Conditions that may need surgery include bunions and hammer toes, ankle arthritis, Achilles tendon disorders and plantar fasciitis.
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 your big toe joint to bend towards the other toes and become deformed. If symptoms carry on over a long period, your toe may need to be surgically corrected. This involves straightening your big toe and metatarsals, a process called an osteotomy. Although this may make your joint stiffer, it works toease the pain.
Most surgery can be performed as a day case and takes up to an hour. Your foot will be bandaged and you’ll need to wear a Velcro surgical shoe forfour to sixweeks afterwards.
If your bunion has been caused by rheumatoid arthritis, you may also develop rheumatoid nodules. These firm, pea-sized lumps can occur at pressure points such as your big toe joints, the back of your heels or on your toes, but they can be surgically removed.
Sometimes swellings or bursae on the joints in your feet are also called bunions, but these aren’t the same as bunions caused by hallux valgus and don’t need surgery.
Hallux valgus is different to hallux rigidus, which isosteoarthritis of the big toe joint. Hallux rigidus causes stiffness in your big toe and you won’t be able to move it as far. If treated early, surgery can be used to remove painful osteophytes (overgrowth of new bone) that can develop and allow more joint movement to return. In more advanced cases, fusion surgery (joining bones together to make one stiff bone where there two) gives excellent pain relief, although it will mean that the joint will no longer bend when you walk so you won’tbe able to wear high-heeled shoes.
Hammer toes
As well as bunions, hallux valgus can also cause your other toes to become clawed or permanently bent. This condition is known as hammer toes. Damages caused by hammer toes can be eased by:
- arthroplasty – removing the deformed joint between your toe bones (phalanges), which leaves the joint flexible
- arthrodesis – fusing your phalanges together, which leaves your toe more stable but means you’ll only be able to wear flat shoes after the operation.
Both procedures are performed as day cases and last around an hour. Your stitches will be removed abouttwo to threeweeks following surgery and you’ll need another dressing fortwo to sixweeks after that. You should limit how much you walk for the firstthree days.
Metatarsal
The joints in your forefoot can be damaged by inflammation of the lining of your joint (synovitis) in some forms of arthritis, for example rheumatoid arthritis. These small joints are called the metatarsophalangeal joints (MTPJs), and they can become dislocated when damaged by arthritis. The pain and discomfort this causes is sometimes described as feeling like you’re walking on pebbles.
If your symptoms are severe and can’t be controlled by other treatment, you may need surgery. The exact surgical procedure and the follow-up you’ll need will depend on how severe the problem is, but often surgery to your big toe and removal of the heads of your MTPJs is carried out in order to make your foot more comfortable and walking easier. Your surgeon will be able to give you more information before the operation.
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 if you have rheumatoid arthritis, or if you’ve had a previous injury to the area. This leads to pain, swelling and occasional deformity of the joint. You may need surgery if your symptoms are severe. There arethree surgical options:
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. Your 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.
In some cases this procedure can be performed using keyhole surgery (arthroscopy), which means it can be done through just a small cut, so your joint doesn’t have to be opened up. The procedure takes betweenone and twohours.
After surgery you’ll need to wear a cast for 6–12 weeks, depending on your situation. You should be able to wear normal shoes after the cast is removed, although some alterations are occasionally needed. It should be easier to walk normally or even more comfortably than you did before surgery if your other joints aren’t affected by arthritis, but running isn’t recommended.
Triple fusion –Triple fusionis 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 todo this.It takes 12–14 weeks for the fusion to be complete.
Ankle replacement – An ankle replacement involves taking out the worn-out ends of your tibia and talus bones and replacing them with a man-made (artificial) ends made out of plastic or metal. Unlike an ankle fusion, a replacement allows you to move your joint after surgery.
The procedure takes betweenone and twohours and you’ll normally need to stay in hospital fortwo days. Your foot will be put in a temporary cast afterwards but then it’ll be bandaged and you may need a splint for support. This allows you to move it fairly soon after surgery, but you’ll probably need to use crutches for aboutsix weeks.
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. Youroccupational therapist orphysiotherapist will advise you on how to take care of the new joint.
As with all joint replacements, there’s a chance thatyour new joint will wear away over time and you may need to have it removed to have ankle fusion surgery. Fusion after a replacement is harder to do than a primary fusion and more bone may need to be removed. You may need a bone graft (where bone is taken from elsewhere in your body, normally your pelvis) to replace the removed bone. This is quite a common procedure, and ankle fusion following a replacement is usually very successful.
Versus Arthritis have recently awarded a grant for the OARS study, which will assess the major factors that predictwhat patients think (patient-reported outcome) in the first year after total ankle replacement.
Achilles tendon disorders
Your 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 within the main tendon or where it attaches to your heel bone. Very occasionally surgery can be used as a method of treatment. This procedure is usually performed as a day case and you’ll need to wear a bandage and use crutches afterwards.
Morton’s neuroma
Morton’s neuroma is a painful condition that involves a nerve that suppliesfeeling to two neighbouring toes. It most commonly affects the nerve to your third and fourth toes. If your symptoms are bad, surgery to remove the painful nerve can be successful. This can be done as a day case and you’ll need to wear a bandage fortwo weeks afterwards.
Tibialis posterior disorder
The tibialis posterior is a muscle that supports the shape of your instep arch. The tendon that connects this muscle to the bone can become inflamed, leading to pain and swelling on the inside of your ankle. Continual swelling can start to cause the tendon to weaken, which can lead to a flatfooted look.
Occasionally, bad cases need surgery to rebuild the instep arch. If your case is long-standing or you haven’t had treatment, three of your hindfoot joints may need to be fused (triple fusion) toease pain.
Both operations take betweenone and twohours and you’ll need to wear a plaster cast for 6–12 weeks after.
Plantar fasciitis
The plantar fascia is a tough band of fibrous tissue that starts at your heel bone and stretches across the sole of your foot to your toes.Plantar fasciitis is inflammation at the site where the fascia attaches under your heel. Very rarely, bad cases may need surgery to release the plantar fascia from the heel bone.
This procedure is usually performed as a day case and it takes less than an hour. You’ll only need to wear a bandage after the operation.
