Foot surgeries

Foot surgical procedures

Hallux valgus

Hallux valgus, commonly known as a bunion, is a common deformity of the big toe. This deformity mainly affects women at all ages of life, as well as men, but mainly in congenital forms.

This deformity can be present at birth, in which case it is called congenital hallux valgus. The hallux valgus deformity can appear at puberty, which is referred to as juvenile hallux valgus. When hallux valgus appears after the age of 20 to 30, it is considered acquired hallux valgus. The width of the foot, foot morphology, and shoe-wearing habits can encourage the onset of hallux valgus. More rarely, trauma to the big toe can lead to ligament injuries and/or sesamoid injuries, which can be responsible for traumatic hallux valgus.

A painless hallux valgus, even if it is unsightly, does not require surgical intervention. Surgery is recommended in cases of pain, difficulty with footwear, or destabilization of the forefoot, that is when hallux valgus causes lesions of the other toes.

Contrary to popular belief, surgical correction of hallux valgus is not particularly painful. In 80% of cases, postoperative pain is absent or of low intensity. In 20% of cases, there is pain, but it is largely relieved by prescribed painkillers.

Surgical correction of hallux valgus involves a metatarsal osteotomy fixed with titanium surgical material, possibly combined with a phalangeal osteotomy.

The procedure is performed on an outpatient basis, meaning you are discharged the same day from the clinic. A postoperative shoe is prescribed for a duration of 45 days. A follow-up visit at three weeks allows for removal of the dressing and checking skin healing, then a check-up at three months post-op with x-rays allows assessment of bone healing.

When correcting hallux valgus on both feet, we offer both procedures sequentially, one week apart.

Hallux rigidus

Hallux rigidus corresponds to painful stiffness of the metatarsophalangeal joint of the big toe.

There are different stages depending on joint mobility during clinical examination and radiographic signs of osteoarthritis.

An asymptomatic hallux rigidus does not require any treatment.

Injections are generally not very effective for pain because of the cartilage lesions and the presence of bony osteophyte impingements.

Several surgical procedures are available depending on the stage of hallux rigidus progression, the morphology of the hallux, and the presence of joint pain or simply impingement due to bony growths.

In cases of pain due to bony impingements restricting dorsal flexion mobility of the hallux, surgical treatment consists of resecting all the metatarsal and phalangeal bony protrusions. This is a debridement with associated cheilectomy. The aim of the surgical treatment is to eliminate dorsal impingements, which can also cause pain when wearing shoes, especially with stiff leather shoes or ones where seams pass over the impingement area.

When the joint is painful, cartilage lesions are more significant. Procedures to decompress the metatarsophalangeal joint are indicated when the first metatarsal is relatively long. This then involves debridement with cheilectomy combined with a shortening osteotomy of the 1st metatarsal, possibly associated with a phalangeal osteotomy.

If the cartilage lesions are too extensive to preserve the joint, we offer, when possible, a spherical pyrocarbon arthroplasty to maintain joint mobility.

If it is not possible to implant a metatarsophalangeal prosthesis, or depending on the patient's wishes, arthrodesis for hallux rigidus is an alternative: this involves permanent fusion of the metatarsophalangeal joint.

All these procedures are performed on an outpatient basis, with discharge the same day from the clinic, under ankle tourniquet. The postoperative course is generally the same, involving wearing a specific postoperative shoe for 1 month to 1 and a half months. An outpatient operation requires the presence of someone close the evening and night after surgery. If this is not possible, an overnight hospital stay will be offered, with discharge the next morning.

Rehabilitation can begin 1 month after the operation, with the help of a physiotherapist or as self-rehabilitation.

The time to resume driving depends on the operated side if driving a car with automatic transmission.

Sequelae deformities of the foot

We take care of sequelae deformities of the foot and ankle. In general, these are ankles or feet that have already been operated on but with a functional result that does not meet the patient's expectations.

Each sequelae deformity is a specific case, so the surgical strategy is tailored to each patient.

The aim of revision or repeat surgery for sequelae deformities is to improve the functional state of patients where possible. Patient expectations and lifestyle are important components of the clinical examination. Standard x-rays and a CT scan are needed to assess the deformities and plan their possible corrections.

This type of operation is carried out on an outpatient basis in most cases. In some situations, it is necessary to perform a bone graft, and if this is taken from the pelvis, especially the iliac crest, hospitalization typically lasts for two nights postoperatively.

Ankle surgical procedures

Ankle Arthroscopy

Arthroscopy is a surgical tool that involves exploring and treating joint lesions through small incisions of about 5 to 10 mm long using a camera and specific instruments. In the ankle, arthroscopy can be performed on the anterior compartment, the posterior compartment, or both compartments during the same surgical procedure. If both compartments require surgical treatment, two different setups are needed during the operation: first, the patient is positioned on their stomach, and in the second stage, the patient is positioned on their back.

The advantage of arthroscopy is to reduce tissue dissections and the length of skin incisions, thereby limiting postoperative pain and the risk of infection. Although postoperative recovery tends to be faster after arthroscopy, healing times are the same as with conventional open surgery.

We use arthroscopy to treat bone and cartilage lesions of the ankle, repair or reconstruct ankle ligaments, perform joint releases, and remove bony blocks or problematic bone fragments.

Arthroscopic procedures are performed on an outpatient basis, with discharge on the same day as the surgery. Immobilization, when necessary, involves a splint, the duration of which varies depending on the procedure performed. Dressings must be changed every 2 days by a home nurse, and stitches are removed 15 days after the operation. Using crutches is generally recommended for about 15 days to avoid putting full weight on the operated ankle, thus reducing the risk of joint swelling.

In the case of a combined procedure—that is, including both an arthroscopic stage and an open stage—a cast immobilization may be necessary for three to six weeks.

Total Ankle Replacement

In cases of ankle osteoarthritis, or destructive inflammatory arthritis, the ankle joint can be replaced with a prosthesis. The total ankle prosthesis helps preserve ankle mobility and protect neighboring joints.

We now use preoperative planning with a protocol CT scan performed at Clinique Saint George. Planning allows us to visualize the prosthesis positioning on the scan and to plan any associated procedures. Once planning is validated, custom-made cutting guides specifically adapted to each patient are 3D printed. These guides are used during the ankle replacement surgery. The benefits of using custom-made cutting guides are a reduction in operating time by about 40 minutes, and a decrease in the number of intraoperative X-rays needed to check prosthesis positioning. The accuracy of implant placement is still to be fully demonstrated.

The surgical procedure lasts between 1.5 and 2 hours. The hospital stay lasts two nights. Cast immobilization is applied for three to six weeks depending on any associated procedures performed during prosthesis placement (ligament reconstruction, corrective osteotomy).

Surgery for Ankle Fracture Sequelae

The sequelae of ankle fracture can fall into three main categories: insufficient surgical treatment of the initial lesions, imperfections in surgical correction due to the complexity of the fracture, and post-traumatic osteoarthritis over the short or long term.

Assessment of ankle fractures initially includes X-rays as well as a CT scan when there is doubt about complex ankle lesions. During surgical treatment of any ankle fracture, we perform an arthroscopy which allows us to drain the fracture hematoma, which is toxic to the cartilage, and to analyze any associated ligamentous injuries. At present, arthroscopy is the most reliable way to assess a syndesmosis injury.

Imperfections in surgical correction are due to the difficulty of treating the fracture. It is important to distinguish between an ankle fracture and a fracture of the tibial plafond or talus. Malleolar fractures are surgically less complicated to treat than fractures of the tibial plafond or talus. Tibial plafond fractures and articular fractures of the talus have a high arthrogenic potential, meaning they are likely to cause osteoarthritis in the short or medium term if the reduction is insufficient.

If a fracture has been well reduced or if an ankle has adapted well to its post-traumatic status, the progress may lead to post-traumatic ankle osteoarthritis in the long term. Post-traumatic ankle osteoarthritis is one of the main indications for total ankle replacement.

Conclusion

We handle all surgical pathologies of the foot and ankle, and we perform first-line surgical procedures as well as surgical interventions for residual deformities.