Foot and Ankle Surgery : Advances in Orthopaedic

Dr Chong Keen Wai, MBBS, MRCS (Edin), M Med (Ortho), FRCS (Edin)(Ortho), Dept of Orthopaedics, Singapore General Hospital

The foot and ankle bears the stress of our whole body weight as we go about our daily activities. This stress is relentless. As we walk over uneven ground, it allows us to accommodate to the undulation, further adding stress to the numerous joints in the foot. Our increasingly active population has also contributed to a rising incidence of ankle sports injuries to the ankle and foot. Fashionable footwear has further added problems as women squeeze their foot into shoes of all shapes and sizes. It is not surprising that pain and deformity in the foot and ankle is a common complaint in any Orthopaedic clinic.

In previous times, the scientific understanding of problems afflicting the foot and biomechanics of the foot were poorly studied and understood. Many doctors adopted a “rest more, walk less and change shoe” type of treatment strategy. This might have worked for patients of the past where expectations were lower. As our population ages, we are expected to retire later. The elderly now no longer has a brood of offsprings to look after them if they are disabled. They need to be independent. They need to be functionally able to look after themselves. They need to enjoy retired life and go on vacations. Active individuals want to continue to enjoy sporting activities. We can now give them the option to be better, faster and go further.

Because we now better understand the biomechanics of the foot and ankle and how deformities start, degenerative conditions of the foot can now be effectively treated by various osteotomies (bone reshaping) to relieve pain by re-balancing the foot such that the stress on affected joints are reduced. In the past, such degenerative conditions were treated with arthrodesis (joint fusion). This sacrifices motion in the foot and puts the adjacent joints at risk of accelerated degenerative changes. Osteotomies and tendon transfers preserve the mobility of joints.

In the case of severely damaged small joints, arthrodesis may still be inevitable. Previously, foot and ankle surgery was associated with significant risks of bony non-union and prolonged time in crutches or wheelchair. Not anymore. Small joints can now be reliably and predictable fused with new and low profile implants that allow early mobility and weight bearing.

Keyhole or arthroscopic surgery is re-defining the ways in which we manage ankle pain in the athletic population. Ankle arthroscopy is already an established common procedure. However, not all pathologies occur in the ankle joint. Lying just below it is a much smaller joint that normally allows us to walk on uneven ground. This is the subtalar joint. It can be easily damaged by landing awkwardly on one’s heels. At the Singapore General Hospital, we have the expertise and have performed on a regular basis, subtalar joint arthroscopy. With the ability to look not just “inside the ankle”, but also “under the ankle”, the management of ankle pain is much enhanced.

At the Singapore General Hospital, keyhole surgery does not just mean arthroscopic surgery alone. Many sporting and also degenerative causes of ankle pain are due to tendon pathology and not joint pathology. It is inadequate to be able to look only inside the joints. We now have the ability to look at the tendons outside the joints endoscopically. Tendons can be lengthened, debrided, and repaired via keyhole incisions with reduced downtime and less pain (Fig 1 and 2).

The technology involved in treating recalcitrant tendon pathology such as tendinosis and plantar fasciitis has also improved. Radiofrequency technology has allowed us to treat tendinosis with predictably good results. Recalcitrant plantar fasciitis can also be treated with smaller incisions which preserve the mechanical integrity of the plantar fascia. The old procedure of performing plantar fascia releases, which runs the risk of the catastrophic consequence of creating an iatrogenic arch collapse, can now be avoided.

Deformities of the forefoot is a very common problem. Hallux valgus and claw toes can cause significant disability in some individuals. The understanding of the pathology and an updated scientific approach to surgical correction based on sound biomechanical principles has made the outcome of surgical corrections much more predictably favourable. Internal fixation with special screws that can be buried in the bone, is used routinely to allow immediate weight bearing without crutches (Fig 3 and 4). It is not necessary to sacrifice joints to correct the majority of claw toe deformities as very distal osteotomies can be performed on the small bones and which can still be internally stabilised by ‘mini’ screws.

Fig 3. Previous hallux valgus surgery performed elsewhere with recurrence of deformity.	Fig 4. After revision surgery with scarf osteotomy and screw fixation.

Ankle joint arthritis used to be a life changing diagnosis. While hips and knees can be replaced with artificial joints, this option did not used to be available to the ankle. Up till recently, a severely arthritic ankle joint can only be effectively treated by fusion (Fig 5). This involves using screws and even steel plates to hold the moving parts of the ankle joint together such that they are permanently incapable of moving anymore. The thinking was that in an arthritic joint, movement causes pain and so, stopping movement will end the pain. Although effective in ending pain, the patient certainly has an abnormal ankle. Studies have shown that this abnormal ankle requires more effort to walk. Also, by fusing the ankle joint, the neighbouring joints in the foot will have to “move more” so as to compensate for the stiffness. These joints will then wear out more quickly and themselves become arthritic.

Total ankle joint replacement is one of the newest technology available to foot and ankle surgeons (Fig 6). Decades ago, hips and knees used to be fused as well. Now, hip and knee replacements are commonplace. Our foot and ankle surgeons can now replace the ankle joint rather than fuse it. Of course, total ankle replacement is not meant for everyone. In those ankles that are severely deformed, this is not feasible and a fusion will still be necessary. Alternatively, the deformity can be corrected before an ankle replacement. A proper assessment by the surgeons will establish whether an artificial ankle joint is suitable.

Orthopaedic foot and ankle surgery is the “young brother” amongst all the orthopaedic subspecialty branches. It is however, important in a well developed orthopaedic service to be well rounded in every subspecialty so as to provide comprehensive care to our patients.