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Foot and Ankle Procedures
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Introduction

For information on the foot and ankle please visit www.fredthefoot.co.uk.

The alignment of the leg is such that the weight passes from the centre of the hip, through the centre of the knee, and into the centre of the ankle. Anything which changes this alignment will alter the way the ankle is loaded and cause it to wear unevenly, and more quickly. 'Bow legs' or 'knock knees' are examples of malalignment, which can affect the ankle.

Similarly ankles which point inwards are more prone to sprains, and consequently early arthritis. In some cases realignment of the bones may be helpful in treatment.

Foot

Hallux rigidus (Latin for a "stiff great toe") is a condition caused by arthritis at the base of the big toe. It commonly affects active and sporty people as a result of repeated trauma. The stiffness of the toe is especially noticeable on the upward bending caused by walking or running.

This stiffness causes pain. As well as the pain and stiffness hallux rigidus causes a bump on the top of the big toe.

Unlike hallux rigidus a bunion is a lump at the base of the great toe, caused by sideways drifting and angulation of the great toe. The lump of a bunion is found on the inside of the big toe, as opposed to the top in hallux rigidus.

The pain from a bunion is most commonly caused by pressure from shoes or, on occasions, by crowding or crossing over of the lesser toes. The latin for a bunion is hallux valgus, as opposed to rigidus. Some people have both hallux valgus and rigidus!

As with the arthritis of any joint, avoiding those activities which cause the symptoms is one option. Obviously not everyone is happy to do this. In ladies, symptoms may be relieved by avoiding high heels.

Anti-inflammatory medications and gels may also help. Stiffening the sole of the shoe may also improve symptoms, although the effects are often short-lived.

Your doctor will advise you if lesser forms of surgery such as removal of bony spurs is appropriate.

A bunion is a lump at the base of the big toe, caused by sideways drifting and angulation of the big toe. A bunion is not a 'bump' on the bone, it is caused by angulation of the bones in the foot. Sometimes it is painful in itself, but more commonly it causes symptoms by pressure on shoe-wear or, on occasions, by crowding or crossing the smaller (lesser) toes. The second toe can become so crowded that it becomes 'clawed,' and crosses over the big toe.

Early and mild bunions may respond to the application of splints or braces, although the effects are often short-lived. Wearing 'corn plasters' or 'pads' may relieve local pressure symptoms. Shoes may be made or adapted to accommodate the bunion within a broad front (toe-box). Some bunions are caused by flat foot and collapse of the arches. These can be helped by arch supports.

More severe bunions can only be corrected by surgery. Surgery should only be undertaken if the symptoms are significant and appropriate non-operative management has been considered. The surgery is usually carried out under a general anaesthetic, with local anaesthetic being used to reduce the amount of general anaesthetic required. Surgery is usually performed either as a day-case (where you do not have to stay in hospital over night at all), or with an overnight stay in hospital.

Morton's neuroma is one cause of metatarsalgia, which is pain in the ball of the foot. In 1876, Thomas Morton described the neuroma: It is due to inflammation of a nerve in the foot. The inflammation is caused by entrapment of the nerve underneath the bones of the ball of the foot. 'Neuroma' means nerve tumour. Tumour in this case means simply enlargement of the nerve, not malignancy or cancer.

The cause of nerve enlargement is repeated injury. The nerve becomes trapped between the metatarsal heads when standing and walking. It usually occurs between the second and third, or third and fourth toes.

The symptoms of Morton's neuroma are pain and numbness in the toes. At times, the pain may be absent and at other times severe enough to cause the individual to stop and take off the shoe. It may feel like a marble moving around under the ball of the foot, and sometimes causes a 'snap'. The examining doctor can sometimes feel this by pressing on the foot. Testing with a pin may reveal numbness in the toes.

Ankle

The ankle joint is a hinge between the tibia (shin bone) and the talus (ankle bone). It allows up and down movement. The fibula bone lies on the outside of the joint. The ankle has to bear 5 to 7 times the body weight during day to day activities, such as standing and walking.

Below the ankle is the subtalar joint. The subtalar joint, between the talus and heel bone (calcaneus) allows side to side movement.

Ankle arthritis can be caused by degeneration (osteoarthritis) or inflammation (e.g. rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis). In both cases the cartilage, which is the shiny white gristle that lines and articulates the joint, becomes damaged. This causes bone to rub on bone, which is painful.

Osteoarthritis is usually secondary to damage to the joint, for example as a result of previous fracture, repeated sprains of the ankle, malalignment of the joint or infection.

Excess body weight can overload a joint and worsen the symptoms of arthritis. Every extra kilogram of body weight is multiplied by 5 to 7 times when it is carried by the ankle.

The alignment of the leg is such that the weight passes from the centre of the hip, through the centre of the knee, and into the centre of the ankle. Anything which changes this alignment will alter the way the ankle is loaded and cause it to wear unevenly, and more quickly. 'Bow legs' or 'knock knees' are examples of malalignment, which can affect the ankle. Similarly ankles which point inwards are more prone to sprains, and consequently early arthritis. In some cases realignment of the bones may be helpful in treatment.

The use of modern technology allows operations to be performed through keyhole incisions and has advantages over conventional surgery, as the ankle responds badly to open incisions, and complications of open surgery are common.

Ankle arthroscopy is performed under a general anaesthetic either as a day-case or with an overnight stay. We will advise you as to which is more appropriate to you.

During the surgery an arthroscope (A small telescope approximately three to four millimetres in diameter) is inserted into the ankle through two or three small puncture wounds. This allows the surgeon to see and operate inside the joint. Operations can be on the soft tissues and the bone, including removal of bony spurs, damaged cartilage and inflamed soft tissue.

The following consultant specialises in foot and ankle procedures: Mr Andrew “Fred” Robinson

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