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Hindfoot Surgery

Triple Arthrodesis

The foot is made up of 26 bones and 33 joints. Three joints at the back of the foot, namely, subtalar, talonavicular and calcaneocuboid joints allow the side to side movement of the foot.

Arthritis is inflammation caused when the cushioning cartilage present on the joints wears away. Arthritis causes pain, swelling, stiffness, and limited movement. The subtalar, talonavicular and calcaneocuboid joints can become deformed from arthritis. A long-standing deformity such as flat foot can also cause severe pain in these joints.

Indications

Triple arthrodesis is indicated to relieve pain and correct deformities only when conservative treatment approaches such as NSAIDS (non-steroidal anti-inflammatory drugs), physical therapy, strapping, steroid injections and bracing fails to provide relief.

Triple Arthrodesis surgery may also be indicated for:

  • Foot deformities that cannot be adequately braced
  • Arthritis
  • Flat foot
  • Joint instability
  • Neuromuscular disorders

Surgical Procedure

Triple arthrodesis is a surgical procedure carried out to fuse the subtalar, talonavicular and calcaneocuboid joints.

The procedure is performed under local or general anaesthesia and takes around 2 to 2.5 hours for completion. Your surgeon will make two incisions on the foot to gain access to the joints. The damaged arthritic cartilage is removed and the bones are re-aligned. Bone graft is filled into the joints to help the bones to fuse. Metal screws and staples are used to keep the bones in place while they heal. The tissue layers and incisions are then sewed back together and dressed with a bandage.

Risks & Complications

As with any surgery, Triple arthrodesis involves certain potential risks and complications. Some of the risks include

  • Non-union wherein the fusion site fails to adequately unite together
  • Infection
  • Wound healing
  • Nerve injury

The risks are increased in patients with diabetes as well as smokers.

Post - Operative Care

After the surgery, your leg will be placed in a splint that reaches up to your knee and you may require crutches for walking. You will be prescribed pain medication to relieve post-operative pain. The foot must be kept raised to reduce swelling.

During your post-operative visit, your foot will be examined to check that the fusion is healing and to remove your stiches. You will be prescribed compression stockings and your foot will be placed in a walking boot. Post-operative care usually involves physical therapy for about 6 weeks. You will be able to get back to work within 12 to 14 weeks once the bones have healed.

Ankle Arthrodesis

Ankle arthrodesis is the surgical fusion of bones that form the ankle joint. The ankle joint is formed by the tibia, talus, and the fibula bones.

The goal of ankle arthrodesis is to relieve pain in the affected joint. This is achieved by surgically eliminating the joint.

Ankle arthrodesis is recommended for the treatment of severe end stage arthritis that has not responded to conservative treatment measures such as medications or injections. The other indications include ankle infections, neurological ankle instability, and tumours.

Ankle conditions should be evaluated for proper diagnosis and treatment. Accurate diagnosis comprises of a detailed medical history and physical examination. Imaging tests such as X-rays, Doppler Test, and MRI may be ordered.

Ankle arthrodesis can be performed as an arthroscopic or open traditional surgery. The approach for an open technique can be either from anterior (front) aspect or lateral (side) aspect of the ankle. The joints are then fused together with the help of screws, wires, plates, or rods. Bone grafting is recommended in cases of substantial bone loss. This is done using a graft taken from the patient (autograft) or donor tissue (allograft). The recovery time following fusion will depend on the technique employed and the health status of the individual patient.

The post-operative guidelines to be followed immediately after ankle arthrodesis include:

  • Keep your cast or dressing dry and do not remove for the specified time given by your surgeon
  • Avoid bearing weight on the operated ankle joint and use crutches or wheelchairs for a few weeks
  • Elevate the foot above heart level to minimize swelling.
  • Eating a healthy diet and quitting smoking will help with healing.

Ankle arthrodesis is usually a safe procedure and complications are uncommon. However, apart from general complications related to any surgery, complications after ankle arthrodesis can include infection, nerve damage, unresolved pain, non-union of bones, excessive swelling and stiffness, and irritation from foreign material such as pins or screws.

Anterior & Posterior Ankle Arthroscopy

Ankle arthroscopy is a minimally invasive surgical procedure in which an arthroscope, a small, soft, flexible tube with a light and video camera at the end, is inserted into the ankle joint to evaluate and treat a variety of conditions.

An arthroscope is a small, fibre-optic instrument consisting of a lens, light source, and video camera. The camera projects an image of the inside of the joint onto a large screen monitor allowing the surgeon to look for any damage, assess the type of injury, and repair the problem.

Indications

Ankle Arthroscopy, also referred to as keyhole surgery or minimally invasive surgery, has proved to be highly effective in managing various ankle disorders including ankle arthritis, unstable ankle, ankle fracture, osteochondral defects of the talus, infection, and undiagnosed ankle pain.

The benefits of arthroscopy compared to the alternative, open ankle surgery, include:

  • Smaller incisions
  • Minimal soft tissue trauma
  • Less pain
  • Faster healing time
  • Lower infection rate
  • Less scarring
  • Earlier mobilization
  • Shorter hospital stay

Procedure

Your surgeon will make 2 or 3 small incisions around the ankle joint. Through one of the incisions an arthroscope is inserted. Along with it, a sterile solution is pumped into the joint to expand the joint area and create room for the surgeon to work.

The larger image on the television monitor allows the surgeon to visualize the joint directly to determine the extent of damage so that it can be surgically treated. Surgical instruments will be inserted through the other tiny incisions to assess and treat the problem.

After the surgery, the instruments are removed, and the incisions are closed and covered with a bandage.

Post-surgical Care

After the procedure, you will be taken to a recovery room. The ankle joint will be immobilized with a splint or cast. The nature and duration of immobilization will depend on the type of repair performed and the preference of the surgeon. The surgical site should be kept clean and dry during the healing process. Patients may be prescribed pain medication for the management of pain. Elevation of the ankle and ice application helps to reduce pain and swelling. Follow your post-operative instructions for the best outcome.

Risks & complications

Ankle arthroscopy is a safe procedure and the incidence of complications is low. However, as with any surgery, risks and complications can occur. Some associated risks with ankle surgery can include infection, damage to blood vessels or nerves, bleeding, and compartment syndrome.

Tibialis posterior Reconstruction

The tibialis posterior tendon is one of the foremost supporting structures of the foot. Overstretched or inflammation of the tendon may lead to flat foot. Tibialis posterior 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.

Total Ankle Replacement

The ankle joint connects the leg with the foot and provides free movement to the foot. It is formed by connecting the bones of the lower leg, tibia and fibula, with the talus, or ankle bone.

The surface of the ankle bones is covered with an articular cartilage. Damage to this cartilage leads to a condition called arthritic ankle, which results in pain and impaired movement of the ankle. Infection, bone fracture, connective tissue disorder, excessive stress, and certain disease conditions such as rheumatoid arthritis, and osteoarthritis are causes of ankle arthritis.

Diagnosis

Ankle arthritis is diagnosed by your physician after taking a history and performing an examination of the symptomatic ankle. Imaging such as X-ray and MRI may be ordered to confirm the diagnosis.

Treatment

Conservative treatment of ankle arthritis involves oral medications and joint injections. However, for patients who are unresponsive to conservative treatment, ankle joint replacement surgery is recommended.

Ankle joint replacement, also known as total ankle arthroplasty, is a surgical procedure performed to relieve pain and immobility due to ankle arthritis.

Ankle joint replacement is also recommended for elderly patients with a severe fracture from osteoporosis, or presence of a tumour in the ankle joint.

Surgical Procedure

Ankle joint replacement surgery is performed under general anaesthesia. Your surgeon makes an incision over the front of the ankle. The muscles are retracted and tendons and ligaments are moved away to expose the ankle joint. The damaged part of the tibia, fibula, and talus bone are then removed using special instruments, and the remaining part of the bones are reshaped to fit the new artificial joint or prosthesis. A bone graft is inserted between the tibia and fibula to create a fusion of the two bones and prevent loosening of the prosthesis. The prosthetics are kept in position by using special bone cement and instrumentation such as screws to support the artificial ankle.

At the end of the surgery, tendons and other structures are placed back in position covering the new joint and the wound is sutured closed and covered with a sterile dressing.

Post-operative Care

Following ankle joint replacement, the patient may need to stay in the hospital for 2-3 days and will be advised on precautions for a successful recovery.

The treated ankle will be immobilized with the help of splints and a bulky dressing. Patients are advised not to put any weight on the ankle for at least 6 weeks and use crutches for walking. Usually a drain tube is inserted into the joint during surgery for draining blood from the incision, and is removed within 1-2 days after the surgery. Swelling and discomfort can be managed by taking prescription pain medicines, applying ice packs, and by elevating the ankle above heart level while resting. You will be referred to physical therapy soon after surgery to regain range of motion of the new ankle. Sutures are removed after 10-15 days and one should take care that the incision is kept clean and dry. Patients should avoid smoking, alcohol consumption, and should eat a healthy diet for the best outcome.

Risk & Complications

As with any major surgery, there are potential risks involved. The possible complications associated with ankle joint replacement include infection, fracture of the tibia or fibula bone, dislocation of the ankle, damage to nerves or blood vessels, blood clots (Deep Venous Thrombosis), loosening of artificial components, failure to relieve pain, instability and stiffness.

Total ankle replacement surgery is used to treat the pain and immobility of severe end stage arthritis that has not responded to non-surgical treatments. The goal of ankle joint replacement surgery is to eliminate your pain and increase the mobility of your ankle joint.

Achilles Tendon Reconstruction

Tendons are soft tissues connecting muscles to bone. The achilles tendon is the longest tendon in the body and is present behind the ankle, joining the calf muscles with the heel bone. Contraction of the calf muscle tightens the achilles tendon and pulls the heel, enabling foot and toe movements necessary for walking, running and jumping.

The achilles tendon is often injured during sports resulting in swelling and pain, a condition called tendonitis. In some cases, severe injury results in a tear or rupture of the Achilles tendon requiring immediate medical attention.

Causes

The tear or rupture of the Achilles tendon is commonly seen in middle aged male weekend athletes with weak tendons due to advanced age and from sudden bursts of activity during sports such as tennis, badminton, and basketball.

People with a history of tendonitis are more susceptible for ruptures as well as those suffering from certain diseases such as arthritis and diabetes, or taking certain antibiotics.

Symptoms

The classic symptom of an Achilles Tendon rupture is the inability to rise on your toes. Patients often describe a “popping” or “snapping” sound with severe pain, swelling and stiffness in the ankle region followed by bruising of the area. If the tendon is partially torn and not ruptured, pain and swelling may be mild.

Diagnosis

The diagnosis of a torn or ruptured Achilles tendon starts with a physical examination of the affected area, followed by a Thompson test in which the calf muscle is pressed with the patient lying on their stomach to check whether the tendon is still connected to the heel or not.

In certain cases, an ultrasound or MRI scan may be needed for a clear diagnosis.

Treatment

The main objective of treatment is to restore the normal physiology of the Achilles tendon so the patient can perform activities as before the injury.

Immediately following a torn or ruptured Achilles tendon you should employ the RICE method as follows:

  • Rest
  • Ice
  • Compression
  • Elevation

Treatment of a torn or ruptured Achilles tendon includes non-surgical or surgical methods. Non-surgical methods involve casting the injured area for six weeks for the ruptured tendon to reattach itself and heal. After removal of the cast, physical therapy is recommended to prevent stiffness and restore lost muscle tone.

Surgery may be recommended especially for competitive athletes, those who perform physical work, or in instances where the tendon re-ruptures. Your surgeon will stitch the torn tendon back together with strong sutures and tie the sutures together. Your surgeon may reinforce the Achilles tendon with other tendons depending on the extent of the tear. If the tendon has avulsed or pulled off the heel bone, your surgeon will reattach the tendon to the heel bone.

There are risks associated with any surgery. Specific risks for surgery to repair the Achilles tendon can include infection, bleeding, nerve injury, and blood clots.

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