Foot Reconstruction

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Introduction

Foot and ankle reconstruction comprises of array of surgical procedures aimed at restoring alignment, function and appearance to the foot and ankle affected by various congenital and acquired conditions, injuries, or deformities.

Indications and Contraindications

Indications

Foot and ankle reconstruction is indicated for a wide range of conditions, including but not limited to:

Trauma: Falls and crush injuries causing fractures, open wounds and soft tissue structure damage.
Congenital Deformities: Conditions present at birth, deformities within the joints, bone fusions, and bone shortening, that lead to abnormal foot and ankle positioning and function.
Degenerative Disorders: rheumatoid arthritis or osteoarthritis causing foot and ankle pain and dysfunction.
Tumours: Malignant or benign tumours affecting the bones, muscles, or soft tissues of the foot.
Neuromuscular Conditions: Nerve disorders like Charcot-Marie-Tooth disease that result in muscle imbalance and progressive foot and ankle deformities.
Chronic Infections: Non-responsive infections that lead to tissue destruction and necrosis (foot ulcers and bone infections)
Acquired deformities: progressive hindfoot, midfoot or forefoot deformities, for example, hallux valgus or acquired painful flatfoot.
Failed Previous Surgeries: Revision surgery for cases where previous interventions have not yielded the desired outcome.

Contraindications

Foot or ankle reconstruction might not be suitable for individuals with:

Severe Systemic Illness or very advanced age: If the risk of complications from anaesthesia or surgery exceeds the potential benefits of the surgery.
Unrealistic Expectations: Unrealistic expectations regarding the outcome of the procedure (for example in cosmetic foot surgery)
Severe Peripheral Vascular Disease or Active Infections: Poor blood circulation in the foot, or active infection hinders healing, and increases the risk of complications or even amputation.

Benefits and Risks

The specific benefits and risks can vary depending on the type of surgery and the patient’s individual circumstances. Here are the main benefits and risks associated with foot reconstruction surgery:

Benefits of Foot Reconstruction Surgery

Pain Relief: Foot reconstruction surgery can provide significant pain relief for individuals suffering from chronic foot pain due to conditions such as deformities, arthritis, or injuries.
Improved Function: The surgery aims to restore or enhance the function of the foot, allowing individuals to walk, stand, and perform daily activities more comfortably and effectively.
Enhanced Mobility: Foot reconstruction can improve mobility and gait, enabling patients to regain their independence and quality of life.
Correction of Deformities: Foot reconstruction surgery can correct deformities such as bunions, hammertoes, or flat feet, resulting in better foot alignment and appearance.
Joint Preservation: In some cases, foot reconstruction procedures aim to preserve joints, preventing further damage and the need for joint replacement surgery.
Reduced Risk of Ulcers: For individuals with conditions like diabetes or Charcot foot, foot reconstruction can reduce the risk of ulcers and other complications.

Risks of Foot Reconstruction Surgery

Infection: Infection is a potential risk with any surgical procedure, including foot reconstruction. Proper wound care and antibiotic administration are essential to minimize this risk.
Nerve or Blood Vessel Damage: There is a risk of damaging nearby nerves or blood vessels during the surgical procedure, which can lead to sensory or motor deficits.
Blood Clots: Foot reconstruction surgery carries a risk of deep vein thrombosis (DVT), a blood clot in the deep veins of the leg and its catastrophic consequences. Measures such as blood-thinning medications and compression stockings are often used to mitigate this risk.
Implant Issues: For surgeries involving the use of implants, there is a risk of implant wear, loosening, or failure over time. This may require revision surgery to address implant-related problems.
Wound Healing Problems: Some patients may experience issues with wound healing, which could result in delayed recovery or the development of complications such as wound infections.
Anaesthesia-Related Complications: Patients undergoing foot reconstruction surgery are at risk of complications related to anaesthesia.
Scarring: Surgery typically results in some degree of scarring at the incision sites. While efforts are made to minimize scarring, it may still be visible.
Limited Activities: Following foot reconstruction, patients may have restrictions on high-impact activities and sports due to the potential for implant wear or other limitations.

Surgical Approach

Foot and ankle reconstruction procedures may include a combination of:

Fracture fixation: Using plates, screws or wires to fix fractures (ex.: plating of metatarsal fractures).

Bone Osteotomy and Realignment: Cutting bones and improving their position to correct deformities or off-load arthritic joints (e.g.: hallux valgus correction, correction of malunion after fracture, above-ankle osteotomy for ankle arthritis and instability).

Joint Arthrodesis: Joint fusion – permanent stiffening of a painful joint to eliminate its movement (e.g.: fusion of a degenerated great toe joint, hammer toe deformity correction).

Tendon Repair, reconstruction or transfer: Suture of tendon, reinforcement of tendon or borrowing a tendon and transferring to a different location to restore proper alignment and function. (ex.: Achilles tendon suture, posterior tibial tendon reconstruction for flat foot or tendon transfer for a foot drop).

Ligament Repair or reconstruction: Reinforcement of a ligament with a suture or replacement with a graft (ex.: ligament reinforcement or reconstruction in ankle instability).
Soft Tissue Reconstruction: Reconstruction of extensive damage of the skin, muscles, and other soft tissues with the assistance of a plastic surgeon (e.g.: soft tissue flaps for traumatic injuries, chronic wounds and ulcers).
Amputation: Unsalvageable limb, in cases of severe trauma, infection, tumour or neuropathic pain, that cannot be effectively treated by other means, may necessitate amputation. The goal is to preserve maximum function while eliminating the danger (e.g.: open wound, infection, tumour) or pain source (e.g.: chronic pain syndromes, CRPS).
External Fixation: External frames involve pins, screws, and external rings or bars for bone and joint stabilisation or for gradual deformity correction in bone or joint (compound fractures, ankle deformities).
Nerve Repair or Decompression: Nerve-related conditions (e.g.: neuromas) or nerve compression syndromes (e.g.: tarsal tunnel syndrome) may require a surgical release to alleviate pain and restore nerve function.
Joint replacement: In severe cases of joint damage or bone loss, implantation of prosthetic components (artificial joint) or joint transplant (allograft) may be considered to restore joint function and reduce pain (e.g.: TAR -total ankle replacement, or ankle transplant).

It’s important to note that the specific surgical approach and combination of techniques chosen for foot and ankle reconstruction will depend on the individual’s condition and their overall health, age and demand.

Pre-Surgery Information

The following is what can be expected prior to a foot reconstruction procedure

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

The surgery

Anaesthesia: General anaesthesia or regional anaesthesia (spinal or epidural) is used to ensure a pain-free procedure.

Surgery: Instrumentation for minimally invasive bone or joint surgery is available in our practice. When an open surgery is performed, carefully placed incisions with respect to all anatomic structures are employed. Surgery is executed according to the pre-surgical plan, to minimise time under anaesthesia and exposure of an open wound to an external environment. Most advanced implants and instruments are employed in our practice for superior surgical outcomes and patient safety. X-rays are available during operation for confirmation of necessary surgical steps and at the end of surgery.

Closure: The incision is closed using sutures. Dressing and a cast, a boot or a sandal are applied.

Post-Surgery Information

Hospital Stay: Simple procedures require a day stay, after complex surgeries you will be admitted to the hospital for a few days for monitoring and initial rehabilitation.
Pain Management: Pain medications will be administered to keep you comfortable.
Immobilisation: Immobilisation typically lasts between 1 week and 6-12 weeks, depending on the surgery type.
Weight-Bearing: If weight-bearing restriction is necessary, typically it lasts between 1 week and 6-12 weeks, depending on the surgery type.

Follow-Up

Regular follow-up appointments with the team will help monitor your progress and address any concerns:

1 week postop: for wound check,
2 weeks postop: for sutures removal,
6 weeks postop: for x-ray assessment of healing progress.

After that, a 3-month postop, 6-month postop, 1-year postop and further an annual follow-up with an x-ray will be mandatory.

Physical Therapy

A tailored rehabilitation program will help regain strength, flexibility, and mobility.

Recovery from foot and ankle surgery can take between 6 weeks to a year, and commitment to rehabilitation as well as follow-up appointments is essential for optimal outcomes. Always consult with your healthcare provider for personalized guidance and recommendations.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000