Introductory Chapter: Foot and Ankle Disorders – Pathology and Surgery

1. Introduction

The number of cases of “Foot and ankle Pathology & Disorders” has been augmented in the last two decades due to the current way of life of the human beings. On the one hand are the trauma categories because of motorbike and car accidents; and on the other hand are the chronic syndromes due to everyday overuse of foot and ankle, as in high demand sports and hobbies, as also in ballet dancing, etc.

This book offers an updated guide to the foot and ankle pathology, and presents everyday trauma categories, as also chondral and joint chronic syndromes at all ages from childhood to adults. Furthermore, the book will allow the reader to evaluate and realize how the foot changes during development from the early stages to adulthood. It also provides an overall outline of the anatomy and foot biomechanics, as also diagnosis of the pathologies, the open or arthroscopic surgical approaches, the treatment alternatives, and complications.

Our book, written by world-renowned experts, offers various points of view on the topics discussed, mainly in six chapters, divided into the following sections: (1) Anatomy and biomechanics of foot and ankle, (2) Basic foot and ankle arthropathies, (3) Hindfoot pathologies, (4) Pediatric orthopedics and flatfoot reconstruction, (5) Podological deformities and management, and (6) Achilles tendon rupture and functional rehabilitation.

“Foot and Ankle Disorders - Pathology and Surgery” will be of major interest for orthopedic residents, as also for orthopedic surgeons at the first steps of their career, and for experienced surgeons seeking updated information.

2. Foot and ankle: anatomy and biomechanics

The foot and ankle are a complex of joints made up of 26 individual bones of the foot. The ankle joint—due to the presence of the structure called ankle mortise—provides a high stability role. The ankle complex motions are dorsiflexion 20 degrees, plantarflexion 55 degrees in the sagittal plane; and inversion 30 degrees with eversion 20 degrees in the frontal plane. When these motions occur as coupled motions, they produce the known supination and pronation movements. The range of motion that is available for dorsiflexion will be around 10–20 degrees and for plantar flexion it will be around 40–55 degrees. The forces acting on the ankle joint bear approximately five times the body weight during stance in a normal walking phase and up to 13 times the body weight during running activities [1, 2].

During the daily living activity, the ankle joint possesses high congruency, because first it has a high stability role and second the load-bearing area is larger and mostly in the stance phase during normal gait. The maximum power of the ankle complex is generated around 50% in gait cycle during the forefoot rocker phase correspondingly with the force production of the plantar flexors which is required for the lower extremity to propel the body forward toward toe-off. The other form of stability for foot is provided by the presence of plantar aponeurosis, which takes up to 60% of the weight bearing and the action tie beam around 25% from the metatarsals. The toe extension during the normal gait cycle makes the plantar aponeurosis to become taut, thereby increasing the ability to withstand larger amount of stress [1, 3].

3. Ankle foot arthropathies

In this chapter, the basic pathologies of foot and ankle are analyzed. To be more specific, in the first part of the chapter, the trauma issues of the ankle, such as ankle sprain, calcaneus or talus fractures, and ankle instability, are presented. In the second part of the chapter, the inflammatory conditions, such as osteoarthritis of foot and ankle, rheumatoid arthritis, gouty arthritis, or neuropathic arthritis, are analyzed. In the third part of the chapter, the congenital foot deformities, such as Club foot or Rocker bottom flat foot and other acquired pathologies as Pes planus and cavus, Hallux valgus, Morton’s or Hammer toe, are described [4, 5, 6, 7].

One of the main problems in 14–17% of patients after ankle sprain pertains to the Osteochondral Lesions (OCLs) of the Talus and these lesions are presented with intermittent or deep pain of the ankle, swelling, plus locking and catching, thereby limiting the patients’ mobility. And although it is widely accepted that the small talus OCLs may be treated nonoperatively, the question that easily arises is which is the best surgical technique for these patients with large OCLs. Traditionally, the treatment of small symptomatic OCLs includes either bone marrow stimulation usually with arthroscopic procedures or autologous osteochondral transplantation. Nevertheless, in adults with large OCLs of the talus (>200 mm²) (focal and contained), the treatment can be challenging, as, on the one hand, the injured articular cartilage shows poor intrinsic reparative competence and, on the other hand, the prescribed techniques till nowadays cannot always offer high success rates in a long-lasting follow-up [7]. In the last decade, taking into consideration first that the periosteum has intrinsic regenerative and regrowth cartilage characteristics; and second that the fresh bone autograft and the aspirated bone marrow contain live mesenchymal precursor cells, novel and innovative technique for ankle OCLs has been presented [8].

4. Hindfoot pathologies

Pain in the foot is prevalent throughout the population, with an estimated range from 17 to 30%. Moreover, more than 25% of the population over the age of 45 have everyday hindfoot pain, which limits their daily activities, causes poor balance and important gait issues, and offers poor health-related quality of life. According to recent studies, at least two-thirds of people have moderate functional daily living issues. Different risk factors for hindfoot pain and pathologies have been identified and analyzed in the literature, such as age, female gender, obesity, posttraumatic osteoarthritis, diabetes, biomechanical factors (lower extremity excessive external rotation, significant pronation of the subtalar joint, weakness of the plantar flexor, and shortening of the achilles tendon), and anatomical variations (pes planus and pes cavus). In this chapter, an overview of the pathologies of the hindfoot that cause hindfoot pain, mainly in patients with bone and soft-tissue overload, foot anatomic disorders, and a decreased range of motion, is provided.

Hindfoot pathologies can be caused by a variety of factors, including overuse, trauma, degeneration, and underlying medical conditions [9, 10]. Some common hindfoot pathologies include tendinopathy of the posterior tibialis tendon or flexor hallucis longus, posterior ankle impingement syndrome (PAIS), calcaneus contusion, stress fractures of the calcaneus or talus, hindfoot rheumatoid arthritis, Paget’s disease, osteomyelitis after posterior foot and ankle open fractures, and cancer metastases [9, 10]. One of the most common problems of hindfoot pathology (mainly in athletes and ballet dancers) is the Posterior Ankle Impingement Syndrome (PAIS), which is usually caused by Os Trigonum (OT) or a hypertrophic posterior talar process Stieda. The most common accessory bone of the foot—although usually asymptomatic, it is true that it may become a severely debilitating problem not only for recreational or competitive athletes, but also for ordinary people in their everyday living. Ankles’ posterior arthroscopy (PA) has been improved considerably in the last 25 years and has become the gold standard procedure for different pathologies of the ankle and hindfoot, as a safe and reliable treatment option. Currently, the indications for ankles’ posterior endoscopy have extended, including both intra- and extra-articular pathologies, and may involve: (1) bone (os trigonum (OT), loose bodies, posttraumatic ossifications, lateral or medial malleolus avulsion fragments, and Haglund’s pathology); (2) cartilage (ankle and subtalar joint osteochondral defects, osteoarthritis, osteochondromatosis, and cystic lesions); or (3) soft tissues (tendinopathy of flexor hallucis longus, inflammation of retrocalcaneal bursa, posttraumatic synovitis, and soft-tissue impingement) [9, 10].

Apart from the OT fractures, the further conditions of posterior impingement should be initially treated conservatively (rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physiotherapy); but when these measures fail, or if we are dealing with high-performance athletes—surgical treatment should be considered early. Of course, it is particularly important for the orthopedic surgeon to assess preoperatively to which of these three categories the patient belongs, so as to be accurate in treating the exact problem [9, 10]. Hence, the purpose of the present chapter is to evaluate the efficiency and the effectiveness of surgical and conservative techniques in hindfoot pathologies; and also, to assess the level of function, outcome measures, and physical examination parameters, with the purpose of providing the readers an overview of clinical results after performing an open or arthroscopic operation. This chapter will help the orthopedic surgeons to manage their patients’ expectations after arthroscopy. It is well known that arthroscopic techniques offer earlier recovery with limited pain, significant improvement in the joint function, and restoration of ankle motion with limited complications versus the open techniques.

5. Flatfoot reconstruction

One of the most common presenting problems in orthopedic surgeons’ everyday practice is the painful flatfoot. The flatfoot pathologies are treated first conservatively with customized orthotics to support the counter arch, and shoe alterations and second with physiotherapy, providing excellent outcomes (heel cord stretching exercises, foot strengthening of the dorsiflexors and invertors). Nevertheless, in some cases, conservative care may not alleviate the associated symptoms of lower limb or the lumbar spine [11, 12].

Management of the adolescent and flexible flatfoot deformity represents a complex task. It requires biomechanical knowledge and analytic mechanics to determine deformity that compensates in a primary plane of dominance. The purpose of the two chapters in this book is to refer to flatfoot and podological deformities and to present clinical evaluation, radiographic assessment, and mechanisms of occurrence. It also proposes surgical management for three types of flatfoot deformity as seen compensating in a dominant plane. In such cases, multiple surgical options are available to treat the underlying deformity and associated symptoms. In the discussion on the various types, biomechanical focus concerning articular geometry and its modes of compensation will be highlighted. The purpose of these two chapters is to discuss and understand the benefits of the reconstructive surgical procedures (osteotomies) for flatfoot treatment and the benefits of the arthrodesis-type procedures [11, 12].

6. Podological deformities and management

Podological deformities are the deformities that mainly occur in the foot complex. The deformities may be congenital or acquired. The commonest congenital deformities in the foot are Congenital Talipes Equino-Varus (CTEV), Vertical Talus, Hallux Valgus, Pes Cavus, Pes Planus, and Claw Toe. The acquired deformities are developed later in life, mainly due to trauma or foot fractures. In this chapter, the various conservative and surgical managements are analyzed, as also the postoperative management with the purpose of correcting the deformities, to improve biomechanical aspect and the gait pattern.

7. Functional rehabilitation after Achilles tendon rupture

Controversy continues to exist regarding optimal treatment of an acute Achilles tendon rupture, despite the research in the last decades. The proposed treatments can be classified into three types: first, conservative management with cast immobilization or functional bracing; second, operative management with open repair (with or without augmentation) and lastly minimally invasive or semi-open procedures with closed percutaneous repair (ultrasound (U/S) guidance or endoscopic control). The proposed postoperative rehabilitation protocols refer to non-weight bearing with below knee cast immobilization for 2 to 3 weeks and afterwards functional bracing for 5 to 6 weeks, and also early ankle motion exercises and partial weight bearing [13, 14].

In the chapter on Achilles tendon, the current literature concerning the management of acute tendon rupture is analyzed. It is observed that open operative treatment has a lower risk of re-rupture (1.4–5%) than nonoperative management (2.4–13.0%). In the meta-analysis of Ochen et al., it is analyzed in detail based on the systematic review that a significant reduction in re-rupture after operative treatment (2.3%) is observed compared to nonoperative treatment (3.9%) [13]. Furthermore, in the study of Khan et al., it is presented that the risk of other complications is diminished by percutaneous repair (26.1% open vs. 8.3% percutaneous group) [14]. From the meta-analysis of the literature, the clear tendency that either conservatively or operatively, early functional rehabilitation should be started as soon as possible, is presented.