk with your doctor about any medications you are taking or plan to take. Arthrodesis is performed as a day-case procedure which doesn’t require an over-night stay in the hospital.

Procedure

The surgery is carried out under the effect of general anaesthesia or an ankle block using local anaesthetic. Your surgeon will make an incision over the big toe joint; trim the bony bump and remove the remaining degenerated cartilage around the joint surface. Your surgeon will then fuse the metatarsal bone and phalange of the big toe. The bones are held in position with the help of screws, metal staples or plates and the joint is stabilised.

Post-operative Care

Following the procedure, you may have to use crutches and wear a wedge shoe for around 6 to 8 weeks to relieve pressure on the front area of the foot. Keep the foot clean and dry and protect it when you have a shower until the wound is completely healed. Avoid driving and long hours of standing for a few weeks. Elevate your operated foot for the first two weeks to promote healing of the wounds and to help alleviate pain. You may experience swelling of the forefoot for a few months. Exercise may be recommended to improve movement, flexibility, and to strengthen the foot.

Risks & Complications

As with any surgery, hallux metatarsophalangeal joint fusion involves certain risks and complications. They include:

  • Infection and swelling
  • Non-healing wounds
  • Nerve injury
  • Malposition of the fused toe
  • Rarely, deep vein thrombosis or pulmonary embolism

  • British Orthopaedic Foot & Ankle Society
  • Royal College Of Surgeon
  • BMI Healthcare
  • London Musculoskeletal Centre
  • Hillingdon Hospital
  • Princess Grace Hospital