A Guide to Foot & Ankle Surgery

When surgery might be needed and what you can expect

In the UK most NHS and private hospitals carry out many different types of foot and ankle surgeries. These include joint replacements, fusion of arthritic joints, deformity correction and diabetes related foot surgery.

Many people with foot and ankle problems will see their family doctor (GP), rheumatologist or podiatrist before they see a surgeon for an operation. They may receive other treatments including:-

• Exercise/Physiotherapy
• Footcare
• Drug treatments (usually painkillers like paracetamol) and nonsteroidal anti-inflammatory drugs or NSAIDs (eg: ibuprofen)
• Disease-modifying anti-rheumatic drugs (DMARDs) for rheumatoid arthritis
• Steroid injections
• Advice on footwear style
• Insoles/orthoses and specially altered shoes

If these treatments do not ease the problem and you still experience pain and discomfort or your feet are becoming deformed then it is important to get an assessment for urgent surgery. The decision for surgery is usually based on lifestyle choices and the information given by the surgeon, rather than being essential in terms of life and death.

Why risk surgery?

The foot and ankle is one the most complicated area of our body. Feet are made up of 26 bones and more than 33 joints arranged in columns and arches that vary in stiffness and flexibility. Many and varied problems can occur in this complicated structure.

The purpose of treatment is to decrease your pain and improve the function of your foot. Most NHS Hospitals do not offer surgery for cosmetic reasons.  But many Private Hospitals do offer cosmetic foot surgery.

Most surgeries go smoothly and patients make a steady recovery.

• 3-6 months after surgery most patients will be comfortably mobile
• 6-12 months after surgery you should be noticeably better than before the surgery
• From 12 months you should regain a feeling of normality

But everyone can vary in their recovery time so don’t be too concerned about a delay in your recovery as long as things are improving.

Complications after surgery occur in approximately 10% of cases. Your particular procedure may carry a higher risk of complications and your surgeon will always discuss this with you.

What can you expect from your surgery?

80% of people experience good to excellent results. On average following surgery. They have significant pain relief and return of good functional movement and strength.

Some discomfort is common for about 3-4 months following surgery. After this, the reduced pain and improved mobility allows patients to walk, sit, drive a car and get along with everyday activities.

What are the most common types of foot and ankle surgery?

Conditions that may require surgery include:

• Bunions
• Hammer toes
• Damaged metatarsal bones
• Arthritis
• Achilles tendon disorders
• Morton’s neuroma
• Tibialis posterior dysfunction
• Plantar fasciitis (although this is very rare)

What are the possible advantages?

The benefits of having surgery can include:

• Pain relief
• Improved function in your feet
• Appearance for feet improved

Surgical outcomes for specific foot and ankle surgeries vary depending on the type of surgery and the individual patient.

What are the possible disadvantages?

The disadvantages of having surgery can include:

• Reduced joint movement, depending on the type of operation
• Replacement joints wearing down quicker than natural joints

What are the possible complications?

Every possible care is taken to prevent complications, but in a few cases these do happen. They may include:

• Increased pain
• Infections
• Stiffness
• Haematoma (bleeding)
• Reduced function
• Altered or loss of feeling
• Occasionally where bones are joined (fused) together, the bones can take longer to fuse together than expected and you won’t be fully mobile for a while longer.
• non-unions (Failed healing of the bone damage) can occur and you may need further surgery.

How does your foot work?

The foot is separated into three different parts.

The front of the foot (Forefoot) is made up of your toe bones (phalanges), which are connected to five long bones (metatarsals) by joints. Joints in your toes don’t move very much. The forefoot takes half of your body’s weight.

The middle of the foot (Midfoot) is made up of five tarsal bones. These form the arch of your foot. Tarsals are connected to the front and back of your foot by muscles and the plantar fascia. When we’re walking or running they act as shock absorbers.

The back of the foot (Hindfoot) is your heel bone (calcaneus) and your ankle (talus). Joined together by the subtalar joint, which allows your foot to move from side to side. Your ankle bone is joined to your leg bones (tibia and fibula) at your ankle joint, which acts like a hinge. Allowing the foot to move up and down.

The muscles in your lower leg are attached to bones in your feet by tendons, and they control movement that allows us to stand, walk, jump.

 

At home – how can I prepare for surgery?

There are several things you can do to prepare and make your hospital stay go as smoothly as possible. Try to start these preparations 1-2 months before your surgery. Always discuss these points at the pre-operative clinic if you are unsure.

There are several things that you can do to prepare and make your hospital stay go as smoothly as possible. Try to start these preparations 1-2 months before your surgery. Always discuss these points at the pre-operative clinic if you are unsure

Are you a smoker?

Smoking will affect your recovery. Try to stop at least 6 weeks before your surgery as smoking can delay healing.

Research shows smoking reduces the blood flow through blood vessels to a quarter of normal flow. This affects wound healing and can lengthen bone healing times or lead to failure of bone healing (this is called non-union). Surgery can be delayed until you have stopped smoking. Also stop taking any nicotine supplements.

Transportation home from the hospital

You may have to make your own arrangements home from the hospital after surgery. Hospital transport is not always available. You will need to make these arrangements in advance. The vehicle should be large enough for you to put your foot up on the back seat while sitting and wearing a seat belt.

Before the Surgery

Most patients are admitted on the day of their surgery but some are admitted the day before. Pack sturdy flat shoes to wear on the un-operated foot and choose loose clothing that will fit over your bandage or plaster cast.

Someone from the surgical team will visit you before surgery to discuss the surgery and answer any remaining questions you may have. They will also mark the leg to be operated on with a marker pen. Don’t wear Nail varnish.

The anaesthetist will usually visit you during this time to help you decide which type of anaesthetic you will have. This decision is based on your medical condition and personal preference. Some patients may have local anaesthetic nerve blocks or spinal anaesthesia to numb the leg. Sedation is also offered. Other patients will prefer to have a general anaesthetic.

Pre-operative review clinic

Before your surgery you could also attend a clinic to see the surgeon. This may be your first opportunity to meet your surgeon.

The purpose of this visit is to assess your fitness for surgery, answer your questions and make sure that things go smoothly on the day of your surgery. You may need to have blood tests, further X-rays or a heart tracing (ECG).

They will review your foot or ankle, X-ray and medical notes and discuss the final plan for your treatment. This is your opportunity to ask any other questions you may have so make a list and bring it with you. You may wish to bring a friend or family member with you.

The appointment may take a couple of hours so please allow for this especially if parking at hospital.

If you miss this appointment your surgery could be postponed or cancelled.

Patient outcomes

You will be asked to complete a questionnaire regarding your symptoms and treatment before surgery and periodically after surgery. This is very important. Your results will help find out what the benefits of different treatments are, as well as allowing the surgeons to compare results with those of other surgeons to make sure they are providing the best service that they can.

How long will you be in hospital?

The average length of stay in the hospital following foot or ankle surgery is between 1-3 days. This is only a guide and individual timelines may vary. Many patients will have day surgery which means they do not have to stay overnight.

After the operation,”what happens next?”

After surgery you will be transferred to the recovery room and then to the ward.

Nursing staff will check your blood pressure, pulse and temperature regularly as well as check your operated leg.

You will either have a bandage, a post-op-boot or a temporary plaster cast (back slab) on your lower leg. This will be well padded to absorb any blood and allow for swelling.

If your surgery included correction of your toes you may have wires sticking out of your toes so be careful moving your leg.

Most patients remain in bed for a period following surgery. This is to control the amount of swelling.

Mobility

You’ll have crutches if you need them after surgery. Some patients may require other aids or adaptations for home use. Ask if these are available for you!

Mobilising and weight bearing

Therapists will want you to get out of bed as soon as is possible, and help you to use crutches (or a walking frame). The therapist will instruct you on how much weight you may take through your foot and for how long. This is critical for your recovery.

• Some patients should not put any weight through their foot until it heals
• Some will be advised to walk on the heel of the foot only while others may be advised to put all of their weight down on the foot

Pain

There will be some pain in your foot or ankle. You will have medication to help reduce this and you must take your tablets as instructed. If you feel the medication isn’t sufficient, you must inform the nursing staff and they will arrange for other medication to be prescribed. There are many other options available.

Swelling

An easy way to control swelling is to keep your foot raised 6 inches above your heart. Do this by lying flat and placing a pillow under your foot.

While you are in the hospital the cast or dressing will be checked regularly for swelling.

Numbness

If you have a local anaesthetic around the nerves of your leg during the surgery you may notice numbness but no pain until the anaesthetic wears off. This is normal and the numbness can last between 12-20 hours.

Starting pain medication while the foot is still numb should help decrease the overall amount of pain after surgery.

A warning!

If your pain or numbness increases, if your leg feels tight in the cast, if you have any bleeding or if the toes change colour and look white or blue compared to the others you must tell the nurse immediately!!

If you have left Hospital when problems arise please contact your Consultant’s secretary via the switch board at your local hospital.

Different surgeons have different ideas about the treatment you’ll need after an operation. This is affected by the type of operation and your health. You should discuss with your surgeon what to expect after the operation. Your nurse or physiotherapist will also be able to offer support.

You’ll have an outpatient appointment after you’ve been discharged so your progress can be checked. Sometimes your GP will help with this aftercare. A district nurse may also be asked to remove stitches and change dressings.

If you stopped taking any of your regular medication or had to alter the dose before the operation, it is very important to talk to your consultant for advice on when you should restart your medication.

At home – minimising your pain

Pain and discomfort decrease gradually over the weeks following surgery.

It is vital that you;

• Take the pain medication regularly to begin with
• Rest often and do not push yourself beyond your limits

If you find your exercise painful, take your pain medications 30 minutes before exercising or going for physiotherapy.

Reducing the swelling

Swelling in your foot and ankle is normal after surgery. This gradually improves but can persist for several months, particularly after periods of exercise. Raise the foot above the level of your heart i.e. lie down and place a pillow under your foot. You can also apply an ice pack (e.g. frozen vegetables) wrapped in a towel. Do not place the ice pack directly on to your skin.

Keep your dressing or plaster cast dry

There are protective waterproof covers for your foot/leg, now available to allow bathing or showering. Check online retailers or pharmacies.

Caring for your wound

• Leave your dressing or cast in place until it is removed or changed in the clinic.
• Keep your wound dry until the wounds have fully healed and any wires are removed.
• If your stitches need to be removed, this is done 10 to 14 days after surgery usually by a nurse in the outpatients clinic or at your GP practice.
• Wires will be removed between 3-6 weeks after the surgery in clinic.

Check for possible problems – See a doctor immediately if:

• Swelling continues to increase despite raising the foot
• Pain worsens and pain medications don’t help
• Your temperature has gone up for more than 4 hours
• You develop chest pains or shortness of breath
• You develop new numbness in your operated leg
• You develop pain and tightness at the back of your leg
• The toes on the operated foot become white or blue when compared to the other foot
• If there is an odour or discharge from under your cast or bandage

Follow-Up Appointments

You will probably get your first follow-up appointment before you go home.

Most patients require an appointment at a clinic at 10 to 14 days after their surgery. At this appointment your wound will be checked and stitches or staples will be removed.

If you have a temporary cast this will be replaced with a full cast or a removable walking boot.

Most patients will then have a second appointment at 6 weeks following surgery and may require regular appointments after this depending on the type of surgery. This may be at the nurse-led clinic, podiatry clinic or orthopaedic clinic depending on the type of surgery and specific treatment. You may be referred for physiotherapy. X-rays can be taken at these appointments.

Good Nutrition

As you recover at home, think about who will help you shop, prepare meals and clean up in the kitchen? A family member or friend who can help would be a huge benefit. Good nutrition is important to help you make a good recovery from your surgery.

Your Medications

This will be discussed at the pre-assessment clinic. The consultant may ask you to stop taking certain medications such as blood thinners (e.g. warfarin or aspirin) before your surgery.

Certain pain killers known as Non-Steroidal Anti-Inflammatory Drugs e.g. Ibuprofen, Diclofenac, have been shown to reduce or slow bone healing. You may be advised to stop taking these after your surgery.

Return to work

This will vary depending on the type of surgery and your job. For example the same surgery may take 2 weeks for an office clerk to return to work but 5 months for a construction worker. You can only estimate return to work dates as complications may cause further delay.

Consider:

Can you work without bearing weight on the foot? If so pain will be the main limiting factor. It is unlikely that you will return to work within two weeks of the surgery.

If you have to weight bear at work and have had fusion surgery it will take you a minimum of three months to be able to bear weight comfortably without a cast or boot. It will usually take six weeks after that to be able to return to work.

Return to driving

Depending on the type of surgery you won’t be able to drive for a number of weeks or as long as you are in a cast or walking boot. You will need to plan for a period when you are unable to drive.

• Only return to driving when able to comfortably and safely change gear and carry out an emergency stop.
• Contact your insurance company for further details as all policies vary.

Air travel

Your team will usually advise against air travel immediately after surgery. They may well  recommend that you avoid air travel to a holiday destination for a minimum of 6 weeks after surgery to reduce the risks such as DVT.

Complications and temporary problems

Most of these do not affect the long-term functional outcome of the surgery. These include:

• Delay in wound healing
• Wound tightness or sensitivity (once the wound heals massaging and moisturising the area will help these symptoms)
• Wound infection
• Delay in bone healing
• Stiffness

Some problems may relate to your general health. Remember any surgery is a stress to your body. Complications relating to any surgery or anaesthetic include:

• Heart attack (this risk applies mostly to patients with previous heart problems)
• Chest infection
• Reaction to the anaesthetic
• Blood clots. These are rare after foot and ankle surgery and it is very important to tell your surgeon if you have had any previous deep vein clots. Some patients will require preventative medications

Smoking – Remember Patients who continue to smoke have a higher risk of complications following their surgery.

Some problems that may require further surgery

• Delay in bone healing
• Painful screws or metalwork
• Wound problems requiring surgical cleaning or plastic surgery
• Loosening or wear of a joint replacement
• Healing of a fusion or a correction in the wrong position

Some less likely complications that may cause long term problems

• Chronic Regional Pain Syndrome (overactive nerve or pain response after the surgery)
• Nerve damage during the surgery (partial nerve injury – burning or tingling, complete nerve injury – numbness)
• Failure of the bones to join (Non-union).
• Infection in the bone

Conditions of the foot & ankle and how to treat them

Bunions

Bunions are bony lumps that develop on the side of your foot and at the base of your big toe. They’re the result of a condition called Hallux Valgus, which causes the big toe joint to bend towards the other toes and become deformed. If symptoms carry on over a long period, the toe may need to be surgically corrected. This involves straightening the big toe and metatarsals, a surgery called an Osteotomy. This may make the joint stiffer, but it works to ease the pain. Hallux valgus is different to Hallux rigidus, which is osteoarthritis of the big toe joint. Hallux rigidus causes the big toe to become stiff and its range of movement is  much reduced.

Hammer toes

As well as bunions, hallux valgus can also cause your other toes to become clawed or permanently bent. This condition is called hammer toes. Damage caused by hammer toes can be eased by:

• Arthroplasty: removing the deformed joint between the toe bones (phalanges), which leaves the joint flexible
• Arthrodesis: fusing the phalanges together, which leaves the toe more stable but means you’ll only be able to wear flat shoes after the operation

Metatarsal damage

The joints in the forefoot can be damaged by inflammation of the lining of the joint (synovitis) in some forms of arthritis, particularly  Rheumatoid arthritis. These small joints are called the Metatarsophalangeal joints (MTPJ), and they can become dislocated when damaged by arthritis. The pain and discomfort this causes can be like walking on pebbles.

Ankle arthritis

Ankle arthritis is usually caused by osteoarthritis. This is where the cartilage covering the ends of your bones gradually roughens and becomes thin, and the bone underneath thickens. It can also be caused by damage from other rheumatic conditions, for example rheumatoid arthritis, or a previous injury. Leading to pain, swelling and occasional deformity and restricted movement of the joint. Surgery may be needed in severe cases.

There are three surgical options:

1: Ankle fusion: Ankle fusion involves removing the damaged ankle joint and fusing your talus bone to your tibia to form a stiff but pain-free ankle. Your foot is fused at a right angle to your leg, in the position it would be if you were standing up. The bones are held together using screws, and new bone grows across, creating one bone where there were two. It normally takes between 12–14 weeks for the fusion to be complete and your bone continues to become stronger after this.

2: Triple fusion: This is the surgical fusion of three joints (the Talonavicular, subtalar and calcaneocuboid joints) either as a treatment for arthritis within these joints or as a method of correcting a stiff foot deformity. A combination of plates, screws or staples is often used to achieve this. Similar to an ankle fusion, it takes 12–14 weeks for the fusion to be complete

3: Ankle replacement: An ankle replacement involves taking out the worn-out ends of your tibia and talus bones and replacing them with manmade (artificial) ends made out of plastic or metal. Unlike an ankle fusion, a replacement allows the joint to move after surgery.

Replacement ankle joints haven’t been used for as long as replacement hips and knees, and they don’t last as long, but they can last for about 10–15 years. Your physiotherapist will advise you on how to take care of the new joint.

 

Achilles tendon disorders

The Achilles tendon is the largest tendon in your body, and the muscle in your lower leg puts a lot of force through it to make you move. As we get older it can start to wear, which can lead to painful swellings in part of the main tendon or where it attaches to the heel bone. Very occasionally surgery can be used as a method of treatment.

Morton’s neuroma

Morton’s neuroma is a painful condition that involves a nerve that supplies feeling to two neighbouring toes. It most commonly affects the nerve to the third and fourth toes. For bad cases, surgery to remove the painful nerve can be successful.

Tibialis posterior dysfunction

The tibialis posterior is a muscle that supports the instep arch shape. The tendon that connects this muscle to the bone can become inflamed, leading to pain and swelling on the inside of the ankle. Continual swelling can start to cause the tendon to weaken, which can lead to a flatfooted look over time. Occasionally, bad cases need surgery to rebuild the instep arch, which can be very successful. In long-standing or untreated cases, three hindfoot joints may need to be fused (triple fusion) to ease pain.

Plantar fasciitis

The plantar fascia is a tough band of fibrous tissue that starts at the heel bone and stretches across the sole of the foot to the toes. Plantar fasciitis is inflammation at the site where the fascia attaches under the heel. Very rarely, bad cases may need surgery to release the plantar fascia from the heel bone.

Foot Fractures

These account for 10% of all the broken bones in the body, and the mechanism of injury usually can give a clue as to what bone might be injured. Fractures of the calcaneus (heel bone) usually occur when a person jumps or falls from a height, landing directly on their feet.

The bones in the foot may be broken in many ways including direct blows, crush injuries, falls and overuse or stress. Signs and symptoms of a broken foot may include:- pain, limping, swelling, bruising, and refusal to bear weight on the affected foot.

Initial treatment may include RICE (rest, ice, compression, elevation). Rest may include the use of crutches to limit weight bearing.

Surgery is an option for serious Bone fractures in the foot & ankle. A combination of plates, screws or staples is often used to achieve a secure healing.

First metatarsal (Big Toe) fractures that are aligned nicely may be treated with a post-op shoe with no weight bearing. If the fracture is displaced, e.g. the bone fragments do not align, then surgery to pin or plate the fracture may be considered.

Infection in a joint replacement (this will require revision surgery)

Damage to the blood vessels of the operated leg.

On occasion a small percentage of these complications may lead to partial or complete amputation of the lower limb.

 

Glossary

Anaesthetist – a clinician who gives patients their anaesthetic.

Bunion – a bony lump on the side of the big toe, caused by hallux valgus. A swelling or bursa on the foot is also called a bunion.

Bursa (plural bursae) – a small pouch of fibrous tissue lined (like a joint) with a synovial membrane. Bursae reduce friction; found where tendons or ligaments pass over bones. Others, however, form in response to unusual pressure or friction – for example, with a bunion.

Cartilage – slippery tough tissue that covers the ends of the bones in joints. It’s a shock absorber and allows smooth movement between bones.

Disease-modifying anti-rheumatic drugs (DMARDs) – drugs used in rheumatoid arthritis to suppress the disease and reduce inflammation. Unlike painkillers and non-steroidal anti-inflammatory drugs (NSAIDs), DMARDs rather than just reducing the pain and stiffness, treat the disease itself. Examples of DMARDs are methotrexate, sulfasalazine,

Hallux rigidus – osteoarthritis of the big toe joint with a stiff, painful, big toe.

Hallux valgus –the big toe pushes across towards the other toes. It can cause deformities such as bunions and hammer toes.

Hammer toes – toes that have contracted into a clawed position. Tendons are tight to begin with and the toes can still be straightened by hand. Gradually the joints become fixed in a curled position. Hammer toes are sometimes known as claw, mallet or retracted toes.

Inflammation – a normal reaction to injury or infection of living tissues. Blood flow increases, resulting in heat and redness in the affected area causing fluid and cells to leak into the tissue, causing the swelling.

Ligament – a tough, fibrous band anchoring the bones on either side of a joint and holding the joint together.

Non-steroidal anti-inflammatory drugs (NSAIDs) – a large family of drugs prescribed to reduce inflammation and control pain, swelling and stiffness. Including ibuprofen, naproxen and diclofenac.

Occupational therapist –specialist who helps people during rehabilitation after surgery helping to  maintain their independence through advice on equipment, adaptations or by changing the way they do things (such as learning to dress using devices after Foot surgery).

Orthosis (plural orthoses) – a device to help part of the body to work better. Used to provide support or to adjust the mechanical function of a joint, (e.g: the Foot). Most foot orthoses are insoles worn inside the shoe.

Osteoarthritis – the most common form of arthritis (mainly affecting the joints in the fingers, knees and hips), causing cartilage thinning and bony overgrowths (osteophytes). End result always causes pain, swelling and stiffness.

Osteophyte – an overgrowth of new bone around the edges of osteoarthritic joints. Spurs of new bone can affect the shape of the joint and may also affect nearby nerves.

Physiotherapist – a trained specialist who helps to keep your joints and muscles moving, helps ease pain and keeps you mobile.

Podiatrist – a trained foot specialist with expertise in non-operative treatment of foot and ankle problems. Podiatrist and chiropodist mean the same thing.

Rheumatoid arthritis – an inflammatory disease affecting the joints, particularly the lining of the joint. Often in both hands or wrists at once.

Rheumatologist – a specialist with an interest in autoimmune diseases and diseases of joints, bones and muscles.

Surgical Boot– Specially designed soft boot to protect toes and surgical wounds, which raises the foot after surgery.

Tendon – a strong, fibrous band or cord that anchors muscle to bone.