DEFORMITIES + SURGERY:

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High arch foot type-

Usually due to congenital (hereditary) alignment of the body’s lower extremity bones, joints, ligaments, and tendons, but there are some neurologic disorders that can create a high arch foot.  These deformities can be severe and debilitating.  The high arch foot can put excessive pressure on joints, skin, nerves, and tendons causing many different pain generating scenarios. 

The focus of surgery is to identify the apex of the problem and the most pain generating problem and focus on that surgically.  Most commonly this is at the midarch area.  This can be reduced with bone cuts and fixating it with internal or external fixation.  Usually reducing one part of a deformity requires addressing other issues.  This usually involves balancing out the rearfoot (bone and or soft tissue) to the newly modified forefoot.

Most reconstructions will require some type of orthotic afterwards for protection and prevention.  These surgeries can take a full year to recover.  Most people are walking in a cast between 4-8 weeks postop.

Flatfoot

a. Congenital

Congenital flatfoot deformities are usually due to congenital (hereditary) alignment of the body’s lower extremity bones, joints, ligaments, and tendons, but there are some neurologic disorders that can create a flat foot.  These deformities can be severe and debilitating.  The flat foot can put excessive pressure on skin, nerves, and tendons causing many different pain generating scenarios.

b. Acquired

This is most commonly due to a tendon rupture, but also can be due to a neurologic disorder or trauma.  The two most common causes are a rupture of the posterior tibialis tendon within the foot (this is the tendon that helps support the arch), or a charcot foot syndrome.

There are also two types, rigid and flexible.  Rigid types are more difficult to reconstruct, and usually require joint fusions.  Flexible types can sometimes be salvaged without major joint fusions.  There are many variables.  A typical flexible flatfoot requires a tendon transfer or repair of the ruptured tendon, a mid-arch joint fusion, and either a joint implant or a bone cut procedure to lengthen the heel bone (Evan’s osteotomy), as well as a lengthening of the Achilles tendon. 

Bunions

A bunion is a joint deformity of the great toe joint.  A bunion is a latin term for a radish.  There are two types of bunions, a medial and a dorsal.  Both can be painful and caused by the mechanics of the foot.  The only way to permanently fix a bunion is with surgery.  Each type can require a different type of surgical procedure.  Bunion pain can be reduced with appropriately prescribed orthotics (see orthotics), as well as shoegear changes.  Obviously conservative care should be exhausted before surgery.     

A traditional bunion is a medial bunion.  This is where the enlargement is directly on the side of the big toe joint.  Usually there is a red, swollen area that can be composed of soft tissue, bursa, ligament and bone.  This develops due to excess force being placed into the great toe joint, combined with shoegear forces.  Typically the foot rolls too far inward (pronation) and overloads the inside of the foot as the heel lifts up and direct force is placed onto the ball of the foot (propulsion). 

This inward force is continued into the big toe, pushing it sideways toward the second toe.  This puts strain on the great toe joint, and causes the joint to open up more from side to side than top to bottom.  This over time puts strain on the joint, ligaments, bone, and skin, enough to cause them to swell.  This repetitive strain ultimately causes a relocation of the great toe (toward the 2nd toe) over time.  This makes the joint surface area smaller, but with greater forces, which will accelerate the onset of arthritis, also causing pain.

Hallux Limitus

A dorsal bunion is also referred to as hallux limitus and/or rigidus.  The dorsal bunion also involves pronation of the rearfoot, but also a hypermobility of the midfoot at the joint behind the great toe joint.  This joint is called the metatarsocuneiform joint.  If this joint has too much motion, then it changes the flexion point of the great toe joint.  This eliminates the joint from being able to flex naturally when loaded, thus causing a limited or rigid joint.  This limitation causes more of a pistoning type effect, as opposed to a gliding of the joint, which causes atypical stress to the joint, and then causes it to breakdown.   The spurring usually takes the path of least resistance, which is to the top of the joint (dorsal).  Over time the joint becomes less and less mobile, as well as bigger, ultimately taking up more room in a shoe, rubbing more, and creating both pain from irritation, but also due to arthritic breakdown of the joint.

This type of joint usually goes on to fusion at some point. As with most conditions there are several ways to approach it.  Conservatively, orthotics are the way to go.  This can help offweight the joint, and reduce pain. For some this does not provide enough relief, and some type of procedure is necessary.  I am an advocate for fusion, as this will be the way to fix the problem without multiple surgeries, hopefully.  Any other alternative (joint clean-up with or without bone cuts, or implant) are all just temporary fixes, that will need further surgery in the future.  Any repeat procedure will increase risks for healing and complications.  This is my reason for fusion, which wil not limit physical activity, only the ability to wear high heels.  The surgical approach I use is illustrated here by Nexa.

See surgical picture section for more pictures regarding bunion surgery.

Hammertoes

This is a diagnosis for a multitude of general toe deformities.  The classic deformity involves minimally 2 joints.  One or two joints within the toe and the joint at the ball of the foot.  These can be flexible or rigid.  These can cause the skin to become irritated, callusing, painful arthritis, and even open sores.  Deformities can become severe enough to cause ligament ruptures and severe malposition of the toe(s).  Treatment options are limited to 3 approaches: shoeing, padding, and or surgery. The surgical approach I use is illustrated here by Nexa.

Tendon injuries

These are fairly common in the foot and ankle, and usually come from mechanical strains and or bone deformities that create inflammation and can lead to longitudinal tearing and/or rupture.  The more obvious cause in a direct injury or trauma causing a sprain, tear, or rupture.  Either on of these scenarios requires fairly aggressive treatment to heal.  Most tendons in the foot not only flex joint, but also create a structural support to the arch and foot.  These are described as dynamic tendons and the ones of greatest concern are the Achilles, Posterior tibialis, and the Peroneal brevis.  All of these tendons will require nonweightbearing cast immobilization and physical therapy.  Some require MRI evaluation and go on to surgery.  The tendon that creates the most complication is the Posterior Tibialis Tendon. (see PTTD) 

Fractures

Fracture management can obviously vary depending on the location and severity.  Inevitably skin, nerves, joints and tendons can also get damaged, further complicating the picture.  Due to the fact that fractures of the foot and ankle have the whole body loaded upon them, multiple fractures can happen at different areas.  Thorough evaluations need to be completed.

The other concern of lower extremity fractures is the ability to create long-term pain due to arthritis, thus needing further surgery to fuse the joint.

External fixation

Dr. Gregory is the only foot and ankle surgeon in the Upper Valley offering traumatic and reconstructive surgery utilizing external fixators.  Dr. Gregory has been trained in Europe, at Orthofix in regards to this surgical application. External fixators are a great resource for foot and ankle surgery because they offer many conveniences to the patient.  Due to the strength of an External fixator, the patient is able to ambulate earlier, does not require a cast, and eliminates need for a second surgery for removing internal screws and plates.

Ankle Joint Replacement

There are several new products recently released that have improved the quality and effectiveness of this procedure.  Dr. Gregory is presently being trained on these new systems(Tornier, In-Bone)and will be offering this service soon. 

Ingrown Toenail / Permanent Nail removal: 

This is a surgical procedure done in the hospital and is closed with suture.  This is done in the hospital because the nail root grow off the bone, thus bone is exposed when removing this surgically.  Any procedure that exposes bone should be completed in a sterile environment. This procedure involves permanently, meaning the nail will not grow back, removing part of or the complete nail.  Once the nail is removed a skin incision, at the base of the nail, is created to remove the nail root (also called the matrix).  This incision is closed with suture.  This can be done under anesthesia or just local.  It will require about 3 weeks to heal, during this time wearing a postoperative, open toe shoe is required. Click here for more information from footphysicians.com