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Complex Trauma and Soft Tissue Reconstruction for the Foot and Ankle

The integrity of the soft tissue (ST) envelope is of paramount importance for any and all foot and ankle reconstructions. Although injury to the ST envelope is most often associated with trauma-related care, elective surgical procedures also are prone to ST complication, as well as certain disease states (e.g., Charcot arthropathy with ulceration, diabetic ulcerations, vascular disease, and infections). This chapter will discuss the reconstructive options…

Congenital Foot Deformities

Congenital foot deformities can result from inherited or extrinsic influences. Knowledge of prenatal growth and foot development is essential to understanding the pathophysiology of and choosing the appropriate treatment for congenital foot deformities. PRENATAL DEVELOPMENT Embryology The skeletal elements of the foot are blastemic by the fifth gestational week; all are present and begin to chondrify between 5 and 6.5 weeks prenatally. The cartilage anlagen of…

Osteochondral Lesions

An osteochondral lesion (OCL) is a defect on the articular surface of a joint with or without subchondral bone involvement. The first report of removal of a loose body from a knee joint, likely an unstable OCL, is attributed to Ambroise Paré in 1558, followed by a description of “cartilage of the joint of the knee separated and ossified” by Alexander Monro in 1738 and descriptions…

Arthroscopy of the Foot and Ankle

ARTHROSCOPY OF THE ANKLE IN THE SUPINE POSITION History In 1910, Hans Christian Jocobaeus, a Swedish physician, started exploring the abdomen and thoracic cavity with the use of a laporothoracoscope. The Danish surgeon Severin Nordenthoff was the first to use endoscopic instrumentation in a knee joint and presented a paper at the German Society of Surgeons in Berlin in 1912, using the term “arthroscopy.” Arthroscopy was…

Stress Fractures of the Foot and Ankle

Overview Stress fractures of the foot and ankle are common and can involve any bone from the tibia to the hallux sesamoids. This entity is a dynamic clinical syndrome that is characterized by exertional pain, localized tenderness, and swelling. Stress fractures classically occur as a result of an acute increase in strenuous repetitive and prolonged muscle action and high-impact loading on bone that fails to accommodate.…

Achilles Tendon Injuries

The literature concerning dysfunction of the Achilles tendon is confusing and contradictory, leaving a physician with a multitude of references that support not only varying etiologies but also treatment regimens diametrically opposed to one another. It would be impractical and impossible to cite all the major contributions from the more than 700 articles in the literature discussing methods of treatment. The purpose of this discussion is…

Athletic Soft Tissue Injuries of the Foot and Ankle

Since its first appearance in the Surgery of the Foot and Ankle, Sixth Edition in 1992, the treatment of foot and ankle injuries in sport has continued to rapidly evolve. There has been an incredible explosion of knowledge related to sports medicine of the foot and ankle. From diagnosis, treatment, rehabilitation, and injury prevention, the expanse of knowledge in sports medicine treatment in foot and ankle…

Lower Limb Prosthetics

Treatment by amputation has been seen as a procedure of last resort. The primary reason for amputation was geared to the preservation of life rather than a return to high levels of function or athletic endeavors. Although amputation has become a more accepted modality of treatment for the severely diseased or traumatized extremity, some surgeons still resist primary amputation as well as significant study of amputation…

Amputations of the Foot and Ankle

Introduction Amputation of part or all of the foot may be the oldest form of foot surgery. Yet many surgeons abhor foot amputations, perhaps due to an innate repugnance of removing a body part, perhaps because amputation is seemingly so unesthetic, or perhaps because amputation is seen as a treatment failure. However, for the patient with either a nonviable or poorly functional foot, an amputation is…

Infections of the Foot and Ankle

The foot provides a unique environment for the development of infections, which can be aggressive and result in significant disability. The foot’s environment is modified by footwear, trauma, systemic illness, and climate. Each of these factors can increase the susceptibility of the foot to infection. Footwear by its nature is occlusive and raises the temperature and humidity around the foot, reaching 100% in the interspaces of…

The Diabetic Foot and Neuroarthropathy

Background Both the burden of disease attributable to diabetes mellitus, and the incidence in our population, continues to rise. According to the National Diabetes Statistical Report, 2014, over 34 million Americans, or almost 10% of the population, are diabetic. Another 88 million Americans have blood sugar levels higher than normal (i.e., prediabetes), but not high enough to meet the stringent criteria of the American Diabetes Association…

Ring External Fixation in the Foot and Ankle

Overview Ring fixation is an incredibly useful technique that adds a valuable dimension in the treatment of lower extremity deformity, ankle arthritis, and limb shortening when traditional methods are not practical. Familiarity with ring fixation is important for foot and ankle surgeons to gain in order to optimize management of lower extremity pathology. A basic understanding of deformity analysis, osteotomy techniques, and principles of external fixation…

Pes Cavus

Pes cavus describes a foot with a high arch that maintains its shapeand does not flatten out with weight bearing. The components of pes cavus, in order of frequency, are an increased calcaneal pitch and varus of the hindfoot, plantar flexion of the medial forefoot, and adduction of the entire forefoot. The predominant deformity in pes cavus may be in the hindfoot, the forefoot, or a…

Pes Planus

Pes Planus The medial arch of the foot consists of a complex of fascia, ligaments, bone, and tendons that create a tough yet elastic structure that helps provide shock absorption and allow for a dynamic character of the foot to aid in standing, walking, running, and jumping. Pes planus refers to a loss of this medial arch of the foot while standing. This can be a…

Disorders of Tendons

Extensor Tendons Extensor tendon injuries of the foot and ankle are uncommon, but understanding their diagnosis and treatment can prevent morbidity from neglected care. Anzel et al evaluated 1014 cases of tendon injuries at the Mayo Clinic and noted that 21 injuries were to the extensors to the toes, a 2% incidence. They did not differentiate between injuries to the extensor hallucis longus (EHL) and extensor…

Hallux Rigidus and Other Forefoot Arthritis

Hallux Rigidus Definition The term hallux rigidus describes a painful condition of the metatarsophalangeal (MTP) joint of the great toe characterized by restricted motion (mainly dorsiflexion) and proliferative periarticular bone formation. It was initially reported in 1887 by Davies-Colley, who described a plantar-flexed position of the proximal phalanx in relationship to the first metatarsal head and proposed the name hallux flexus . A few months later,…

Midfoot Arthritis

Introduction Midfoot arthritis is a common source of foot pain and deformity. There are numerous underlying etiologies resulting in arthritis of the midfoot of which posttraumatic arthritis is the most common. Nonoperative treatment of midfoot arthritis can be effective. If pain is refractory to nonoperative management or deformity worsens, surgical treatment is often sought. Surgical options for midfoot arthritis are mainly limited to various midfoot arthrodeses…

Hindfoot and Pantalar Arthritis

Hindfoot and pantalar arthritis causes debilitating pain and functional limitation and is frequently associated with varus or valgus deformity, prior trauma, or inflammatory arthritis. Arthrodesis was initially described in 1878 as a way of stabilizing the foot for paralytic deformities. The tarsal bones were denuded of cartilage and the foot immobilized to allow fusion across the joints. Techniques advanced in the early 1900s as an understanding…

Avascular Necrosis and Total Talus Replacement

Introduction and Etiology Avascular necrosis (AVN, or osteonecrosis) is death of bone due to lack of blood supply. The talus is at risk for vascular insult due to the nature of its limited and tenuous blood supply. AVN of the talus is caused by either (1) trauma or (2) nontraumatic causes including hypercortisolism, corticosteroid use, human immunodeficiency virus (HIV), renal transplant, alcoholism or pancreatitis, irradiation, multiple…

Ankle Replacement

Total ankle replacement (TAR) is increasingly recommended as a treatment option in patients with end-stage ankle osteoarthritis. Ankle arthrodesis can no longer be accepted as the sole gold standard procedure for end-stage ankle arthritis. Between 2005 and 2014, diagnosis-adjusted rates of TAR in the USA Medicare population increased 182% (7.6 to 21.5 per 1000 ankle arthritis diagnoses) while ankle fusion rated decreased 32% (34.5 to 32.3…