Foot & Ankle Service

The foot and ankle is often the target for relentless stress while bearing our body weight as we go about our daily activities at work, home or while engaged in sporting pursuits. This combination can often result in a number of painful injuries and conditions when least expected. At the Department of Orthopaedic Surgery in Singapore General Hospital, our Foot and Ankle Service works closely with the Trauma Service to provide a wide range of specialised medical and surgical care to help patients recover from foot- and ankle-related problems. Our customised approach ensures patients get the best treatment for a faster recovery. We use a multidisciplinary approach to skilfully treat the broad range of foot and ankle injuries and conditions that can occur at any stage of life.

Conditions:

Here at SGH, our specialty trained surgeons treat all conditions involving the foot and ankle. They include these conditions:

• Bunions

• Hammer and claw toes

• Flatfeet and High arched feet

• Arthritis of the foot and ankle

• Ankle ligament sprains and tears

• Ankle cartilage problems

• Heel pain and Achilles Tendon pain

• Deformities of the foot and ankle

• Fractures and complex injuries of the foot and ankle

• Diabetic related conditions of the foot including Charcot neuroarthropathy

• Charcot neuroarthropathy

1. Bunions

A bunion is a bony bump that forms on the joint at the base of your big toe. It forms when your big toe pushes against your next toe, forcing the joint of your big toe to get bigger and stick out. The skin over the bunion might be red and sore.

Wearing tight, narrow shoes might cause bunions or make them worse. Bunions can also develop as a result of an inherited structural defect, stress on your foot or a medical condition, such as arthritis. Smaller bunions (bunionettes) can develop on the joint of your little toe.

2. Hammer, mallet and claw toes

Hammertoe and mallet toe are foot deformities that occur due to an imbalance in the muscles, tendons or ligaments that normally hold the toe straight. The type of shoes you wear, foot structure, trauma and certain disease processes can contribute to the development of these deformities. A hammertoe has an abnormal bend in the middle joint of a toe. Mallet toe affects the joint nearest the toenail. Hammertoe and mallet toe usually occur in your second, third and fourth toes. If the toes are curled downward at both joints, the condition is called claw toe.

3. Arthritis of the foot and ankle

Arthritis is inflammation of one or more of your joints. It can cause pain and stiffness in any joint in the body and is common in the small joints of the foot and ankle. There are more than 100 forms of arthritis, many of which affect the foot and ankle. All types can make it difficult to walk and perform activities you enjoy. The major types of arthritis that affect the foot and ankle are osteoarthritis, rheumatoid arthritis and posttraumatic arthritis.

4. Ankle ligament sprains and tears

An ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear. Ankle sprains are common injuries that occur among people of all ages. They range from mild to severe, depending upon how much damage there is to the ligaments. Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.

Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue. If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.

5. Ankle Cartilage problems

The ankle is a complex joint consisting of the tibia, talus, and fibula bones. The most common bone in the ankle to have cartilage injury is the talus. The cartilage of the talus is like any other articular cartilage and is arranged similarly to that in other weight-bearing joints. Injury to the ankle and stretching (instability) of the ligaments can lead to cartilage injury to the ankle joint.

Common ankle injuries such as sprains and fractures are a major cause of cartilage damage. Cartilage injury becomes more likely as the energy and severity of an ankle injury increases.

6. Heel pain and Achilles Tendon pain

One may develop heel pain when they pound their feet on hard surfaces playing sports or wear shoes that irritate sensitive tissues. Heel pain is the most common problem affecting the foot and ankle.

Achilles tendinitis is a common condition that causes pain along the back of the leg near the heel. The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration.

7. Deformities of the foot and ankle

It is also normal for the shape of your child's feet and ankles to change over time. For example, almost all children start out with flatfeet and develop arches later. However, if your child has pain or other symptoms or has trouble being active or fitting into shoes, treatment may help. For babies with congenital foot or ankle deformities, it's important to assess their condition and often to begin treatment right after birth.

The conditions we treat include the following:

• Accessory Navicular

The navicular is a bone on the inside of the midfoot. An accessory navicular is an extra bone or piece of cartilage next to the navicular.

• Cleft Foot

A foot that has a split, often V-shaped, from the toes toward the ankle. The foot might be missing one or more toes and the long bones that would lead to those missing toes.

• Flatfoot

Your child has flatfoot when the arches on the inside of their feet are flattened, allowing the entire soles of their feet to touch the floor when you stand up. A common and usually painless condition, flatfoot can occur when the arches don't develop during childhood.

In other cases, flatfoot develop after an injury or from the simple wear-and-tear stresses of age. Flatfoot can sometimes contribute to problems in one’s ankles and knees because the condition can alter the alignment of their legs.

• Cavus Foot (High-arched foot)

High-arched foot, also known as Cavus foot, is a condition in which the foot has a very high arch. As a result of this high arch, an excessive amount of weight is placed on the ball and heel of the foot when walking or standing.

As the high arches make their ankles roll outward slightly, children with cavus foot may feel like their ankles are about to give out. Sometimes they sprain their ankles over and over again. Cavus foot can lead to a variety of signs and symptoms, such as pain and instability. It can develop at any age and can occur in one or both feet.

• Clubfoot

Clubfoot describes a range of foot abnormalities usually present at birth (congenital) in which your baby's foot is twisted out of shape or position. In clubfoot, the tissues connecting the muscles to the bone (tendons) are shorter than usual. Clubfoot is a fairly common birth defect and is usually an isolated problem for an otherwise healthy newborn. Clubfoot can be mild or severe. If your child has clubfoot, it will make it harder to walk normally, so doctors generally recommend treating it soon after birth.

• Macrodactyly

Toes that are larger than normal due to extra growth of the bones and soft tissue.

• Polydactyly

Having an extra toe. The extra digit may range from a small, raised bump to a complete, working toe. Most of the time, it's smaller than the other digits and not well formed

• Skewfoot

A form of flatfoot in which the midfoot points toward the outside of the leg and the forefoot (closer to the toes) points toward the inside of the leg. Skewfoot is also called Z foot, S-shaped foot or serpentine foot.

• Tarsal Coalition

Tarsal coalition is a type of flatfoot. It occurs when two or more of the tarsal bones, found in the middle and back of the foot, join together. These bones are usually separate.

Tarsal coalition belongs to the category of flatfoot called rigid flatfoot. The feet of children with tarsal coalition look the same as the feet of children with other forms of flatfoot. Their feet angle outward from the leg and they do not have an arch in the middle. However, feet with a tarsal coalition are stiff, not flexible like some other forms of flatfoot.

Unlike with other forms of flatfoot, babies are not born with a tarsal coalition. Instead, their feet flatten out as they get older, usually between the ages of 8 and 16.

• Vertical Talus

The talus is a bone in the ankle below the bones of the lower leg and above the heel bone. Normally, the talus points toward the toes. In vertical talus, it points toward the bottom of the foot, and the forefoot (from the middle of the foot to the toes) points toward the body. This creates a foot with an upside-down arch that looks like the rocker of a rocking chair.

8. Fractures and complex injuries of the foot and ankle

Injuries to the foot and ankle are commonly encountered, especially among athletes, and can lead to morbidity if not managed appropriately.

Common sports-related foot and ankle injuries include the following:

• Lateral talar process fractures

• Os trigonum injuries

• Lisfranc injuries

• Turf toe

• Navicular stress fractures

• Syndesmotic injuries

9. Diabetic related conditions of the foot

For people with diabetes, common foot problems can lead to infections and serious complications such as amputation etc.

Some of these conditions are:

• Athlete’s foot

• Fungal infection of the nails

• Calluses

• Corns

• Blisters

• Bunions

• Dry Skin

• Foot Ulcers

• Hammertoes

• Ingrown toenails

• Plantar Warts

10. Charcot Arthopathy

Charcot arthropathy, or neuropathic arthropathy, is a condition that affects some diabetic patients with peripheral neuropathy (loss of sensation) after eight to 10 years. It is a progressive condition of the musculoskeletal system that is characterized by joint dislocations, pathologic fractures and debilitating deformities.

11. Posterior Tibial Tendon Dysfunction

Posterior Tibial Tendon Dysfunction is a condition in which the tendon connecting the calf muscle to the inner foot is torn or inflamed. Consequently, the damaged tendon can no longer serve its main function of supporting the arch of the foot.

Surgical Techniques

Trained in a myriad array of skills which include traditional open surgery to arthroscopy and minimally invasive surgery as well as the use of the external and circular fixators, our specialists strive to find the best solution for your problem.

1. Flatfoot Reconstruction

Flatfoot reconstruction is corrective surgery for a collapsed arch that causes the condition of flatfoot. The collapsed arch causes your foot to point outward. This can happen as a result of conditions affecting the foot or ankle such as arthritis or posterior tibial tendon dysfunction.

There are many different causes of flatfoot, which in turn determine the types of flatfoot reconstruction surgery needed. The following are some of the conditions as well as the treatment options available:

Posterior tibial tendon dysfunction

Flatfoot is a main result of this condition and can be treated by the following flatfoot reconstruction surgeries:

Gastrocnemius Recession
Lengthening of the Achilles tendon.
Tenosynovectomy
Cleaning of the tendon.
Tendon transfer
The diseased tendon is removed and replaced by tendon from another area of the foot. If the tendon is only partially damaged, the inflamed part is cleaned and removed, then attached to a new tendon.
Osteoteomy
Cutting and reconstructing bones in the foot to rebuild the arch.

Rheumatoid arthritis of the foot and ankle

Flatfoot can sometimes be a painful side effect of this condition and can be treated with the following surgeries:

Fusion
During the procedure, all of the cartilage is removed from the joint and replaced with bone graft material to fuse the joints together. Fusing of the joint creates one solid bone to eliminate any pain from the previously moving joint. Instrumentation can be used to further secure the bones while they fuse together.
Triple Fusion (Triple Arthrodesis)
A triple arthrodesis consists of the surgical fusion of three joints in the back of the foot with bone graft material and/or instrumentation. The procedure is also carried out to relieve pain from arthritic, deformed, or unstable joints.

Injury

When the ligaments of the foot are injured, the joints can fall out of proper alignment. Eventually, the torn ligaments will no longer be able to provide support, which can then lead to complete collapse of the arch. Surgeries for flatfoot resulting from injury include:

Internal Fixation
This surgical procedure involves realignment of the bones using metal instrumentation such as plates and screws.
Subtalar Implant
This implant is a small, soft-threaded titanium device that is inserted into the side of the hind foot section and is used to restore height to the arch in the foot. The placement of the subtalar implant prevents rolling of the ankle and provides arch support. Tissue can grow normally around the implant, which also helps to hold it in place.

Diabetic collapse (Charcot foot)

People with diabetic foot can suffer from a more severe version of flatfoot, because, as a result of nerve damage, the diabetic often does not feel any pain from the collapse of the arch. As a result, the condition can progress further than normal and can result in a severely deformed foot. Listed below are some common procedures used to correct this problem:

Surgery for bony prominence
Fusion surgery
Surgery that lengthens the Achilles tendon

2. Ankle Fusion (Ankle Arthrodesis)

Ankle fusion, also known as ankle arthrodesis, is a type of surgery to fuse the bones of your ankle into one piece. The procedure is usually done to treat arthritis in the ankle.

Ankle fusion is a surgery to fuse 2 or more bones in the ankle. This helps stop the pain and swelling. Your surgeon will make an incision in your ankle to work on the joint. He or she will then compress the bones together and attach them with plates, nails, screws, or other hardware. A bone graft in some cases, an ankle fusion can be done with minimally invasive surgery. This uses a smaller incision and a tiny camera to help do the surgery.

3. Total Ankle Arthroplasty

Total ankle arthroplasty (TAA), also known as total ankle replacement, is a surgical option for patients with arthritis of the ankle. This operation can relieve pain and maintain motion in the arthritic ankle joint and is an alternative to arthrodesis (ankle fusion) which can relieve pain but eliminates motion in the joint.

4. Lateral Ankle Ligament Reconstruction Surgery

Lateral ankle ligament reconstruction is a surgery to tighten and firm up one or more ankle ligaments on the outside of your ankle. It’s also known as the Brostrom procedure. It is most often done as an outpatient surgery, so you can go home the same day.

5. Ankle Distraction Arthroplasty

Ankle distraction arthroplasty is an innovative procedure for treating ankle arthritis in select patients. Unlike ankle fusion and ankle replacement, which sacrifices the ankle joint in an effort to decrease pain from arthritis, ankle distraction arthroplasty focuses on joint restoration instead. The procedure uses mechanical unloading of the diseased joint to reverse the effects of arthritis and significantly lower pain without damaging the ankle joint, thus preserving ankle motion.

6. Bunion Surgery

Surgical treatment for bunion deformities usually involves an osteotomy, a procedure in which a cut or cuts are made in the affected bone or bones to restore proper alignment. Different techniques are used depending on the type of deformity; selection is guided by the degree of deformity present and the goals of preventing recurrence and achieving the most rapid recovery possible.

Listed below are some of these techniques:

• Distal Chevron Osteotomy

• Scarf or Ludloff Osteotomy

• Crescent Osteotomy

• Lapidus Bunionectomy

7. Fusions of foot bones and ankles

Fusion surgery, also known as arthrodesis, is a surgical procedure where the bones of the joint are fused using screws, making them as one continuous bone.

It may be performed by various techniques which include the following:

Arthroscopic ankle fusion

A fibreoptic instrument and surgical instruments are inserted through the tiny incisions and the inflamed tissues and bony outgrowths are removed.

Open ankle fusion

A large incision is made at the ankle joint and the corrective surgery will be performed. In conditions where the ankle is tilted inwards and the fibula bone is enlarged open ankle fusion would be the better choice as it allows for entire excision and helps in restoring the normal dimensions to the ankle which may not be the case with arthroscopic surgery.

8. Surgery to correct limb deficiency or length inequality

Limb length inequality occurs when one leg is shorter than the other. This condition can be caused by trauma to a growth plate while a child is still growing or from a fracture, genetic condition, infection or syndrome. A certain amount of limb length inequality is normal among the general population, but those with a greater difference may require treatment.

Limb lengthening procedures are very complex. Hence, they are usually reserved for patients with significant discrepancies in length. Lengthening can be performed either externally or internally.

In patients who have finished growing, the longer limb can sometimes be shortened to even out the leg lengths.

9. Forefoot Reconstruction

Numerous deformities are associated with Rheumatoid Arthritis, which is a disease of joints and can therefore, affect any articulation of the forefoot. Treatment for rheumatoid forefoot must be directed towards the patient’s chief complaint, as well as any at-risk area in the forefoot.

Treatment options include:

For mild to moderate deformity
Claw toe correction
For moderate to severe forefoot deformities
Fusion surgery is desired and may include:

First Metatarsophalangeal (MTPJ) arthrodesis
Fusion of the great toe is an operation to stiffen the joint at the base of the great toe (first metatarsophalangeal joint), removing bony bumps and correcting any deformity. The commonest reason for fusing the great toe is arthritis of the big toe joint. This may be isolated arthritis of the big toe (“hallux rigidus”) or part of a generalised arthritis of the foot (usually rheumatoid arthritis)
Lesser toe procedures
Hoffman-Clayton procedure

10. Cavus Foot Reconstruction

The surgical procedures involved with the correction of the cavus foot are varied. These may include correction of the bony deformity, ankle looseness and the muscle imbalances that cause the deformity. The goal is to provide a foot that evenly distributes weight along both inside and outside edges. A variety of incisions may be needed to perform the procedures related to the correction of the cavus foot.

Surgical techniques used include the following:

• Soft tissue surgery

• Tendon transfers

• Bony surgery

• Dorsiflexion osteotomy of the first metatarsal

• Calcaneal osteotomy

• Toe surgery

Patient Outcomes

For both ankle joint replacement and ankle arthrodesis, most patients (85 percent) with either procedure experienced significant reduction in pain and improvement in functional capacity in comparison to before their surgery.

Whether one procedure is better than another comes down to the specific needs of each patient. Both ankle arthrodesis and ankle arthroplasty can provide significant pain relief, improved quality of life and a return to activities.

Over the last 10 years, ankle arthroplasty has been growing in popularity as the implants available for replacement have improved.

Arthroscopic procedures offer several advantages for the patients as there is minimal tissue rupture, minimal blood loss and they can expect a quicker recovery. Furthermore, the fusion or union rates are higher with this technique.

As with all foot and ankle surgeries, age, effective postoperative pain control and fulfilled expectations are some of the factors that are associated with increased postoperative satisfaction.