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Ankle Joint Replacement Versus Ankle Fusion Surgery

Ankle Joint Replacement Versus Ankle Fusion Surgery
Richard A. Zell, M.D.

Hip and knee replacement surgeries have very good results for the great majority of patients with arthritis. There are many studies showing the longevity of these implants with low complication rates.  While orthopaedic surgeons always attempt to treat patients initially with non-operative modalities (which includes anti-inflammatory medications, physical therapy, and injections with corticosteroid or hyaluronic acid), joint replacement surgery can be required if these modalities do not provide significant relief. Research has shown that joint replacement is a reliable surgery that provides patients with good function and pain relief.

raz-ankle-picture-II.pngWhile not as common as knee or hip arthritis, the ankle can also develop arthritis. Ankle arthritis affects many patients and can occur after injuries such as ankle fractures.  Recent studies have shown that the disability resulting from ankle arthritis is just as debilitating as that from hip or knee arthritis (Glazebrook, 2008).  These studies were done using the SF36 functional score which is a standard measure to determine a patients outcomes both before and after surgery.  Unlike the hip or knee where joint replacements have had good results, the optimal operative treatment for ankle arthritis has not been as clear.

The traditional treatment for ankle arthritis has been arthrodesis or fusion.  In this procedure, the ankle joint is exposed, any remaining cartilage on the ends of the bone is removed, and the bone surfaces of the talus and tibia are compressed using screws and/or plates.  This allows the bones of the ankle to heal in a manner similar to the way that the bones in a fracture heals.  This procedure eliminates the pain from the joint at the expense of decreased ankle motion.  Most patients do reasonably well with ankle fusion even given this loss of motion.  We have progressed our ankle fusion technique to an arthroscopically assisted procedure in some patients which allows the surgery to be done with smaller incisions and a shorter healing time.  While an ankle fusion is a good operation that significantly decreases patients’ pain, there are disadvantages to the procedure. The ankle becomes stiff due to the lack of motion and subsequent arthritis can develop in surrounding joints of the foot due to the increased weight they need to bear and increased motion they need to perform.

star_silho.pngAn alternative to an ankle fusion is an ankle joint replacement.  In this procedure, the bones of the ankle (the tibia and the talus) are replaced with a metal cap.  A piece of plastic between the ends of the bone acts as the gliding surface of the joint allowing the ankle to move.  This design is similar to a knee replacement.

There have been many attempts at ankle replacement through the years.  In the 1970s and 1980s, there were various replacement implants designed and trialed, however the results of these surgeries were poor. Many patients required further surgery and eventual removal of the implants. Such complications led to the eventual abandonment of ankle replacement surgery in the United States until a more viable surgery was discovered.

Foot and ankle surgeons, in both Europe and the US, continued to work on ankle replacements and, by the late 1990s, there was one US ankle replacement that was approved by the FDA.  This implant was called the Agility ankle replacement and was significantly better than the previous ankle replacements. However, there were still many failures of the implant, most notably involving the talus or lower ankle component.

Over the last 15 years, more advanced ankle replacements were initially introduced in Europe and have been gradually approved in the United States. These improved implants more accurately reproduce the anatomy and biomechanics of the ankle which have led to better clinical results following surgery and long lasting durability. One such implant is the STAR ankle replacement that has been found to have a 95% survival rate of the implant 10 years status-post surgery (Kofoed, 2004).  Several studies have been completed comparing ankle replacement and ankle fusion surgery. The results of these studies imply that pain relief is comparable with both surgeries, however the ankle replacements patients have improved function (Saltzman, 2009). While it has been a long time in the making, ankle replacement surgery has finally become a good alternative to ankle fusion in select patients.

Ankle Joint Replacement Photo's
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Ankle Sprains & Fractures - Conservative and Surgical Treatment Options

Ankle Sprains and Fractures
Richard A. Zell, M.D.

Ankle injuries can occur in the workplace. Two common injuries include: ankle sprains, and ankle fractures.

The bones that make up the ankle include: the Tibia, Fibula and Talus. The bones of the ankle joint are stabilized by ligaments. These include the medial or inside ligaments (Deltoid ligament) and the ankle-joint.jpgoutside or lateral ligaments. There are also ligaments that connect the Fibula and Tibia above the ankle called Syndesmotic ligaments. Ankle sprains are injuries to these ligaments. They occur after inversion (the ankle rolling in) or twisting injuries. Sprains typically involve the lateral ligaments but can also involve the Syndesmotic or Deltoid ligament. Injuries to the Syndesmtoic ligaments are called high ankle sprains and are common injuries in football players but can also occur in the workplace. There are three grades of ankle sprains (1-3) that describe a progression from a stretch injury to complete disruption of the ligaments.

Treatment of ankle sprains typically involves RICE (rest, ice, compression and elevation). Lower grade sprains are managed with an ankle brace/Aircast while higher grade sprains are managed in a walking or CAM boot. The CAM walker allows the patient to weight bear without the ankle having to move and become more inflamed. Patients are allowed to weight bear as tolerated with assist of crutches as required. Physical therapy is helpful in the recovery of ankle sprains. PT is not started initially in order to allow the swelling/inflammation to decrease.

The great majority of lateral ankle sprains can be managed without surgery. Studies have shown that even with complete disruption/tearing of the ligaments, patients do better with non-operative treatment rather than surgery to repair the ligaments. There are some exceptions where surgery is required such as patients that have an ankle sprain associated with a bone chip or osteochondral defect. These patients require an ankle arthroscopy to remove/repair the bone fragment. At times, injuries to the ligaments above the ankle (Syndesmotic ligaments) can be associated with a shift of the bones of the ankle and this injury also requires surgery. Some patients may have continued or chronic symptoms several months after an ankle sprain and may require surgery to tighten the lateral ligaments if they are loose (Brostrom procedure). Other patients have continued inflammation/scarring after a sprain and may require an ankle arthroscopy and debridement.

The amount of time out of work following an ankle sprain depends on the grade of the injury and the patient’s job. Grade I sprains typically heal in approximately 2-3 weeks. Grade III sprains can take 6-8 weeks or longer to fully heal. Patients with ankle sprains can typically be sent back to work on modified duty as the treatment of ankle sprains typically allows weight bearing to tolerance with a brace or boot. Patients will likely need time off for physical therapy and allowances may be required for use of a brace/limited walking. Patients with jobs that include working on unprotected heights/ladders/etc. may not be able to return to full duty for several weeks. Ankle fractures can also occur after twisting injuries and can also be caused by other traumatic events such as falls or motor vehicle accidents. The fracture or ‘break’ can involve the Fibula and/or the Tibia. Fractures of the Talus will not be discussed in this review.

Ankle fractures typically occur in characteristic patterns depending on the position of the foot/mechanism of injury. Some fractures can occur without disruption of the ankle joint/displacement of the bones (non-displaced fractures) while other injuries lead to gross shifting of the facture fragments/alignment of the joint.

Some ankle fractures can be treated without surgery if the bony fragments are in overall good alignment. These patients can be managed in a cast or possibly a removable boot or Cam walker. There are other patients thathave a minimally displaced fracture and traditionally it was difficult to determine the proper treatment for these patients (casting or surgery). It has been found that special radiographic tests called stress views can help determine which patients require surgery.

Displaced ankle fractures typically require surgery. The goal of ORIF (open reduction internal fixation) is to return the bones of the ankle to their anatomic or pre-fracture position and then the bone fragments are held in position with plates screws or other metal implants.

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Recovery from ankle ORIF includes initial immobilization in a splint (placed in the operating room). Patients require narcotic medication initially and a daily Aspirin (to decrease the risk of DVT). Sutures are typically removed at two weeks s/p surgery and the patient is placed in a cast or a removable boot. This boot may be removed several times per day to allow the patient to perform gentle range of motion exercises. Patients are kept non weight bearing for at least 6 weeks s/p surgery. Crutches or a knee walker are required. Once the fracture has healed adequately (usually at 6 weeks s/p surgery) the patient may start weight bearing in a cast boot and eventually transition into a sneaker. Physical therapy is started when the cast is removed. Many patients also require a course of work conditioning.

Risks of surgery include infection, wound healing problems, and local nerve injury. These risks can lead to a less optimal result. In order to avoid these risks, patients are encouraged to stop smoking before surgery to decrease the risk of wound healing problems or infection. Wound healing difficulties can also be avoided by waiting until the swelling is decreased before proceeding with ORIF.

Time out of work after ankle fracture again depends on the severity of the injury. Most ankle fractures require non weight-bearing for at least 6 weeks. This is followed by 6 weeks of rehab to allow return of strength and motion. The pain and swelling from injury typically prevents work over the initial 7-10 days after injury. For patients with a non-displaced fracture, return to modified duty is possible after 10 days with accommodations for their NWB status and use of a cast or brace. Patients requiring surgery may not be able to return to modified duty until at least 3-4 weeks after surgery. The return to full duty status after ankle ORIF can be prolonged (6 months of longer) for patients who perform heavy work such as laborers or construction workers.

Cartilage Injury of the Ankle and Repair

Richard A. Zell, M.D.

Cartilage is the smooth, gliding surface that lines each of our joints. This tissue allows joints to move freely and gives us our ability to walk, run, jump and play sports. There are many orthopaedic conditions that are caused by damage to the cartilage. The most common disorder is arthritis in which there is a global loss of cartilage. The cause of arthritis is typically hereditary but can also be secondary to inflammatory conditions (such as Rheumatoid Arthritis or gout) or trauma. There are also conditions in which a small amount of cartilage (sometimes with a segment of underlying bone) in a joint is damaged. This can occur after an ankle or knee injury, and are common problems in young and middle-aged athletes. The condition has been called an osteochondral lesion or osteochondritis dissecans when it occurs in the knee and osteochondral lesion of the Talus (OLT) when it occurs in the ankle. The injury is usually located in the lower bone of the ankle joint or the talus.

An OLT usually occurs after an ankle injury such as a sprain or fracture. During these injuries, the lining cartilage of the joint is bruised or sheared off during the twisting injury. Patients will complain of ankle pain, stiffness, swelling and possibly feelings of “catching” in their ankle. Physical examination demonstrates pain with motion of the ankle, swelling, and at times, instability of the ankle. X-rays are obtained to make sure patients do not have fractures or arthritis of the ankle. Occasionally, a small avulsion of bone that the cartilage is attached to, can be seen on the radiographs. An MRI is the best test to reveal an OLT and is helpful for making sure that there are not other causes for the patients pain (such as tendonitis, stress fractures etc.).

A cartilage injury does not necessarily mean surgery. Previous studies have shown that approximately 45% of patients can actually avoid surgery (Tol et al, 2000). Non-surgical treatment includes immobilization in a walking boot/cast, physical therapy, and NSAIDs. If patients have symptoms for more than 6 weeks to 3 months, surgery is recommended.

Even with all of the advances in medicine over the years, there is no perfect treatment for cartilage defects. We do not have the ability to fabricate cartilage that has the same make-up and structure of native cartilage. There are different surgical options available however, for cartilage defects that have been shown to recreate tissue that is close in form/structure to native cartilage and will allow patients to be pain free and return to sports. These procedures include: microfracture, mosaicplasty, allograft reconstruction, autologous cartilage transplantation, and juvenile cartilage transplantation.

The traditional treatment for cartilage injury or defects is microfracture. This is a procedure that can be done using the arthroscope and small incisions. An incision is made so that a small camera may be placed into the ankle joint. A second incision is then made for placement of instruments to allow removal of all loose cartilage in the area of the cartilage defect. Once all loose cartilage is removed, there will be an area of exposed bone. Multiple perforations or drill holes are then made in the bone to allow bleeding and ultimate formation of fibrocartilage or scar cartilage. This tissue fills in the gap with time. The tissue is not as resilient as our normal cartilage but seems to work well. Patients are allowed to move their ankle shortly after surgery but are kept non weight bearing for a few weeks. Return to sports occurs approximately 3 months following surgery. This technique has been found to be best for smaller cartilage defects (less than 1.5 cm in diameter) and is helpful in approximately 79-90% of patients (Ferkel, 2008).

There are certain cartilage defects in the talus that are larger in size. There are also some patients who have undergone a mircrofracture procedure and still having pain or feelings of catching. These patients can undergo a larger procedure called a mosaciplasty. This surgery involves taking a plug of cartilage and bone from another area of the body and placing it in the area of the cartilage defect. Most often the cartilage and bone plug is taken from the knee (in an area of the joint that can function well without cartilage). Using special instruments, the cylindrical plug is then placed into the talus which brings healthy bone and cartilage to resurface the joint. This is a larger procedure that often requires larger incisions and, at times, an osteotomy (cutting the bone of the tibia) to allow placement of the cartilage plug. Mosaicplasty has good results in approximately 90% of patients (Imhoff, 2011) and is best for patients with moderate size defects of the talus cartilage.

There are certain patients who have an OLT in which a large percentage of the talus cartilage is damaged. These patients are often managed with use of an allograft talus. In this procedure, an allograft talus, which is a talus that comes from a person who has passed away and has donated their organs/bones to help others, is obtained from a tissue bank. Prior to sending the allograft talus to the operating room, the tissue is tested for disease to ensure that the tissue/bone is safe for use. During the surgery, special instruments are used to take part of the allograft talus and secure it to the patient’s own talus to resurface the joint surface. This is not a common surgery but can work well for patients with large to massive defects of the talus.

Some novel techniques exist that can be used for talar cartilage defects. One technique is autologous cartilage transplantation. With this procedure, a piece of cartilage is taken from the ankle during an arthroscopy and sent to a company called Genzyme. The company will then harvest the chondrocytes (cartilage cells) from the sample and will grow approximately 12 million new cartilage cells. These cells are sent back to the OR in liquid form. Patients undergo a second surgery in which the grown cartilage cells are placed in the defect and covered with a patch. With time, the implanted cartilage cells allow new cartilage to grow and fill in the defect. This procedure has been done for the past 15 years and is helpful for larger defects of the talus.

Recently, another company has used juvenile cartilage from young donors for cartilage defects. The cartilage is taken from young people who have passed away and whose family has consented to have their tissue donated. This tissue is tested to make sure there is no contamination or disease and then packaged for use in the OR. At the time of surgery, the juvenile cartilage is placed into the cartilage defect and secured with fibrin glue. As time goes by, the cells in the donated cartilage fill in the gap. It is felt that the young age of the donated tissue allows a more robust filling in and repair of the cartilage defect. Studies are underway to see if this treatment will be more helpful than previous techniques for cartilage defects.

Treatment of cartilage defects continue to be an evolving area of study in orthopaedics. This paper concentrated on cartilage defects in the ankle, however the same techniques are used for cartilage defects in the knee and other joints.

Foot & Ankle Surgery Photo’s
 

1st MTP Fusion with Bone Graft

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Achilles Tendoniits Surgery

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Ankle Fracture ORIF

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Lapidus Bunionectomy

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OCD Talar Dome Arthroscopy

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Pilon Ankle Fracture ORIF

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Fragility Fractures - Osteoporosis (Trauma) and Treatment

Pathologic fractures are fractures that occur in weakened bone. Osteoporosis is the most common cause of weakening of the bone but other conditions such as: cancer, infection, inherited bone disorders or bone cysts can also cause the bone to be weak. A fragility fracture is one caused by a relatively minor trauma such as a fall from a standing height. Normally one can fall from a standing height without causing a fracture of a bone. These fractures are associated/caused by osteoporosis. All bones are susceptible to a fragility fracture. Three common examples of a fragility fracture include: vertebral fractures, fractures of the neck of the femur, and Colles fractures of the wrist.

Bone is a living tissue that is constantly being formed and resorbed. Osteoporosis refers to a condition in which the bone density is decreased. This condition is caused by an imbalance between the formation and breakdown of bone. We all lose bone as we become older. By our mid-thirties there is approximately 0.5% loss of our bone per year. When one has osteoporosis, there is greater loss than formation of bone. Patients with osteoporosis have lost approximately 30-40% of their bone density. Understandably this can lead to a higher risk of fracture. One study has shown that 40% of 50 year old females will have an osteoporotic fracture during their lifetime. Osteoporosis is more common in woman than men. The risk of hip fracture after age 50 is 15-18% in woman and 6% in men.

Some fractures require surgery and one of the mainstays of Orthopaedic fracture care is plate and screws. The AO group in Switzerland developed the modern plating systems that we use to treat many fractures. The dynamic compression plate allowed stability of fractures for healing and the ability to move the joints near the fracture allowing good return of function. Traditional plates rely on friction between the plate and bone to hold the fracture stable. The plate is attached to the bone by the screws. If the bone quality is poor (as in osteoporosis) the screws may not hold causing less than ideal stability. When doing surgery on a patient with osteoporosis the surgeon often gets the feeling that there is no bite or stability to the screws (feels like you are placing a screw in Styrofoam). This does not provide confidence that the plate and screws will provide the stability needed to hold the bones in position until the fracture heals. Making matters worse, elderly patients often do not have the strength to avoid weight-bearing on the fractured extremity. This places the fracture and plate/screws under more stress than would be seen in younger patients.

In the past there was not a great solution for treatment of certain fractures in the elderly patient with osteoporosis. Different strategies have been proposed including injecting bone cement in the bone before placing screws in order to allow more 'bite' of the screws. Other patients were treated with different devices such as external fixators (for wrist fractures) or rods (for certain fractures of the femur or tibia). These advances were helpful but did not allow us to stabilize every fracture.

In the 1990s the AO group developed a new concept of plating called locked plating. The screws in these systems lock into the plate and therefore do not rely on the density/strength of the bone. The screw and plate create a fixed angle construct that is less prone to loosening or toggling. They have been found to have a positive role in stabilization of osteoporotic fractures (Cordey & Perren, Injury 2000). In addition locked plates have been found to be helpful in treating unstable or more difficult fracture patterns (for example allowing use of one plate for tibial plateau fractures that traditionally required use of 2 plates). They have also allowed stabilization of certain fractures in the elderly osteoporotic patients such as: the wrist/Colles fracture, and proximal humerus fractures. Before locked plating these fractures were with treated with casts or benign neglect often leading to stiff/minimally functioning joints.

Recently, many of these locked plates have been pre-contoured to fit a specific part of the bone. For instance there are locking plates designed for the distal aspect of the femur or for the fibula in the ankle. This can make surgery easier and quicker (no more timely bending of plates). Use of these pre-contoured plates has also allowed more effective stabilization of difficult fractures and also at times allowed plates to be placed in a percutaneous manner (without a large incision) which may be beneficial in certain patients such as the elderly. The locked plates also have many novel uses including stabilization of fractures near a total knee implant that previously had no good solution. Overall these new plates have allowed orthopaedists to treat many more difficult fractures in the elderly osteoporotic patients.

Hallux Rigidus and Types of Surgery

Arthritis is a condition in which the cartilage or lining surface of a joint wears away. This condition can be hereditary or related to trauma or injury. This loss of cartilage causes inflammation in the joint with resultant pain. As the cartilage wears away, the body forms spurs on the top part of the joint. A bone spur or osteophyte is a bony growth/extra bone that forms on the edge of a joint. It forms as the body tries to repair itself by building extra bone. This spurring or extra bone can lead to stiffness of a joint.

Hallux Rigidus is arthritis of the 1st toe joint. This has also been called a dorsal bunion. The arthritis involves the large joint of the big toe called the MTP joint (between the 1st metatarsal and the proximal phalanx). The 1st MTP joint is an important joint during walking. It can bend up to 90 degrees. The 1st MTP joint can develop arthritis at a young age (patients in their 30's or 40's). The cause of the arthritis is thought to be secondary to a prior injury or hereditary. Patients often have pain and irritation from shoe wear (secondary to the shoe rubbing on the bone spurs). The joint becomes stiff and swollen.

Many patients can be treated with wider/extra depth shoes. Other patients feel better in a stiffer shoe. In a stiff shoe, such as a clog, the stiff 1st MTP joint does not have to bend as much when walking. A further non-operative treatment option is the use of orthotics. In particular an orthotic with a carbon fiber insole can be helpful in order to decrease motion in the 1st toe joint. Other options include use of NSAIDs (such as Advil or Ibuprofen) and possible cortisone injections.

If there are increasing symptoms/limitations, a patient will require surgery. There are four surgical options for Hallux Rigidus including: cheilectomy, interpositional arthroplasty, replacement and fusion.

1st MTP Cheilectomy

This procedure involves removing the painful and prominent bone spurs on the top of the toe joint. This is done to allow increased motion through the MTP joint, decrease shoe wear irritation from the bony prominence, and eliminate some early arthritis on the upper surface of the joint. Typically, the top 1/3 of the MTP joint has arthritic changes. The bone spurs and arthritic areas need to be removed in order to allow increased motion and improvement in symptoms. This procedure is effective only for patients who have arthritis involving the top part (dorsal aspect) of the joint. It is not indicated in patients with extensive arthritis involving the entire joint (ie: more severe or end/late-stage Hallux Rigidus).

Recovery from a cheilectomy is typically relatively rapid. Patients are allowed to weight bear as tolerated in a stiff-soled shoe following surgery. There is no need for crutches. The sutures are removed at approximately ten days s/p surgery. Patients are allowed to return to a sneaker by three weeks s/p surgery. Typically 2-3 visits of physical therapy are used for instruction in a home exercise/motion program. Return to sports is approximately six weeks s/p surgery. However, residual pain and swelling can be expected to limit some activities for at least a few more months post-operatively.

Potential complications of the surgery include infection, wound healing problems and irritation of the nerve that provide sensation to the toe. Patients are instructed in cleaning their foot the night before surgery and IV antibiotics are given during surgery to decrease the chance of infection. Patients who smoke are encouraged to stop smoking before/after surgery to allow full, rapid wound healing.

One other potential complication of a cheilectomy would be continued 1st toe pain. The cheilectomy removes the bone spurs, however it does not reverse the arthritis in the joint. If the arthritis is significant some patients have continued pain and may need a different procedure. . This need for a further procedure can occur relatively quickly if there was more wear and tear arthritis in the great toe joint than expected.

Interpositional Arthroplasty

This procedure involves removal of bone spurs, as in a cheilectomy, followed by a placement of tissue to resurface/form a new gliding surface for the joint. At times further resection of bone (than that for a cheilecotmy) is required. This procedure has typically been done for patients with more significant arthritis that do not want to consider a fusion of the joint. After the bone spurs are removed a portion of the lining of the joint or capsule can be placed between the two bones of the 1st MTP joint. Sometimes a genetically engineered substance (such as treated human skin cells i.e. Graft Jacket from Wright Medical) is used. This substance can be used a spacer or cushion between the two bones or can be draped over the end of the bones to allow the two bones to glide against each other. This gliding surface is not as good as normal cartilage, but can allow a mobile pain-free joint.

Recovery from an interpositional arthroplasty is similar (however usually prolonged) to a cheilectomy. Risks of surgery are similar to the risks after cheilectomy surgery.

The long term results of this procedure can be variable. Many patients do well for many years while others have continued difficulties and require a fusion procedure.

Joint Replacement

This procedure involves replacement of one side or both sides of the 1st MTP joint with metal or other substance. This would be similar to joint replacement of a hip. The initial replacements were made of silicone and there have been other replacements made of metal that have been manufactured. Most Orthopaedists do not routinely use these devices as the results of these implants in the Orthopaedic literature have not been reliable. In particular, many of these reports describe loosening of the implants with resorption/destruction of the bone causing pain, deformity of the toe and need for further surgery. Most patients who require further surgery undergo a fusion of the joint. At times this can be a difficult surgery secondary to lose of bone requiring use of bone graft.

Fusion

A fusion consists of making the 1st toe joint stiff by removing the remaining cartilage of the joint and allowing the two bones to heal together. This procedure is done by preparing the joint surfaces and then placing screws or using a plate to compress the two bones together. The two bones heal together in a similar process to bones healing in a fracture. A fusion (also known as an arthrodesis) is very reliable in decreasing pain at the expense of decreased motion. Having a fused joint sounds very limiting, however patients can be very active including walking and many sports. It is possible to play tennis and some patients can also run. There are some limitations with shoe wear such as limited use of high heel shoes for woman. The majority of patients are happy with the results of a fusion.

A fusion can be necessary if other procedure for Hallux Rigidus fail. In particular, continued pain after a cheilectomy often requires a fusion. Failure of a joint replacement is typically managed with a fusion although this can be a difficult procedure requiring use of bone graft (often from the pelvis area or iliac crest) to account for bone destruction from the failed replacement procedure.

Recovery from a fusion typically includes use of a hard soled shoe although casting/walking boots are used at times. Typically weight bearing is allowed after 3 weeks although some patients are not allowed to place full weight until later. Most patients can progress to a sneaker by 4-6 weeks s/p surgery.

Risks of surgery include similar risks to a cheilectomy in terms of infection, wound healing difficulties or nerve irritation. Some patients are bothered by the metal used for the fusion. If a plate is used it is often prominent and needs to be removed after the fusion is healed. The other specific risk of a fusion procedure would be a non-union. A non-union means that the two bones do not fuse or heal together. This occurs in approximately 10% of cases. It can be related to smoking. If a non-union occurs and there is continued pain, a revision fusion using bone graft may be necessary.

Knee Surgical Case Photo’s
Interdigital Neuroma - (Morton’s Neuroma)

Richard A. Zell, M.D.

An Interdigital Neuroma or Morton’s Neuroma is an inflammation (peri-neural fibrosis) of the common digital nerve as it courses under the transverse metatarsal ligament in the forefoot. This nerve provides sensation between the toes. An Interdigital Neuroma normally affects the 2nd interdigital space (between the 2nd and 3rd toe) or the 3rd interdigital space (between the 3rd and 4th toe. ) It is very uncommon in the 1st and 4th web space. One must consider other etiologies of pain in patients with pain in these areas.

Patients with an Interdigital Neuroma complain of burning and tingling in the interspace of the involved toes. The pain can radiate to the toes. At times patients may describe a vague pain that radiates up the leg. Symptoms are exacerbated by walking and running. With walking (especially during toe off) the interdigital nerve becomes compressed by the intermetatarsal ligament in the plantar aspect of the forefoot. High-heeled shoes with a narrow toe box exacerbate the symptoms from a neuroma as there is compression of the forefoot by the shoe.

Physical Exam demonstrates tenderness to palpation of the forefoot just proximal to the toes in the area between the metatarsal heads. Some patients have a snap or click with compression of the forefoot. This is called a Mulder’s click and some think that this is secondary to bursal inflammation that can accompany an Interdigital Neuroma. At times the nerve enlargement is palpable. One can consider a diagnostic lidocaine/ bupivacaine injection beneath the intermetatarsal ligament to confirm the diagnosis.

The differential diagnosis of a Interdigital Neuroma includes: a metatarsal stress fracture (pain is more dorsal), metatarsalgia(pain under metatarsal heads and not in the interspace), synovitis/instability of the MTP joint (tenderness over the MTP joint rather than the interspace), degenerative joint disease, or possibly a lumbar disc herniation.

Radiographs of the foot are obtained to rule out bony pathology. An MRI can show the neuroma however it is not usually necessary to make the diagnosis. Some patient require a bone scan if there is concern regarding degenerative joint disease of the MTP joint.

Many Interdigital Neuromas can be managed without surgery. Patients are advised to obtain wider shoes with lower heels to reduce the pressure on the forefoot. Metatarsal pads are soft felt pads placed just proximal to the metatarsal heads and this serves to unweight the area of the neuroma. A metatarsal bar is a similar device built into an orthotic. Larger braces such as an AFO can be used, however these can be cumbersome. Some patients benefit from one to two cortisone injections into the interspace. This decreases the inflammation around the neuroma. Multiple injections should be avoided to prevent fat pad atrophy/degeneration of the volar plate or collateral ligaments.

Patients with long standing symptoms (greater than 6 months) may require surgery. Surgery is not indicated in patients with a poor circulatory status, atypical symptoms, or reflex sympathetic dystrophy. During surgery an incision is made on the dorsum of the foot over the appropriate interspace. The transverse intermetatarsal ligament is divided. The thickened common digital nerve is identified along with the branching proper digital nerves. The nerve is then dissected proximally and divided 1-2 cm proximal to the weight-bearing pad of the forefoot. The entire neuroma and all distal nerve branches are removed. A neuroma will be formed at this area of the proximal transection, however it should not be symptomatic. Patients are allowed to weight bear in a post-op shoe. Review of the literature demonstrates that approximately 80% of patients are significantly improved following surgery. Major activity restrictions are uncommon and patients can return to all sports and activities. Some patients report some shoe wear restrictions. There can be numbness between the toes, however this is typically not bothersome.

Patello-Femoral Pain & Arthritis (Conservative & Surgical Treatment)

Patello-Femoral Pain Syndrome and Patello-Femoral Arthritis

Disorders of the patella or kneecap are a common cause of visits to the Orthopaedist. One such condition that affects younger patients is patello-femoral pain syndrome. Patello-femoral arthritis can occur with progressive wear and tear of the knee.

Anatomy

The knee consists of three separate parts or joints. These include: the medial and lateral tibia-femoral joint (between the thigh and shin bone) and the patello-femoral joint (the kneecap joint).

The patella (kneecap) is the moveable bone on the front of the knee. The patella is a sesamoid bone (contained within a tendon) that connects the large muscles of the thigh (Quadriceps muscle) to the tibia (shin bone). The quadriceps tendon attaches the quadriceps muscles to the patella and the patellar tendon connects the patella to the tibia. Tightening up the quadriceps muscles places a pull on these tendons causing the knee to straighten. The patella acts like a fulcrum to increase the force of the quadriceps muscles.

The underside of the patella is covered with articular cartilage. Articular cartilage is a smooth, slippery covering found on joint surfaces. This covering helps the patella glide (or track) in a groove in the femur or thigh bone.

Patello-Femoral Pain Syndrome/Arthritis

Patello-femoral pain syndrome describes a condition in which patients have pain from the patello-femoral joint. This has been called chondromalacia patella in the past. This condition can be related to: overuse of the patello-femoral joint, early wear and tear changes of the cartilage and/or mal-alignment.

Patello-femoral arthritis describes a similar condition in which there is 'wear and tear' or loss of the cartilage on the patella. This loss of cartilage is called arthritis. The joint does not glide as freely as it should. This is a more advanced problem that can often cause increased pain and disability.

Cause of Patello-Femoral Pain Syndrome/Arthritis

It is thought that the way in which the patella tracks within the femoral groove contributes to these conditions. The quadriceps muscle helps control the position of the patella in the femoral groove. If part of the quadriceps is weak (for any reason such as a knee injury) a muscle imbalance can occur. With a muscular imbalance, the pull of the quadriceps muscle may cause the patella to pull more to one side than the other. This imbalance causes more pressure on the articular cartilage on one side of the patella than the other. In time, this pressure can irritate or damage the articular cartilage.

Another type of imbalance may exist secondary to the patient's bony anatomy (shape and alignment of the bones). Some people are born with a greater than normal angle between the femur (thighbone) and the tibia (shinbone) at the knee joint. Women tend to have a greater angle than men. The patella normally sits at the center of this angle within the femoral groove. When the quadriceps muscle contracts, the angle in the knee straightens, pushing the patella to the outside of the knee. In cases where this angle is increased, the patella tends to shift outward with greater pressure on the cartilage on the outer part of the patella. This can damage the articular cartilage in this area of the patella.

Other patients have an anatomic variation in the size/depth of the grove in the femur. For example, the groove in the femur can be shallow allowing the patella to slip or shift to the side. This slippage can damage the cartilage underneath the patella.

Imbalance can also occur secondary to tightness of the soft tissue structures surrounding the patella. Some patients have a tight capsule or lining of the knee on the outside portion of the patella. This leads to increased pressure on the cartilage on the outer part of the patella. This is called Lateral Patellar Pressure Syndrome.

These conditions can cause irritation of the patellar cartilage, inflammation of the knee and increasing pain. This represents patello-femoral pain syndrome. With long-standing irritation, patellar cartilage loss can occur leading to patello-femoral arthritis.

Presenting Symptoms

Patients with patello-femoral pain syndrome are typically young and athletic. Most often they do not have an injury. Some patients may develop symptoms of patello-femoral pain syndrome after falling onto the front part of the knee or after a car accident in which the knee hits the dashboard.

Typically patients have pain around the front part of the knee and along the edges of the patella. At times patients report a sensation of the patella is slipping. This is thought to be a reflex response to pain and not necessarily instability of the knee. Patients report pain when walking down stairs or hills. Keeping the knee bent for long periods, as in sitting in a car or movie theater, may cause pain. The knee may grind, or produce a crunching sound with squatting or going up/down stairs. Some patients can also have knee swelling when there is degeneration of the patellar cartilage.

Diagnosis

The diagnosis of patello-femoral pain syndrome is typically based on the history and physical exam.

An X-ray can help determine if the patella is properly aligned in the femoral groove. X-rays taken with the knee bent at several different angles can help determine if the patella seems to be moving through the femoral groove in the correct alignment. The X-ray may also show arthritis between the patella and femur or thigh bone.

An MRI is not typically needed to make the diagnosis of patello-femoral difficulties, but is obtained at times to r/o other problems in the knee causing symptoms (meniscal injuries or ligament injuries).

Treatment

Most patello-femoral problems including patello-femoral pain syndrome can be treated without surgery. The initial treatment for a patellar problem begins by decreasing the inflammation in the knee. A period of rest and anti-inflammatory medications, such as ibuprofen, is often helpful. Physical therapy is the most important component of the treatment of patello-femoral pain syndrome. Initially the PT program is focused on decreasing pain and inflammation. Ice, massage and ultrasound can help limit pain and swelling. As the pain and inflammation become controlled, the physical therapist will work with the patient to improve flexibility, strength, and muscle balance about the knee.

Bracing or taping the patella can also be helpful in allowing patients to exercise and perform activities with less pain. Most braces for patello-femoral problems are made of soft fabric, such as cloth or neoprene. They slide onto the knee like a sleeve. A small buttress pads the lateral or outside of the patella to keep the patella lined up within the groove of the femur. An alternative to bracing is to tape the patella in place. Taping is performed by the physical therapist to help realign the patella. The idea is that by bracing or taping the knee, the patella stays in better alignment within the femoral groove.

Surgery

If nonsurgical treatment fails to provide significant improvement, surgery may be suggested. The procedure used for patello-femoral problems varies. In severe cases a combination of one or more of the following procedures may be necessary.

- Arthroscopic Method
Arthroscopy is useful in the treatment of patello-femoral problems of the knee. Arthroscopy is an operation that involves placing a small fiber-optic TV camera into the knee joint. Looking directly at the articular cartilage surfaces of the patella and the femoral groove is the most accurate way of determining how much wear and tear there is in these areas. By using the arthroscope or camera the patella can be visualized as it articulates with the groove in the femur. The tilt of the patella and the way that the patella tracks can be seen. If there are areas of articular cartilage damage behind the patella that are creating a rough surface, special tools can be used during surgery to smooth the surface and likely reduce knee pain. This procedure is sometimes referred to as shaving or a chondroplasty.

- Lateral Release
If your patella problems appear to be caused by a misalignment problem, a procedure called a lateral release may be suggested. This procedure is done to allow the patella to shift back to a more normal position and relieve pressure on the articular cartilage. In this operation, the tight ligaments on the outside (lateral side) of the patella are cut, or released, to allow the patella to become less tilted and slide evenly in the groove of the femur. These ligaments eventually heal with scar tissue that fills in the gap created by the surgery, but they no longer pull the patella to the outside as strongly as before the surgery. This helps to balance the quadriceps mechanism and equalize the pressure on the articular cartilage behind the patella.

- Ligament Tightening Procedure
In some cases of severe patellar misalignment, a lateral release alone may not be enough. In order to realign the pull of the quadriceps mechanism, the tendons on the inside edge of the knee (the medial side) may have to be tightened as well. This can be done using an open incision or arthroscopically.

- Bony Realignment
If the misalignment is severe, the bony attachment of the patellar tendon may also have to be shifted to a new spot on the tibia bone. The patellar tendon attaches the patella to the lower leg bone (tibia) just below the knee. By moving a section of bone where the patellar tendon attaches to the tibia, surgeons can change the way the tendon pulls the patella through the femoral groove. This is done by removing a section of bone where the patellar tendon attaches on the tibia, moving it medially (towards the inside of the knee) and then repairing the segment of bone back to the tibia with screws. This surgery is called a Fulkerson Procedure.

Once the surgery heals, the patella should track better within the center of the groove, spreading the pressure equally on the articular cartilage behind the patella.

- Cartilage Procedure
In more advanced cases of patellar arthritis, there are procedures that allow placing new cartilage/material in the area of arthritis or cartilage loss. The type of surgery needed for articular cartilage is based on the size, type, and location of the damage. Along with surgical treatment to fix the cartilage, other procedures may also be done to help align the patella to put less pressure on the healing cartilage.

Arthroscopic procedures to shave the patella or a simple lateral release can usually be done on an outpatient basis, meaning you can leave the hospital the same day. If your problem requires the more involved surgical procedure where bone must be cut to allow moving the patellar tendon attachment, you may need to spend one night in the hospital.

Tarsal Tunnel Syndrome (Conservative & Surgical Treatment)

Richard A. Zell, M.D.

Tarsal Tunnel Syndrome is a less common condition caused by the compression of the tibial nerve in the tarsal tunnel. This condition is akin to Carpal Tunnel Syndrome of the upper extremity in which the median nerve is compressed by the transverse carpal ligament in the wrist. In Tarsal Tunnel Syndrome, the tibial nerve is compressed by the flexor retinaculum behind and distal to the medial malleolus. The compression of the tibial nerve can be caused by: a lipoma, ganglion, bony exostosis or neoplasm within the tarsal tunnel. Other causes of compression include: a plexus of veins or an accessory flexor digitorum longus muscle. The condition can be associated with a flatfoot or valgus position of the heel.

Patients with Tarsal Tunnel Syndrome complain of ankle pain that radiates along the plantar side of the foot and sometimes up into the calf. Other patients report parathesias or foot numbness. Physical exam can demonstrate a positive Tinel sign behind the medial malleolus. Other patients have increased pain with manual compression over the tarsal tunnel. Some patients may have atrophy of the foot. Two point discrimination tests may be abnormal on the plantar aspect of the foot.

EMG and nerve conduction tests can be helpful in the diagnosis of Tarsal Tunnel Syndrome. A recent study reported that 81% of patients with tarsal tunnel syndrome had abnormal EMG studies. An MRI is a useful study in the work up of patient with Tarsal Tunnel Syndrome as it can be used to identify space-occupying structures within the tarsal canal as well as the specific site of compression of the tibial nerve.

Many patients improve with rest, NSAIDS and possibly orthotics. Surgery is recommended for patients with persistent symptoms and a space-occupying lesion within the tarsal canal. During a Tarsal Tunnel Release an incision is made along the medial aspect of the ankle and the tibial nerve and its branches are decompressed. The cause of the compression is removed i.e. the venous plexus surrounding the nerve or the ganglion compressing the nerve is removed.


Pre-Op / Post-Op Instructions


Pre-Operative Instructions for Surgery

Now that you have decided to proceed with surgery, our office will get you ready for your surgical day. Renee (Dr. Zell's Clinical Care Coordinator) will contact you to set up a date for your surgery and will help make the arrangements for your surgical day. We will contact your insurance company to check on your coverage for surgery. For our Workmen's Compensation patients, we will assure that surgery has been approved by your carrier.

  • Most patients will require a medical clearance with their primary care physician. We have specific paperwork that needs to be completed by your doctor that we will fax to his/her office. The tests required before surgery (lab work, chest x-ray, EKG) will depend on your age, medical history, and procedure. Some patients may be sent to priority testing at the hospital if their surgery is emergent or if their medical doctor is not available to perform the pre-operative work. Some patients may also be sent to see the anesthesiologist at the hospital/surgery center.
  • A pre-operative appointment will be set up with Dr. Zell approximately one week prior to surgery. This will allow you and Dr. Zell to discuss the specifics of your surgery and go over any questions. During this appointment you may be given towlettes to be used prior to your surgery.

Please let us know if you are taking any of the following medications: Blood thinners (such as Coumadin, Plavix or Aspirin), Insulin, Accutane, seizure medications, steroids (such as Prednisone), rheumatologic medications (such as Embrel). Patients taking blood thinners will need to adjust or stop them prior to surgery to decrease bleeding during the procedure. Some patients on Coumadin will need to switch to Lovenox before surgery. Accutane patients will need blood tests pre-operatively to check liver function.

Stop taking Herbal supplements, vitamins, Aspirin, Advil, Motrin, Aleve and other NSAID medications for 10 days before surgery. These medications can increase bleeding during surgery. It is OK to take Tylenol during the 10 days prior to surgery.

Do not eat or drink anything after midnight the night before surgery.

On the morning of the day of surgery you may brush your teeth (provided you do not swallow any water). Do not eat or drink anything the morning of surgery. Wear loose fitting, comfortable clothes to the hospital/surgery center. Please removal all jewelry and nail polish. If you wear contact lenses, please remove them and wear glasses.

Preparing for Post-Op (time after surgery)

Try and plan for your recovery before surgery. Inform your family and friends about your surgery should you need help during your recovery. Some patients find it helpful to prepare/freeze meals. Have ice bags available which are helpful for pain relief/swelling. These can simply be a bag of frozen vegetables or fancier ice bags from a surgical supply store/sports store.

We will be happy to answer any questions you may have. Please call 203-865-6784 to speak with Renee/Dr. Zell.

Post-Op Instructions - Knee Arthroscopy

Anesthesia:

After undergoing a procedure that required a general anesthetic, you may feel a little off for a day or two. During that time you should not drink alcoholic beverages, make important decisions or engage in any potentially hazardous activities.

It is common to feel slightly nauseated after anesthesia. Start with a light, low fat diet until your appetite returns. It is common to have constipation after surgery secondary to the combination of inactivity, effects of general anesthesia, and narcotic medications. To prevent post-operative constipation, increase water and fiber to your diet. Remain as active as possible. If there are increasing difficulties with constipation, try Metamucil (2 TBS in a large glass of water) or use a stool-softener (such as Senokot or Colace). If you continue to have difficulties, please call your primary care physician.

Bathing and Wound Care:

It is not unusual for some blood to show on the dressing. If bleeding seems to be continuing and the area is larger than 2 inches, please call the office.

The dressing should cover the wounds and support the leg but should not feel overly tight or uncomfortable. If the dressings seems too tight you should call the office or go the ER if after hours.

Cover the dressings with plastic or use a plastic bag when showering. If the dressing becomes wet it can be dried with a hair dryer or if too wet please call the office.

If instructed by Dr. Zell, you can remove the ace-wrap and cotton dressing 4 days after surgery. It is OK to get the sutures or tape strips wet when you shower. Please dry the incision and then cover them with a Band-Aid after showering. Do not use Bacitracin or Neosporin. You should not submerge the incisions in a tub, Jacuzzi, or pool.

If you are uncomfortable with removing the dressing, it is fine for you to leave the dressings in place until you are seen back in office.

Pain Management:

A long acting local anesthetic is injected into the area of your incisions/knee after surgery and usually wears off 6-12 hours later.

The interval for taking pain medication, as noted on your bottle (such as every 4 hours), is a minimum interval. You should not take the medication more frequently than instructed. You may take the medication less often (such as every 6-8 hours) if you are not in pain.

You have been prescribed a short acting narcotic pain medication (such as Percocet or Vicodin). This medication is taken to relieve pain but not to prevent it. You should not set your alarm clock to remind you to take your pain medication, nor should you take it on a set schedule if you are not hurting, as this can result in overdosing of the medication.

As long as you do not have ulcers or kidney problems, you may also use a NSAID (such as Ibuprofen or Aleve) in addition to or instead of the narcotic medication. An average sized adult may take three 200mg Ibuprofen every 8 hours or Naprosyn (Aleve) one pill 2x per day with food for a period of two weeks.

Ice and Elevation:

You should go directly home from the hospital/surgery center and lie down with your knee elevated so that it is above the heart.

Place ice packs on your knee (it will work even with the dressings in place) and change them as needed. Ice packs can simply be a bag of frozen vegetables or fancier ice bags from a surgical supply store. You will not feel much of the cold through the dressing initially but it will still help to decrease swelling and pain.

Elevation is the other best way to decrease pain and swelling. The leg will often throb when it is not elevated. Elevation can also decrease the risk of blood clots, by decreasing pooling in the leg. Work on moving your ankle/toes as this will keep the blood flowing in your leg.

Weight Bearing and Crutches:

Unless specifically instructed otherwise, you may bear weight on your leg as tolerated. This means that if you are able to put weight on your leg with minimal discomfort and with good control of your leg than it is OK to stand/walk. You were likely given crutches at the hospital/surgery center and these are to be used as a guide for the 1st few days after surgery. Other patients will continue to use the crutches if they do not feel confidant placing weight on the leg. It is also Ok to use a walker instead of crutches as needed.

Range of Motion:

Unless you have been given a brace/knee immobilizer (that restricts your range of motion), you may move your knee as tolerated. Initially it is important to work on extension or straightening of the knee. This can be done by placing a support behind the heel (with nothing under the knee) for 10 minutes each hour. Do not sleep with a pillow or support behind the knee as this will lead to difficulties keeping the knee straight. The second day after surgery you may start to work on bending the knee. A good way to start is to sit on a table and let your leg bend to 90 degrees with the force of gravity. The knee motion should improve each day.

Physical Therapy:

Most patients will be sent to physical therapy after surgery. Typically this will start approximately 7 days after surgery. The physical therapist will give you a series of exercises to work on the motion and strength of the knee. They will also chart the progress you make in your recovery.

Driving:

After you are able to walk without crutches and without limping, your leg is mechanically able to perform the tasks associated with normal driving. It can take up to six weeks before the strength/speed recovers to do things such as a panic stop.

Every patient is different in regards to their pain control/ability to concentrate/ability to recover strength after surgery. You must make your own determination as to whether you are safe to drive. It is often helpful to practice in a parking lot before heading out on the roads.

You cannot drive if you are taking narcotic pain medication.

Follow Up:

You should have an appointment already scheduled to see Dr. Zell in approximately 7-10 days after surgery. This will be written on your discharge instructions from the hospital/surgery center. If you do not have an appointment, or if you need to change the date/time, please call Renee (Dr. Zell's Clinical Coordinator) at 203-865-6784.

Reasons To Call The Office Before Your Follow Up:

Fever greater than 101.5 (it is common to have a low grade fever the first night or two after surgery)

Redness or swelling that is spreading from the edges of the incision

Pain that is severe and worsening and that is not relieved by rest, elevation and pain medication

Chest pain, trouble breathing or shortness of breath

Post-Op Instructions Foot & Ankle Surgery (Initially Non-Weight Bearing)

Anesthesia:

After undergoing a procedure that required a general anesthetic, you may feel a little off for a day or two. During that time you should not: drink alcoholic beverages, make important decisions or engage in any potentially hazardous activities.

It is common to feel slightly nauseated after anesthesia. Start with a light, low fat diet until your appetite returns. It is common to have constipation after surgery secondary to the combination of inactivity, effects of general anesthesia, and narcotic medications. To prevent post-operative constipation, increase water and fiber to your diet. Remain as active as possible. If there are increasing difficulties with constipation, try Metamucil (2 TBS in a large glass of water) or use a stool-softener (such as Senokot or Colace). If you continue to have difficulties, please call your primary care physician.

Bathing and Wound Care:

It is not unusual for some blood to show on the dressing or splint. If bleeding seems to be continuing and the area is larger than 2 inches, please call the office.

The dressing should cover the wounds and support the leg/ankle/foot but should not feel overly tight or uncomfortable. If the dressings seems too tight you should call the office or go the ER if after hours.

Cover the splint/dressings with plastic or use a plastic bag when showering. If the splint/dressing becomes wet it can be dried with a hair dryer or if too wet please call the office.

Do not remove your dressing or your splint.

Pain Management:

A long acting local anesthetic is injected into the area of your incisions after surgery and usually wears off 6-12 hours later.

The interval for taking pain medication, as noted on your bottle (such as every 4 hours), is a minimum interval. You should not take the medication more frequently than instructed. You may take the medication less often (such as every 6-8 hours) if you are not in pain.

You have been prescribed a short acting narcotic pain medication (such as Percocet or Vicodin). This medication is taken to relieve pain but not to prevent it. You should not set your alarm clock to remind you to take your pain medication, nor should you take it on a set schedule if you are not hurting, as this can result in overdosing of the medication.

As long as you do not have ulcers or kidney problems, you may also use a NSAID (such as Ibuprofen or Aleve) in addition to or instead of the narcotic medication. An average sized adult may take three 200mg Ibuprofen every 8 hours or Naprosyn (Aleve) one pill 2x per day with food for a period of two weeks.

Ice And Elevation:

You should go directly home from the hospital/surgery center and lie down with your leg elevated so that it is above the heart.

Place ice packs on your foot or ankle (it will work even with the dressings in place) and change them as needed. Ice packs can simply be a bag of frozen vegetables or fancier ice bags from a surgical supply store. You will not feel much of the cold through the dressing initially but it will still help to decrease swelling and pain.

Elevation is the other best way to decrease pain and swelling. The leg will often throb when it is not elevated. Elevation can also decrease the risk of blood clots, by decreasing pooling in the leg. Work on moving your ankle/toes as this will keep the blood flowing in your leg.

Weight Bearing and Crutches:

You have been instructed to be non-weight bearing. This means that you cannot place weight on the leg that had surgery. If you place pressure on your leg that had surgery you may shift the metal that has been placed at the time of your surgery or change the alignment of the bones achieved at surgery.

It is Ok to use a knee walker or standard walker instead of crutches as needed. If you would like information on the knee walker please call our office at 203-865-6784 and speak to Renee (Dr. Zell's clinical coordinator).

Range of Motion:

It is OK to move your knee and your toes. Your ankle and other joints of your foot are most likely immobilized in a splint, cast or dressing.

Physical Therapy:

Most but not all patients will be sent to physical therapy in their recovery s/p surgery. When PT will be started will depend on the type of surgery you have had. The physical therapist will give you a series of exercises to work on the motion and strength of all of the muscles in your lower leg including your foot and ankle. The physical therapist will also chart the progress you make in your recovery.

Driving:

After you are able to walk without crutches and without limping, your leg is mechanically able to perform the tasks associated with normal driving. In many foot/ankle procedures, patients are not allowed to weight bear for 6 weeks or longer s/p surgery. It usually also takes a few further weeks before the swelling decreases to get in a shoe (also required to start driving). This typically means that it can take 9-10 weeks after more extensive foot/ankle surgeries before patients are ready to drive.

Every patient is different in regards to their pain control/ability to concentrate/ability to recover strength after surgery. You must make your own determination as to whether you are safe to drive. It is often helpful to practice in a parking lot before heading out on the roads.

You cannot drive if you are taking narcotic pain medication.

Follow Up:

You should have an appointment already scheduled to see Dr. Zell in approximately 7-10 days after surgery. This will be written on your discharge instructions from the hospital/surgery center. If you do not have an appointment, or if you need to change the date/time, please call Renee (Dr. Zell's clinical coordinator) at 203-865-6784.

Reasons To Call The Office Before Your Follow Up:

  • Fever greater than 101.5 (it is common to have a low grade fever the first night or two after surgery)
  • Redness or swelling that is spreading from the edges of the incision
  • Pain that is severe and worsening and that is not relieved by rest, elevation and pain medication
  • Chest pain, trouble breathing or shortness of breath

The office phone number is 203-865-6784 for any questions or emergencies.

There is a doctor on call 24 hours per day. After hours, please call 203-865-6784 and the doctor on call will be paged. If you think you have an urgent problem that needs to be seen right away go to the emergency room or dial 911.