HOSPITAL FOR SPECIAL SURGERY:SPECIALISTS IN MOBILITY

WINTER 2007 Horizon

Focus on the Foot and Ankle

At the Forefront of Foot and AnkleTreatmentJonathan T. Deland, MD,(left), and his colleaguesare pioneering a num-ber of surgical treat-ments and approachesfor a range of complexdisorders with a goal ofpreserving maximumfunction.

Focus on the Foot and Ankle

At the turn of the 20th Century, Royal Whitman, MD, a surgeon with

the New York Society for the Ruptured and Crippled – the precursor

to Hospital for Special Surgery – made international history with his

surgical procedure for stabilizing f lail-like ankle joints that often

resulted from infantile paralysis. r. Whitman’s work estab-lished the Hospital’sworldwide reputation in

the treatment of foot andankle disorders and launched a lega-cy of innovation that continues tothis day under the leadership ofJonathan T. Deland, MD, Chief of theFoot and Ankle Service.

When you consider that each foothas more than 25 bones supported bythree groups of ligaments and thatyour feet log on average 1,000 milesper year, it is no surprise that condi-tions of the foot and ankle affect mil-lions each year. “The Hospital’s Footand Ankle Service is one of thelargest and most active services in thecountry,” says Thomas P. Sculco, MD,Surgeon-in-Chief. “From non-opera-tive conditions to the most complex

trauma and deformities in childrenand adults, our physicians are com-mitted to relieving pain and returningpatients to their normal activities.Through basic and clinical research,this outstanding team is also seekingto improve techniques for treatingthese often challenging disorders.”

Making StridesIn June 2004, Zarela Martinez suf-fered a fracture in the tibia and thefibula of her right leg and a torn ACL.“I had treatment for my knee, but byputting all the pressure on my leftfoot to compensate, one day it justturned totally, and I couldn’t walk,”recalls Ms. Martinez. A restaurateurwhose demanding life includes managing her Manhattan restaurantand promoting her own line of prod-ucts, Ms. Martinez could ill afford the disability.

“Ms. Martinez had a complex footand ankle problem that affected herposterior tibial tendon – the soft tis-sue that supports the arch,” explainsAndrew J. Elliott, MD, one of sevenorthopedic surgeons with theHospital’s Foot and Ankle Service.“She developed a flat foot with severepain.” Dr. Elliott performed recon-struction surgery to provide Ms.Martinez with a more normal func-tioning foot that would enable her toreturn to her very active life.

Posterior tibial tendon insufficien-cy suffered by Ms. Martinez is ofgreat interest to Special Surgery’sfoot and ankle specialists. “When theposterior tibial tendon and ligamentsthat support the arch gradually giveway, the foot starts to change shape,deform, and collapse,” says Dr. Elliott.“Patients can present with pain on

1

D

Pacesetters The Foot and Ankle Service of Hospital

for Special Surgery – with seven dedicat-

ed orthopedic surgeons – is the largest

of its kind in the country. Patients

benefit from the individual and collabo-

rative expertise and pioneering research

of (left to right) David S. Levine, MD,

Matthew M. Roberts, MD, Martin J.

O’Malley, MD, Walther H.O. Bohne, MD,

Jonathan T. Deland, MD, Chief, Andrew

J. Elliott, MD, and John G. Kennedy,

MD, who are expertly trained in the full

range of foot and ankle disorders.

Gait KeepersHoward J. Hillstrom, PhD, Director of

the Leon Root, MD, Motion Analysis

Laboratory, uses sophisticated technolo-

gy, including 3D multicolored animation

of the pressures beneath one’s feet,

to quantify how someone walks, runs,

or stands. A staff of research engineers

and physical therapists evaluate patients

for range of motion, muscle function,

alignment, reflexes, and any anomalies

to appreciate the patient’s structure

before measuring function.

controlled area of damage to the ten-don. This then stimulates the body’shealing response.

Ankle InsightsMartin J. O’Malley, MD, Director ofthe Foot and Ankle Fellowship,spends a lot of time behind a camera –one so small that it fits inside anankle joint. Ankle arthroscopy allowsDr. O’Malley to peer inside using thesmallest of instruments and a verytiny fiber optic camera. “The ankle isa small, very tight joint,” notes Dr.O’Malley. “With the ankle, you have touse a distractor to pull the ankle jointapart just to get in. Once you get in,it’s difficult to operate because youhave such a limited space. Often, thecartilage you need to reach is blockedby the tibia. We had to find innovativeways to gain access to these injurieswithout big incisions, and get the car-tilage to heal so patients can return totheir activities.”

Dr. O’Malley uses ankle arthroscopyto treat many athletes, particularlybasketball players and dancers,whose injuries can put an end totheir careers. “These athletes oftendevelop bone spurs in the front oftheir ankles that we can treat arthro-scopically. With a professional ath-lete, our goal is to treat the injury asminimally invasive as possible tospeed their recovery, which can takefour to six months if it is an osteo-

chondral injury involving both carti-lage and bone. This is a very commoncondition for us and we are trying tofind a way to treat it without doingtoo much damage to the ankle jointand, at the same time, trying to pro-mote healing biologically. We are con-stantly working on ways to help theseinjuries heal.”

Addressing Athletic InjuriesThe foot and ankle are the most com-monly injured joints in recreationaland elite athletes. Injuries can rangefrom ankle sprains, stress fractures,and osteochondral lesions to nerve,ligament, and tendon damage.

“The goal of treatment is to pro-vide a rapid return to sports activi-ties, while addressing any mechanicalor biologic causes of the initialinjury,” says John G. Kennedy, MD.“All athletes, whether elite or week-end warriors, young or old, share thesame goal – that is to return to func-tion in as short a time possible.”

Many injuries can be addressedwith non-surgical strategies, and theuse of external bone stimulators hasincreased the rate of return to sportfor many athletes with stress frac-tures. This is augmented by a biome-chanical evaluation in the running labto prevent future injury wherever pos-sible. According to Dr. Kennedy, over90 percent of ankle sprains can be

the inner side of their ankle radiatinginto the mid part of their foot. Thetendon can develop either a partialtear or degeneration called tendono-sis. When the tendon fails, the liga-ments can also fail.”

The degenerative process of tendonosis can affect not only theposterior tibial tendon, but also anyof the other tendons that supportthe foot and ankle. “Physical therapyis usually the first line of defense,” continues Dr. Elliott. “While this may not heal the problem, physicaltherapy can provide the patient with relief of their discomfort andreturn them to an acceptable level of functioning.” When the problembegins to interfere with normal activities, however, surgery may beneeded to either reconstruct the tendon or to debride or remove thediseased portion.

At the same time, Dr. Elliott andhis colleagues are looking at ways tominimize the surgical trauma andavoid having to disturb the tendonitself. “Radiofrequency is a new tech-nique that we are evaluating not onlyfor its role in providing pain relief,but also as a means of stimulating thehealing process within the damagedtendons,” he says. According to Dr. Elliott, a small radiofrequencyblast is used to cause an isolated

2

All Together NowTraumatic injuries tothe foot and ankleoften require pins andother hardware toreconstruct fracturedbones not only toensure they heal correctly, but, as DavidS. Levine, MD, explains,to improve the joint’salignment and reducedeformity with a goaltoward minimizing the development ofarthritis.

Intricate TerrainMartin J. O’Malley, MD,must navigate complexbone, cartilage, and softtissue structures whenperforming reconstruc-tive surgeries to treatfoot and ankle disorders.Dr. O’Malley and his colleagues continuallypursue new ways to surgically repair injurieswithout big incisions andfacilitate cartilage heal-ing so patients can returnto normal activity asquickly as possible.

treated without surgery, once thecause of the injury is determined, withprecisely directed physical therapy.

An Arch Enemy“People who have a high-arched foot,or cavus foot, can suffer from a con-stellation of foot and ankle problems.The presentation may be subtle,”says Matthew M. Roberts, MD. “It islike having one leg of a tripod that istoo long, making it unstable. As aresult, high arches are associatedwith recurrent ankle instability orsprains. This instability needs to beaddressed; otherwise, there is anincreased risk for ankle arthritis.”

Notes Dr. Roberts, it is importantto determine if cavus foot is responsi-ble for other problems in the foot inorder to provide the appropriatetreatment. “For example,” he says, “if we operate on a peroneal tendoninjury and don’t address the higharch, the tendon repair may not healcorrectly.”

Forefoot Deformities: What Lies BeneathMetatarsalgia is a forefoot deformityoften mistaken for bunions. Withmetatarsalgia, patients have painaccompanied by a bony prominenceon the ball of their foot. “To surgical-ly address the most severe problems

improve a joint’s alignment, reduceits deformity, and to minimize thepotential for developing arthritis,”says Dr. Levine.

One of the more common surgeriesperformed by the Hospital’s foot andankle surgeons is open reduction and internal fixation. “Open reductionmeans you make an incision to visual-ize the fracture, then perform areduction, putting the fragments backtogether,” explains Dr. Levine.Internal fixation involves the place-ment of metallic hardware to createstability until the bone can restoreitself to its original state. Certain fractures can be done less invasivelythrough limited incisions, reducing thetrauma to the soft tissue caused bythe surgery and promoting a morerapid recovery of that soft tissue enve-lope. These techniques have beenadvanced over the past decade withthe introduction of instruments andhardware tailored for use within thesmall confines of the foot and ankle.

Concerned about preventing theloss of bone density or disuse osteo-porosis in patients during the six-week, post-surgical recovery periodin which an ankle must not bearweight, Dr. Levine, with Joseph M.Lane, MD, Chief of the Hospital’sOsteoporosis Center, is beginning astudy of the protective effects of

High Arches, Big Problems According to Matthew M. Roberts, MD,

a cavus or high-arched foot is associated

with ankle instability leading to arthritis,

sesamoid injuries under the big toe,

plantar fasciitis or heel pain, stress

fractures of the outer metatarsals, and

peroneal tendon disorders on the side

of the ankle. Says Dr. Roberts, “Unless

you recognize that someone has a high

arch, you are only treating the symptoms

and not correcting the basic problem.”

45

Sound AdviceUltrasound tech-

nology, which

allows the Hospital’s

radiologists to look in

great detail at soft tis-

sue around joints, tendons,

and muscles, has become an important

tool for diagnosing foot and ankle prob-

lems. Sound waves are sent and received

through a small hand-held device known

as a transducer (above). The returning

sound waves are used to produce the

images that can indicate abnormalities.

If the Shoe Fits……you may be able to avoid

foot problems. Shoes that are

too tight or too high can pro-

mote the development of foot

and ankle pathologies. Walking

in high heels can lead to a con-

tracture of the Achilles tendon,

ankle sprains and breaks, corns,

calluses, hammertoes (below),

arthritis, and even chronic knee

pain. X-ray image is from

H.Turvey/Photo

Researchers.

osteoporosis therapies, such asActonel. Notes Dr. Levine, “We wantto prevent patients recovering froman ankle fracture from developing aregional osteoporosis in their leg andtherefore be put at greater risk for afragility fracture in the future.”

Ankle Replacement: A Continuing ChallengeWhen arthritis pain in the ankle jointcan no longer be managed withoutsurgery, ankle fusion or anklereplacement are the only methodsavailable to control pain and retainfunction. “While ankle fusion willrelieve pain and allow the foot to stillmove adequately, it puts stress onother joints, potentially leading tomore arthritis,” notes Dr. Deland.“Ankle replacement puts less stresson other joints and provides a morenormal gait pattern, but we are wor-ried about durability.”

Pursuit of a successful prostheticankle joint has been ongoing fordecades. The pressure on the ankle isthree times that of the hip or knee,making it more difficult to replace.“Because the ankle is such a smalljoint, there is only so much space inwhich to place the implant,” notes Dr. O’Malley. The Hospital’s foot andankle surgeons continue to search forthe ideal prosthetic ankle joint, and Dr. Deland recently participated in a

multicenter study by the Food andDrug Administration (FDA) of theScandinavian Total Ankle Replacement(STAR) device, which is now awaitingFDA approval. In addition, Dr. Deland,in collaboration with Charles Saltzman,MD, Chairman of Orthopaedics at theUniversity of Utah, and others aredesigning a more anatomically correctankle replacement and expect to bringthis new model to market within thenext few years.

Blending Science and SurgeryThe Foot and Ankle Service continu-ally draws on the research interestsand expertise of its surgeons todevelop and refine treatments.Posterior tibial tendon insufficiencyis a major focus of the research of Dr. Deland, who is well-known for hisexpertise in this area. With supportfrom the National Institutes of Healthand the Orthopaedic Research andEducation Foundation, he is develop-ing and perfecting surgical proce-dures for posterior tibial tendoninsufficiency that preserve motionand function in the foot while achiev-ing good alignment. Surgery involvesnot only reconstructing the tendon,but also moving the heel – whichhelps support the foot and restorealignment – back into place.

A grateful patient, Susan Rose,helped make possible the establish-ment of an outcomes research centerfor the Foot and Ankle Service. TheCenter is evaluating surgical out-comes for patients with posterior tibial tendon insufficiency, cartilageproblems, and other conditions andallows the Hospital’s surgeons to follow patient progress and improvetreatments. “This is a big step for-ward,” says Dr. Deland.

More severe deformities that can-not be corrected with this procedurepresent a greater challenge – onethat Dr. Deland and his colleaguesseek to solve with an innovativeapproach in which they lengthen thebone in the outside of the foot tohelp restore the arch. “You accom-plish this by adding bone,” notes Dr. Deland. “The size of that piece ofbone is critical in how well thepatient is going to do. If you put intoo little, you can undercorrect it. If you put in too much, you can overcorrect it and make the foot toostiff.” Dr. Deland has developed aunique approach using special trialwedges he designed that are insertedin one-millimeter increments untilthe proper correction is achieved.

The work of the foot and ankle sur-geons often takes them into the LeonRoot, MD, Motion Analysis Laboratory,directed by Howard J. Hillstrom, PhD.

Fine-Tuning a DiagnosisNerve damage is a frequent problem of

persons with diabetes, especially with

the feet, because it prevents

patients from feeling pain and

realizing they have injuries. This

can lead to painful foot ulcers

and even amputation. To meas-

ure the nerve reflexes of diabet-

ic patients, Walther H.O. Bohne,

MD, (at right) uses a tuning fork

test, that has been proven to be

a useful and reliable way to

diagnose diabetic nerve disease.

of metatarsalgia,” says Dr. Deland,“we correct the alignment of the toe,including the bunion if there is one,and shorten the prominent bones.This requires very precise judgment.If we can take pressure patterns inthe OR using a device that stimulatesweight bearing, we can determine theamount of correction needed for thebest possible outcome.”

Treating Trauma“Most acute injuries to the foot andankle – unless they are open fracturesor dislocations – are not surgicalemergencies,” says David S. Levine,MD. In fact, cautions Dr. Levine, themajority of injuries to the foot andankle should not be surgically treatedimmediately because they are oftenassociated with significant swelling.“We have a great respect for, andneed, to be careful of these injuries,”he says. “We call it ‘respecting thesoft-tissue envelope.’ If we add toomuch surgical trauma on top of theinjury too soon, wound healing maynot occur.”

Dr. Levine and his colleagues callon the Hospital’s imaging capabilities(CT or MRI scanning) to learn abouta fracture’s complexity, as well as its soft-tissue injury, well beforeentering the OR to fix the fracture.“The main reason we perform sur-gery following traumatic injury is to

All Together NowTraumatic injuries tothe foot and ankleoften require pins andother hardware toreconstruct fracturedbones not only toensure they heal correctly, but, as DavidS. Levine, MD, explains,to improve the joint’salignment and reducedeformity with a goaltoward minimizing the development ofarthritis.

Intricate TerrainMartin J. O’Malley, MD,must navigate complexbone, cartilage, and softtissue structures whenperforming reconstruc-tive surgeries to treatfoot and ankle disorders.Dr. O’Malley and his colleagues continuallypursue new ways to surgically repair injurieswithout big incisions andfacilitate cartilage heal-ing so patients can returnto normal activity asquickly as possible.

treated without surgery, once thecause of the injury is determined, withprecisely directed physical therapy.

An Arch Enemy“People who have a high-arched foot,or cavus foot, can suffer from a con-stellation of foot and ankle problems.The presentation may be subtle,”says Matthew M. Roberts, MD. “It islike having one leg of a tripod that istoo long, making it unstable. As aresult, high arches are associatedwith recurrent ankle instability orsprains. This instability needs to beaddressed; otherwise, there is anincreased risk for ankle arthritis.”

Notes Dr. Roberts, it is importantto determine if cavus foot is responsi-ble for other problems in the foot inorder to provide the appropriatetreatment. “For example,” he says, “if we operate on a peroneal tendoninjury and don’t address the higharch, the tendon repair may not healcorrectly.”

Forefoot Deformities: What Lies BeneathMetatarsalgia is a forefoot deformityoften mistaken for bunions. Withmetatarsalgia, patients have painaccompanied by a bony prominenceon the ball of their foot. “To surgical-ly address the most severe problems

improve a joint’s alignment, reduceits deformity, and to minimize thepotential for developing arthritis,”says Dr. Levine.

One of the more common surgeriesperformed by the Hospital’s foot andankle surgeons is open reduction and internal fixation. “Open reductionmeans you make an incision to visual-ize the fracture, then perform areduction, putting the fragments backtogether,” explains Dr. Levine.Internal fixation involves the place-ment of metallic hardware to createstability until the bone can restoreitself to its original state. Certain fractures can be done less invasivelythrough limited incisions, reducing thetrauma to the soft tissue caused bythe surgery and promoting a morerapid recovery of that soft tissue enve-lope. These techniques have beenadvanced over the past decade withthe introduction of instruments andhardware tailored for use within thesmall confines of the foot and ankle.

Concerned about preventing theloss of bone density or disuse osteo-porosis in patients during the six-week, post-surgical recovery periodin which an ankle must not bearweight, Dr. Levine, with Joseph M.Lane, MD, Chief of the Hospital’sOsteoporosis Center, is beginning astudy of the protective effects of

High Arches, Big Problems According to Matthew M. Roberts, MD,

a cavus or high-arched foot is associated

with ankle instability leading to arthritis,

sesamoid injuries under the big toe,

plantar fasciitis or heel pain, stress

fractures of the outer metatarsals, and

peroneal tendon disorders on the side

of the ankle. Says Dr. Roberts, “Unless

you recognize that someone has a high

arch, you are only treating the symptoms

and not correcting the basic problem.”

45

Sound AdviceUltrasound tech-

nology, which

allows the Hospital’s

radiologists to look in

great detail at soft tis-

sue around joints, tendons,

and muscles, has become an important

tool for diagnosing foot and ankle prob-

lems. Sound waves are sent and received

through a small hand-held device known

as a transducer (above). The returning

sound waves are used to produce the

images that can indicate abnormalities.

If the Shoe Fits……you may be able to avoid

foot problems. Shoes that are

too tight or too high can pro-

mote the development of foot

and ankle pathologies. Walking

in high heels can lead to a con-

tracture of the Achilles tendon,

ankle sprains and breaks, corns,

calluses, hammertoes (below),

arthritis, and even chronic knee

pain. X-ray image is from

H.Turvey/Photo

Researchers.

osteoporosis therapies, such asActonel. Notes Dr. Levine, “We wantto prevent patients recovering froman ankle fracture from developing aregional osteoporosis in their leg andtherefore be put at greater risk for afragility fracture in the future.”

Ankle Replacement: A Continuing ChallengeWhen arthritis pain in the ankle jointcan no longer be managed withoutsurgery, ankle fusion or anklereplacement are the only methodsavailable to control pain and retainfunction. “While ankle fusion willrelieve pain and allow the foot to stillmove adequately, it puts stress onother joints, potentially leading tomore arthritis,” notes Dr. Deland.“Ankle replacement puts less stresson other joints and provides a morenormal gait pattern, but we are wor-ried about durability.”

Pursuit of a successful prostheticankle joint has been ongoing fordecades. The pressure on the ankle isthree times that of the hip or knee,making it more difficult to replace.“Because the ankle is such a smalljoint, there is only so much space inwhich to place the implant,” notes Dr. O’Malley. The Hospital’s foot andankle surgeons continue to search forthe ideal prosthetic ankle joint, and Dr. Deland recently participated in a

multicenter study by the Food andDrug Administration (FDA) of theScandinavian Total Ankle Replacement(STAR) device, which is now awaitingFDA approval. In addition, Dr. Deland,in collaboration with Charles Saltzman,MD, Chairman of Orthopaedics at theUniversity of Utah, and others aredesigning a more anatomically correctankle replacement and expect to bringthis new model to market within thenext few years.

Blending Science and SurgeryThe Foot and Ankle Service continu-ally draws on the research interestsand expertise of its surgeons todevelop and refine treatments.Posterior tibial tendon insufficiencyis a major focus of the research of Dr. Deland, who is well-known for hisexpertise in this area. With supportfrom the National Institutes of Healthand the Orthopaedic Research andEducation Foundation, he is develop-ing and perfecting surgical proce-dures for posterior tibial tendoninsufficiency that preserve motionand function in the foot while achiev-ing good alignment. Surgery involvesnot only reconstructing the tendon,but also moving the heel – whichhelps support the foot and restorealignment – back into place.

A grateful patient, Susan Rose,helped make possible the establish-ment of an outcomes research centerfor the Foot and Ankle Service. TheCenter is evaluating surgical out-comes for patients with posterior tibial tendon insufficiency, cartilageproblems, and other conditions andallows the Hospital’s surgeons to follow patient progress and improvetreatments. “This is a big step for-ward,” says Dr. Deland.

More severe deformities that can-not be corrected with this procedurepresent a greater challenge – onethat Dr. Deland and his colleaguesseek to solve with an innovativeapproach in which they lengthen thebone in the outside of the foot tohelp restore the arch. “You accom-plish this by adding bone,” notes Dr. Deland. “The size of that piece ofbone is critical in how well thepatient is going to do. If you put intoo little, you can undercorrect it. If you put in too much, you can overcorrect it and make the foot toostiff.” Dr. Deland has developed aunique approach using special trialwedges he designed that are insertedin one-millimeter increments untilthe proper correction is achieved.

The work of the foot and ankle sur-geons often takes them into the LeonRoot, MD, Motion Analysis Laboratory,directed by Howard J. Hillstrom, PhD.

Fine-Tuning a DiagnosisNerve damage is a frequent problem of

persons with diabetes, especially with

the feet, because it prevents

patients from feeling pain and

realizing they have injuries. This

can lead to painful foot ulcers

and even amputation. To meas-

ure the nerve reflexes of diabet-

ic patients, Walther H.O. Bohne,

MD, (at right) uses a tuning fork

test, that has been proven to be

a useful and reliable way to

diagnose diabetic nerve disease.

of metatarsalgia,” says Dr. Deland,“we correct the alignment of the toe,including the bunion if there is one,and shorten the prominent bones.This requires very precise judgment.If we can take pressure patterns inthe OR using a device that stimulatesweight bearing, we can determine theamount of correction needed for thebest possible outcome.”

Treating Trauma“Most acute injuries to the foot andankle – unless they are open fracturesor dislocations – are not surgicalemergencies,” says David S. Levine,MD. In fact, cautions Dr. Levine, themajority of injuries to the foot andankle should not be surgically treatedimmediately because they are oftenassociated with significant swelling.“We have a great respect for, andneed, to be careful of these injuries,”he says. “We call it ‘respecting thesoft-tissue envelope.’ If we add toomuch surgical trauma on top of theinjury too soon, wound healing maynot occur.”

Dr. Levine and his colleagues callon the Hospital’s imaging capabilities(CT or MRI scanning) to learn abouta fracture’s complexity, as well as its soft-tissue injury, well beforeentering the OR to fix the fracture.“The main reason we perform sur-gery following traumatic injury is to

All Together NowTraumatic injuries tothe foot and ankleoften require pins andother hardware toreconstruct fracturedbones not only toensure they heal correctly, but, as DavidS. Levine, MD, explains,to improve the joint’salignment and reducedeformity with a goaltoward minimizing the development ofarthritis.

Intricate TerrainMartin J. O’Malley, MD,must navigate complexbone, cartilage, and softtissue structures whenperforming reconstruc-tive surgeries to treatfoot and ankle disorders.Dr. O’Malley and his colleagues continuallypursue new ways to surgically repair injurieswithout big incisions andfacilitate cartilage heal-ing so patients can returnto normal activity asquickly as possible.

treated without surgery, once thecause of the injury is determined, withprecisely directed physical therapy.

An Arch Enemy“People who have a high-arched foot,or cavus foot, can suffer from a con-stellation of foot and ankle problems.The presentation may be subtle,”says Matthew M. Roberts, MD. “It islike having one leg of a tripod that istoo long, making it unstable. As aresult, high arches are associatedwith recurrent ankle instability orsprains. This instability needs to beaddressed; otherwise, there is anincreased risk for ankle arthritis.”

Notes Dr. Roberts, it is importantto determine if cavus foot is responsi-ble for other problems in the foot inorder to provide the appropriatetreatment. “For example,” he says, “if we operate on a peroneal tendoninjury and don’t address the higharch, the tendon repair may not healcorrectly.”

Forefoot Deformities: What Lies BeneathMetatarsalgia is a forefoot deformityoften mistaken for bunions. Withmetatarsalgia, patients have painaccompanied by a bony prominenceon the ball of their foot. “To surgical-ly address the most severe problems

improve a joint’s alignment, reduceits deformity, and to minimize thepotential for developing arthritis,”says Dr. Levine.

One of the more common surgeriesperformed by the Hospital’s foot andankle surgeons is open reduction and internal fixation. “Open reductionmeans you make an incision to visual-ize the fracture, then perform areduction, putting the fragments backtogether,” explains Dr. Levine.Internal fixation involves the place-ment of metallic hardware to createstability until the bone can restoreitself to its original state. Certain fractures can be done less invasivelythrough limited incisions, reducing thetrauma to the soft tissue caused bythe surgery and promoting a morerapid recovery of that soft tissue enve-lope. These techniques have beenadvanced over the past decade withthe introduction of instruments andhardware tailored for use within thesmall confines of the foot and ankle.

Concerned about preventing theloss of bone density or disuse osteo-porosis in patients during the six-week, post-surgical recovery periodin which an ankle must not bearweight, Dr. Levine, with Joseph M.Lane, MD, Chief of the Hospital’sOsteoporosis Center, is beginning astudy of the protective effects of

High Arches, Big Problems According to Matthew M. Roberts, MD,

a cavus or high-arched foot is associated

with ankle instability leading to arthritis,

sesamoid injuries under the big toe,

plantar fasciitis or heel pain, stress

fractures of the outer metatarsals, and

peroneal tendon disorders on the side

of the ankle. Says Dr. Roberts, “Unless

you recognize that someone has a high

arch, you are only treating the symptoms

and not correcting the basic problem.”

45

Sound AdviceUltrasound tech-

nology, which

allows the Hospital’s

radiologists to look in

great detail at soft tis-

sue around joints, tendons,

and muscles, has become an important

tool for diagnosing foot and ankle prob-

lems. Sound waves are sent and received

through a small hand-held device known

as a transducer (above). The returning

sound waves are used to produce the

images that can indicate abnormalities.

If the Shoe Fits……you may be able to avoid

foot problems. Shoes that are

too tight or too high can pro-

mote the development of foot

and ankle pathologies. Walking

in high heels can lead to a con-

tracture of the Achilles tendon,

ankle sprains and breaks, corns,

calluses, hammertoes (below),

arthritis, and even chronic knee

pain. X-ray image is from

H.Turvey/Photo

Researchers.

osteoporosis therapies, such asActonel. Notes Dr. Levine, “We wantto prevent patients recovering froman ankle fracture from developing aregional osteoporosis in their leg andtherefore be put at greater risk for afragility fracture in the future.”

Ankle Replacement: A Continuing ChallengeWhen arthritis pain in the ankle jointcan no longer be managed withoutsurgery, ankle fusion or anklereplacement are the only methodsavailable to control pain and retainfunction. “While ankle fusion willrelieve pain and allow the foot to stillmove adequately, it puts stress onother joints, potentially leading tomore arthritis,” notes Dr. Deland.“Ankle replacement puts less stresson other joints and provides a morenormal gait pattern, but we are wor-ried about durability.”

Pursuit of a successful prostheticankle joint has been ongoing fordecades. The pressure on the ankle isthree times that of the hip or knee,making it more difficult to replace.“Because the ankle is such a smalljoint, there is only so much space inwhich to place the implant,” notes Dr. O’Malley. The Hospital’s foot andankle surgeons continue to search forthe ideal prosthetic ankle joint, and Dr. Deland recently participated in a

multicenter study by the Food andDrug Administration (FDA) of theScandinavian Total Ankle Replacement(STAR) device, which is now awaitingFDA approval. In addition, Dr. Deland,in collaboration with Charles Saltzman,MD, Chairman of Orthopaedics at theUniversity of Utah, and others aredesigning a more anatomically correctankle replacement and expect to bringthis new model to market within thenext few years.

Blending Science and SurgeryThe Foot and Ankle Service continu-ally draws on the research interestsand expertise of its surgeons todevelop and refine treatments.Posterior tibial tendon insufficiencyis a major focus of the research of Dr. Deland, who is well-known for hisexpertise in this area. With supportfrom the National Institutes of Healthand the Orthopaedic Research andEducation Foundation, he is develop-ing and perfecting surgical proce-dures for posterior tibial tendoninsufficiency that preserve motionand function in the foot while achiev-ing good alignment. Surgery involvesnot only reconstructing the tendon,but also moving the heel – whichhelps support the foot and restorealignment – back into place.

A grateful patient, Susan Rose,helped make possible the establish-ment of an outcomes research centerfor the Foot and Ankle Service. TheCenter is evaluating surgical out-comes for patients with posterior tibial tendon insufficiency, cartilageproblems, and other conditions andallows the Hospital’s surgeons to follow patient progress and improvetreatments. “This is a big step for-ward,” says Dr. Deland.

More severe deformities that can-not be corrected with this procedurepresent a greater challenge – onethat Dr. Deland and his colleaguesseek to solve with an innovativeapproach in which they lengthen thebone in the outside of the foot tohelp restore the arch. “You accom-plish this by adding bone,” notes Dr. Deland. “The size of that piece ofbone is critical in how well thepatient is going to do. If you put intoo little, you can undercorrect it. If you put in too much, you can overcorrect it and make the foot toostiff.” Dr. Deland has developed aunique approach using special trialwedges he designed that are insertedin one-millimeter increments untilthe proper correction is achieved.

The work of the foot and ankle sur-geons often takes them into the LeonRoot, MD, Motion Analysis Laboratory,directed by Howard J. Hillstrom, PhD.

Fine-Tuning a DiagnosisNerve damage is a frequent problem of

persons with diabetes, especially with

the feet, because it prevents

patients from feeling pain and

realizing they have injuries. This

can lead to painful foot ulcers

and even amputation. To meas-

ure the nerve reflexes of diabet-

ic patients, Walther H.O. Bohne,

MD, (at right) uses a tuning fork

test, that has been proven to be

a useful and reliable way to

diagnose diabetic nerve disease.

of metatarsalgia,” says Dr. Deland,“we correct the alignment of the toe,including the bunion if there is one,and shorten the prominent bones.This requires very precise judgment.If we can take pressure patterns inthe OR using a device that stimulatesweight bearing, we can determine theamount of correction needed for thebest possible outcome.”

Treating Trauma“Most acute injuries to the foot andankle – unless they are open fracturesor dislocations – are not surgicalemergencies,” says David S. Levine,MD. In fact, cautions Dr. Levine, themajority of injuries to the foot andankle should not be surgically treatedimmediately because they are oftenassociated with significant swelling.“We have a great respect for, andneed, to be careful of these injuries,”he says. “We call it ‘respecting thesoft-tissue envelope.’ If we add toomuch surgical trauma on top of theinjury too soon, wound healing maynot occur.”

Dr. Levine and his colleagues callon the Hospital’s imaging capabilities(CT or MRI scanning) to learn abouta fracture’s complexity, as well as its soft-tissue injury, well beforeentering the OR to fix the fracture.“The main reason we perform sur-gery following traumatic injury is to

Caring forthe Footand Ankle

Traumatic Injuries

Disorders of the Tendon

OsteochondralLesions of the Talus

Rheumatoid Arthritis

Foot and ankle trauma encompass a rangeof injuries that include fractures of one or more bones, as well as damage to liga-ments, tendons, and nerves. The severityof these injuries can range from low-energy trauma, such as twisting a foot byfalling off a curb or sliding into secondbase to higher energy injuries caused by afall off a scaffold.

According to Dr. David S. Levine, high-impact fractures can result in shatteredbones or an open fracture in which thebone protrudes through the skin. A frac-ture of the foot or ankle can heal in adeformed position causing pain and aninability to bear weight, and could becomearthritic after many years. Because gravitycauses fluid to pool in the foot, massiveswelling after a traumatic injury is common.

Once swelling has diminished, theHospital’s orthopedic surgeons may usefixation devices, including small platesand screws, to hold the bone togetherand allow it to heal. With the initial useof an external fixator and the appropri-ate timing of surgery, the need for casting – which can result in a straightbut stiff limb – can be eliminated.

Conditions of the foot and ankle – from the common bunion to rare and complex joint and tendon disorders – represent a major area of expertise for clinicians atHospital for Special Surgery.

The Hospital’s foot and ankle specialistsare finding innovative ways to treatthese injuries through smaller incisionsand promote cartilage healing, includingstimulating the bone arthroscopically to produce new tissue; transplantingcartilage and bone from another area toimplant in the ankle; and retrogradedrilling, which involves drilling up to thelesion without disturbing the cartilage.

Tendon problems can bring chronic anddebilitating pain and swelling. Tendinitismay be localized during or following activity.Tendonosis may cause swelling or a hardnodule of tissue on the back of the leg. In posterior tibial tendon insufficiency, thefoot can collapse as the ligaments give way.This may cause pain on the inner side of theankle and into the mid-section of the foot.

At Special Surgery, depending on theinjury, tendon conditions are first treat-ed conservatively with medicationsand/or orthotics to help relieve symp-toms. When surgery is indicated, oursurgeons incorporate minimally inva-sive approaches, whenever possible, torepair the tendon. They may also useradiofrequency to stimulate a healingresponse in the affected tendon.

According to Dr. Martin J. O’Malley, if the cartilage is damaged, it may slowly deterio-rate over time – changing from a smoothfrictionless surface to one that is irregular.Generally, patients present with an ankleinjury that hasn’t healed. Symptoms may beminimal, and can include swelling, bruising,a grating feeling with movement, weakness,or instability of the joint.

Frequently occurring as a result of traumaor injury to the ankle, osteochondrallesions involve damage to the cartilage ofthe talus bone located below the anklejoint. Cartilage has a very poor ability toheal itself, and if the bone below it isinjured as well, it loses its blood supply.The goal of treatment is to stimulate thebone to heal and maintain the integrity ofthe cartilage.

Tendons connect muscles to bone, andcan tear or rupture if they are pulled toohard or if they degenerate. Inflammation(tendinitis), degeneration (tendonosis)and ruptured tendons are common problems encountered in the foot andankle. Most cases of tendinitis are causedby injury, overuse, or a mechanicalabnormality.

Rheumatoid arthritis (RA) is a systemicautoimmune disorder affecting joints inthe upper and lower extremities. Nearlyall patients with RA develop symptoms inthe foot or ankle, generally beginning inthe toes and forefeet, followed by prob-lems in the back of the foot, and eventu-ally the ankles. RA affects not only thejoints, but also soft tissues such as ten-dons and ligaments.

In RA, the body’s immune system reactsagainst itself and can cause pain, swelling,and stiffness in the joints, sole, or ball ofthe foot. The inflammation may cause thejoints to feel warm, and because RA is systemic, fatigue and weight loss may alsooccur. In addition, the foot may becomedeformed as toes curl and stiffen, andwalking can become difficult.

Rheumatologists under the direction ofDr. Stephen A. Paget, Physician-in-Chief, apply the latest therapies,including biological-response modifiers,to suppress the disease and preventjoint damage and deformities. If RA hasalready progressed, treatment optionsinclude local steroid injections,orthotics, and physical therapy, as wellas non-steroidal anti-inflammatorymedications.

Crystal Diseases –Gout andPseudogout

The Diabetic Foot

Clubfoot

Stress Fractures

Crystal diseases, the most commonbeing gout and pseudogout, can causeextreme and disabling pain in thefoot, primarily the big toe and ankle.These conditions are consideredautoinflammatory, which means theydevelop in response to local factors.Gout is caused by crystals formedfrom uric acid; pseudogout is theresult of calcium crystals.

A classic presentation of gout is aperson who awakens at night withexcruciating pain and tenderness inthe toe, with heat and redness, thatcontinue to worsen over the nextseveral hours. The initial symptomsof pseudogout are similar, and thediagnosis is differentiated by exami-nation of the joint fluid. Gout canalso appear in the ankle, knee, elbow,and many other joints.

Theodore R. Fields, MD, rheumatolo-gist, notes that an acute attack ofgout responds well to anti-inflamma-tory medications, steroid injections,and ice applications. A preventionregimen for gout may includecolchicine to inhibit factors con-tributing to inflammation, and allopurinol to lower uric acid. Forpseudogout, colchicine can also helpprevent recurrence of attacks.

Diagnosis Overview Symptoms Treatment

The Hospital’s orthopedic surgeonsare able to treat clubfoot so that the foot can function normally. Theycorrect the foot using the Ponsetitechnique – a process of weeklymanipulations and casting – tostretch the joints, ligaments, and tendons, and remold the bones back into position.

An early sign of the diabetic foot isswelling, sometimes mistaken for aninfection, but which is actually bone deterioration near the joints. As the joint crumbles, the arch of thefoot reverses and becomes flatterwith bony prominences from thefragments that are present on thesole. These can cause skin to breakdown leading to ulcers.

Patients must be vigilant in monitor-ing their feet to avoid injuries thatcan lead to amputation. A patientwith unexplained swelling shouldseek immediate medical attention.Dr. Walther H.O. Bohne combines anin-depth history, physical exam, andimaging studies to determine theappropriate intervention, as well ascounsels patients on foot care.

Clubfoot affects a child’s foot andankle, twisting the heel and toesinward. The affected foot tends to besmaller than normal, with the toespointing downward and the forefootturning inward. The heel cord is alsotight, causing the heel to be drawnup to the leg, making it impossible toput the foot flat on the ground. Theclubfoot, calf, and leg are smaller andshorter than normal.

Clubfoot is a congenital deformitythat occurs in about one in everythousand births in the United States. If a parent had a first degree relativewith clubfoot, the incidence increas-es. “If not corrected, a child canhave difficulty with walking, runningor normal activities,” says Dr. DavidM. Scher. Clubfoot is frequentlydiagnosed at 20 weeks gestationthrough a fetal ultrasound.

Diabetes is an insidious disease thatinvolves many organ systems. Sincemost patients lose some sensation inthe lower extremities because ofnerve damage, they are at risk forinjuring the sole of the foot withoutknowing it. Unattended, minorinjuries can lead to infections, deepulcers, and ultimately bone and jointinvolvement.

Stress fractures are minute cracksthat can occur in the bones of thefoot and lower leg when musclesbecome fatigued and unable toabsorb repeated impacts. They canalso occur if osteoporosis or anotherdisease has weakened the bones.The most commonly affected site isthe second or third of the long bonesbetween the toes and the midfoot.

Stress fractures generally present aslocalized dull pain that is not associ-ated with trauma and worsens duringexercise or weight-bearing activities.There may be some swelling at thesite. Tenderness when touched is akey characteristic. If the activity thatcaused the stress fracture is resumedtoo quickly, larger, harder-to-healfractures can develop.

According to Dr. Linda A. Russell,rheumatologist, if an individual has astress fracture in their foot, a bonedensity measurement should betaken to determine if osteoporosis is present. The most important treatment is rest. If osteoporosis isdiagnosed, medications are availableto help prevent future fractures.

Forefoot Deformities

Among common forefoot conditionsare hallux valgus (bunion) andmetatarsalgia. With bunions, the bigtoe deviates toward the second toecausing a painful prominence at thebase of the big toe. Metatarsalgia is apainful condition caused by the com-pression of a small toe nerve betweentwo displaced metatarsal bones.

Bunions appear as a bulging bump onthe inside of the base of the big toe.Common signs include redness,swelling, and intermittent or chronicpain. Pain may also develop in thesecond toe if the big toe is pushingagainst or overlapping this toe. Theclassic symptom of metatarsalgia ispain in the ball of the foot that canbe acute, recurrent, or chronic.

Surgery is indicated when there ispain, limitation of function, and pro-gression of deformity. In metatarsal-gia, the Hospital’s surgeons realignthe bones of the toe. With bunions,they perform reconstructive surgeryto repair the bone and joint deformi-ties, correct the cause of the bunion,and prevent it from growing back.

Diagnosis Overview Symptoms Treatment

Fracture fixation

Tendon repair

Miniature arthroscopy

Stephen A. Paget, MD

Gout crystals

Nerve testing

Hallux valgus (bunion)

Linda A. Russell, MD

David M. Scher, MD

With 28 bones, 33 joints, and 112 ligaments, the foot and ankle is an

anatomically complex weight-bearingstructure. Some of its components arefragile and some are immensely strong.Some need to be flexible and others morerigid. In order to walk, to run, to stand, tojump, each of these remarkable elementsmust move together in perfect harmony.

Soleus muscle

Peroneuslongus muscle

Lateral malleolus (fibula)

Retinaculum

Peroneus longus tendon

Extensor digitorumbrevis muscle

Peroneus brevis tendon

Peroneus tertius tendon

Soleus muscle

Flexor digitorumlongus muscle

Flexor hallucislongus muscle

Achilles tendon

Extensor hallucislongus tendon

Extensor digitorum longus tendon

Flexor digitorumlongus tendon

Flexor hallucislongus tendon

Medial malleolus (tibia)

Tibialis posterior tendon

Tibialis anterior tendon

Caring forthe Footand Ankle

Traumatic Injuries

Disorders of the Tendon

OsteochondralLesions of the Talus

Rheumatoid Arthritis

Foot and ankle trauma encompass a rangeof injuries that include fractures of one or more bones, as well as damage to liga-ments, tendons, and nerves. The severityof these injuries can range from low-energy trauma, such as twisting a foot byfalling off a curb or sliding into secondbase to higher energy injuries caused by afall off a scaffold.

According to Dr. David S. Levine, high-impact fractures can result in shatteredbones or an open fracture in which thebone protrudes through the skin. A frac-ture of the foot or ankle can heal in adeformed position causing pain and aninability to bear weight, and could becomearthritic after many years. Because gravitycauses fluid to pool in the foot, massiveswelling after a traumatic injury is common.

Once swelling has diminished, theHospital’s orthopedic surgeons may usefixation devices, including small platesand screws, to hold the bone togetherand allow it to heal. With the initial useof an external fixator and the appropri-ate timing of surgery, the need for casting – which can result in a straightbut stiff limb – can be eliminated.

Conditions of the foot and ankle – from the common bunion to rare and complex joint and tendon disorders – represent a major area of expertise for clinicians atHospital for Special Surgery.

The Hospital’s foot and ankle specialistsare finding innovative ways to treatthese injuries through smaller incisionsand promote cartilage healing, includingstimulating the bone arthroscopically to produce new tissue; transplantingcartilage and bone from another area toimplant in the ankle; and retrogradedrilling, which involves drilling up to thelesion without disturbing the cartilage.

Tendon problems can bring chronic anddebilitating pain and swelling. Tendinitismay be localized during or following activity.Tendonosis may cause swelling or a hardnodule of tissue on the back of the leg. In posterior tibial tendon insufficiency, thefoot can collapse as the ligaments give way.This may cause pain on the inner side of theankle and into the mid-section of the foot.

At Special Surgery, depending on theinjury, tendon conditions are first treat-ed conservatively with medicationsand/or orthotics to help relieve symp-toms. When surgery is indicated, oursurgeons incorporate minimally inva-sive approaches, whenever possible, torepair the tendon. They may also useradiofrequency to stimulate a healingresponse in the affected tendon.

According to Dr. Martin J. O’Malley, if the cartilage is damaged, it may slowly deterio-rate over time – changing from a smoothfrictionless surface to one that is irregular.Generally, patients present with an ankleinjury that hasn’t healed. Symptoms may beminimal, and can include swelling, bruising,a grating feeling with movement, weakness,or instability of the joint.

Frequently occurring as a result of traumaor injury to the ankle, osteochondrallesions involve damage to the cartilage ofthe talus bone located below the anklejoint. Cartilage has a very poor ability toheal itself, and if the bone below it isinjured as well, it loses its blood supply.The goal of treatment is to stimulate thebone to heal and maintain the integrity ofthe cartilage.

Tendons connect muscles to bone, andcan tear or rupture if they are pulled toohard or if they degenerate. Inflammation(tendinitis), degeneration (tendonosis)and ruptured tendons are common problems encountered in the foot andankle. Most cases of tendinitis are causedby injury, overuse, or a mechanicalabnormality.

Rheumatoid arthritis (RA) is a systemicautoimmune disorder affecting joints inthe upper and lower extremities. Nearlyall patients with RA develop symptoms inthe foot or ankle, generally beginning inthe toes and forefeet, followed by prob-lems in the back of the foot, and eventu-ally the ankles. RA affects not only thejoints, but also soft tissues such as ten-dons and ligaments.

In RA, the body’s immune system reactsagainst itself and can cause pain, swelling,and stiffness in the joints, sole, or ball ofthe foot. The inflammation may cause thejoints to feel warm, and because RA is systemic, fatigue and weight loss may alsooccur. In addition, the foot may becomedeformed as toes curl and stiffen, andwalking can become difficult.

Rheumatologists under the direction ofDr. Stephen A. Paget, Physician-in-Chief, apply the latest therapies,including biological-response modifiers,to suppress the disease and preventjoint damage and deformities. If RA hasalready progressed, treatment optionsinclude local steroid injections,orthotics, and physical therapy, as wellas non-steroidal anti-inflammatorymedications.

Crystal Diseases –Gout andPseudogout

The Diabetic Foot

Clubfoot

Stress Fractures

Crystal diseases, the most commonbeing gout and pseudogout, can causeextreme and disabling pain in thefoot, primarily the big toe and ankle.These conditions are consideredautoinflammatory, which means theydevelop in response to local factors.Gout is caused by crystals formedfrom uric acid; pseudogout is theresult of calcium crystals.

A classic presentation of gout is aperson who awakens at night withexcruciating pain and tenderness inthe toe, with heat and redness, thatcontinue to worsen over the nextseveral hours. The initial symptomsof pseudogout are similar, and thediagnosis is differentiated by exami-nation of the joint fluid. Gout canalso appear in the ankle, knee, elbow,and many other joints.

Theodore R. Fields, MD, rheumatolo-gist, notes that an acute attack ofgout responds well to anti-inflamma-tory medications, steroid injections,and ice applications. A preventionregimen for gout may includecolchicine to inhibit factors con-tributing to inflammation, and allopurinol to lower uric acid. Forpseudogout, colchicine can also helpprevent recurrence of attacks.

Diagnosis Overview Symptoms Treatment

The Hospital’s orthopedic surgeonsare able to treat clubfoot so that the foot can function normally. Theycorrect the foot using the Ponsetitechnique – a process of weeklymanipulations and casting – tostretch the joints, ligaments, and tendons, and remold the bones back into position.

An early sign of the diabetic foot isswelling, sometimes mistaken for aninfection, but which is actually bone deterioration near the joints. As the joint crumbles, the arch of thefoot reverses and becomes flatterwith bony prominences from thefragments that are present on thesole. These can cause skin to breakdown leading to ulcers.

Patients must be vigilant in monitor-ing their feet to avoid injuries thatcan lead to amputation. A patientwith unexplained swelling shouldseek immediate medical attention.Dr. Walther H.O. Bohne combines anin-depth history, physical exam, andimaging studies to determine theappropriate intervention, as well ascounsels patients on foot care.

Clubfoot affects a child’s foot andankle, twisting the heel and toesinward. The affected foot tends to besmaller than normal, with the toespointing downward and the forefootturning inward. The heel cord is alsotight, causing the heel to be drawnup to the leg, making it impossible toput the foot flat on the ground. Theclubfoot, calf, and leg are smaller andshorter than normal.

Clubfoot is a congenital deformitythat occurs in about one in everythousand births in the United States. If a parent had a first degree relativewith clubfoot, the incidence increas-es. “If not corrected, a child canhave difficulty with walking, runningor normal activities,” says Dr. DavidM. Scher. Clubfoot is frequentlydiagnosed at 20 weeks gestationthrough a fetal ultrasound.

Diabetes is an insidious disease thatinvolves many organ systems. Sincemost patients lose some sensation inthe lower extremities because ofnerve damage, they are at risk forinjuring the sole of the foot withoutknowing it. Unattended, minorinjuries can lead to infections, deepulcers, and ultimately bone and jointinvolvement.

Stress fractures are minute cracksthat can occur in the bones of thefoot and lower leg when musclesbecome fatigued and unable toabsorb repeated impacts. They canalso occur if osteoporosis or anotherdisease has weakened the bones.The most commonly affected site isthe second or third of the long bonesbetween the toes and the midfoot.

Stress fractures generally present aslocalized dull pain that is not associ-ated with trauma and worsens duringexercise or weight-bearing activities.There may be some swelling at thesite. Tenderness when touched is akey characteristic. If the activity thatcaused the stress fracture is resumedtoo quickly, larger, harder-to-healfractures can develop.

According to Dr. Linda A. Russell,rheumatologist, if an individual has astress fracture in their foot, a bonedensity measurement should betaken to determine if osteoporosis is present. The most important treatment is rest. If osteoporosis isdiagnosed, medications are availableto help prevent future fractures.

Forefoot Deformities

Among common forefoot conditionsare hallux valgus (bunion) andmetatarsalgia. With bunions, the bigtoe deviates toward the second toecausing a painful prominence at thebase of the big toe. Metatarsalgia is apainful condition caused by the com-pression of a small toe nerve betweentwo displaced metatarsal bones.

Bunions appear as a bulging bump onthe inside of the base of the big toe.Common signs include redness,swelling, and intermittent or chronicpain. Pain may also develop in thesecond toe if the big toe is pushingagainst or overlapping this toe. Theclassic symptom of metatarsalgia ispain in the ball of the foot that canbe acute, recurrent, or chronic.

Surgery is indicated when there ispain, limitation of function, and pro-gression of deformity. In metatarsal-gia, the Hospital’s surgeons realignthe bones of the toe. With bunions,they perform reconstructive surgeryto repair the bone and joint deformi-ties, correct the cause of the bunion,and prevent it from growing back.

Diagnosis Overview Symptoms Treatment

Fracture fixation

Tendon repair

Miniature arthroscopy

Stephen A. Paget, MD

Gout crystals

Nerve testing

Hallux valgus (bunion)

Linda A. Russell, MD

David M. Scher, MD

With 28 bones, 33 joints, and 112 ligaments, the foot and ankle is an

anatomically complex weight-bearingstructure. Some of its components arefragile and some are immensely strong.Some need to be flexible and others morerigid. In order to walk, to run, to stand, tojump, each of these remarkable elementsmust move together in perfect harmony.

Soleus muscle

Peroneuslongus muscle

Lateral malleolus (fibula)

Retinaculum

Peroneus longus tendon

Extensor digitorumbrevis muscle

Peroneus brevis tendon

Peroneus tertius tendon

Soleus muscle

Flexor digitorumlongus muscle

Flexor hallucislongus muscle

Achilles tendon

Extensor hallucislongus tendon

Extensor digitorum longus tendon

Flexor digitorumlongus tendon

Flexor hallucislongus tendon

Medial malleolus (tibia)

Tibialis posterior tendon

Tibialis anterior tendon

All Together NowTraumatic injuries tothe foot and ankleoften require pins andother hardware toreconstruct fracturedbones not only toensure they heal correctly, but, as DavidS. Levine, MD, explains,to improve the joint’salignment and reducedeformity with a goaltoward minimizing the development ofarthritis.

Intricate TerrainMartin J. O’Malley, MD,must navigate complexbone, cartilage, and softtissue structures whenperforming reconstruc-tive surgeries to treatfoot and ankle disorders.Dr. O’Malley and his colleagues continuallypursue new ways to surgically repair injurieswithout big incisions andfacilitate cartilage heal-ing so patients can returnto normal activity asquickly as possible.

treated without surgery, once thecause of the injury is determined, withprecisely directed physical therapy.

An Arch Enemy“People who have a high-arched foot,or cavus foot, can suffer from a con-stellation of foot and ankle problems.The presentation may be subtle,”says Matthew M. Roberts, MD. “It islike having one leg of a tripod that istoo long, making it unstable. As aresult, high arches are associatedwith recurrent ankle instability orsprains. This instability needs to beaddressed; otherwise, there is anincreased risk for ankle arthritis.”

Notes Dr. Roberts, it is importantto determine if cavus foot is responsi-ble for other problems in the foot inorder to provide the appropriatetreatment. “For example,” he says, “if we operate on a peroneal tendoninjury and don’t address the higharch, the tendon repair may not healcorrectly.”

Forefoot Deformities: What Lies BeneathMetatarsalgia is a forefoot deformityoften mistaken for bunions. Withmetatarsalgia, patients have painaccompanied by a bony prominenceon the ball of their foot. “To surgical-ly address the most severe problems

improve a joint’s alignment, reduceits deformity, and to minimize thepotential for developing arthritis,”says Dr. Levine.

One of the more common surgeriesperformed by the Hospital’s foot andankle surgeons is open reduction and internal fixation. “Open reductionmeans you make an incision to visual-ize the fracture, then perform areduction, putting the fragments backtogether,” explains Dr. Levine.Internal fixation involves the place-ment of metallic hardware to createstability until the bone can restoreitself to its original state. Certain fractures can be done less invasivelythrough limited incisions, reducing thetrauma to the soft tissue caused bythe surgery and promoting a morerapid recovery of that soft tissue enve-lope. These techniques have beenadvanced over the past decade withthe introduction of instruments andhardware tailored for use within thesmall confines of the foot and ankle.

Concerned about preventing theloss of bone density or disuse osteo-porosis in patients during the six-week, post-surgical recovery periodin which an ankle must not bearweight, Dr. Levine, with Joseph M.Lane, MD, Chief of the Hospital’sOsteoporosis Center, is beginning astudy of the protective effects of

High Arches, Big Problems According to Matthew M. Roberts, MD,

a cavus or high-arched foot is associated

with ankle instability leading to arthritis,

sesamoid injuries under the big toe,

plantar fasciitis or heel pain, stress

fractures of the outer metatarsals, and

peroneal tendon disorders on the side

of the ankle. Says Dr. Roberts, “Unless

you recognize that someone has a high

arch, you are only treating the symptoms

and not correcting the basic problem.”

45

Sound AdviceUltrasound tech-

nology, which

allows the Hospital’s

radiologists to look in

great detail at soft tis-

sue around joints, tendons,

and muscles, has become an important

tool for diagnosing foot and ankle prob-

lems. Sound waves are sent and received

through a small hand-held device known

as a transducer (above). The returning

sound waves are used to produce the

images that can indicate abnormalities.

If the Shoe Fits……you may be able to avoid

foot problems. Shoes that are

too tight or too high can pro-

mote the development of foot

and ankle pathologies. Walking

in high heels can lead to a con-

tracture of the Achilles tendon,

ankle sprains and breaks, corns,

calluses, hammertoes (below),

arthritis, and even chronic knee

pain. X-ray image is from

H.Turvey/Photo

Researchers.

osteoporosis therapies, such asActonel. Notes Dr. Levine, “We wantto prevent patients recovering froman ankle fracture from developing aregional osteoporosis in their leg andtherefore be put at greater risk for afragility fracture in the future.”

Ankle Replacement: A Continuing ChallengeWhen arthritis pain in the ankle jointcan no longer be managed withoutsurgery, ankle fusion or anklereplacement are the only methodsavailable to control pain and retainfunction. “While ankle fusion willrelieve pain and allow the foot to stillmove adequately, it puts stress onother joints, potentially leading tomore arthritis,” notes Dr. Deland.“Ankle replacement puts less stresson other joints and provides a morenormal gait pattern, but we are wor-ried about durability.”

Pursuit of a successful prostheticankle joint has been ongoing fordecades. The pressure on the ankle isthree times that of the hip or knee,making it more difficult to replace.“Because the ankle is such a smalljoint, there is only so much space inwhich to place the implant,” notes Dr. O’Malley. The Hospital’s foot andankle surgeons continue to search forthe ideal prosthetic ankle joint, and Dr. Deland recently participated in a

multicenter study by the Food andDrug Administration (FDA) of theScandinavian Total Ankle Replacement(STAR) device, which is now awaitingFDA approval. In addition, Dr. Deland,in collaboration with Charles Saltzman,MD, Chairman of Orthopaedics at theUniversity of Utah, and others aredesigning a more anatomically correctankle replacement and expect to bringthis new model to market within thenext few years.

Blending Science and SurgeryThe Foot and Ankle Service continu-ally draws on the research interestsand expertise of its surgeons todevelop and refine treatments.Posterior tibial tendon insufficiencyis a major focus of the research of Dr. Deland, who is well-known for hisexpertise in this area. With supportfrom the National Institutes of Healthand the Orthopaedic Research andEducation Foundation, he is develop-ing and perfecting surgical proce-dures for posterior tibial tendoninsufficiency that preserve motionand function in the foot while achiev-ing good alignment. Surgery involvesnot only reconstructing the tendon,but also moving the heel – whichhelps support the foot and restorealignment – back into place.

A grateful patient, Susan Rose,helped make possible the establish-ment of an outcomes research centerfor the Foot and Ankle Service. TheCenter is evaluating surgical out-comes for patients with posterior tibial tendon insufficiency, cartilageproblems, and other conditions andallows the Hospital’s surgeons to follow patient progress and improvetreatments. “This is a big step for-ward,” says Dr. Deland.

More severe deformities that can-not be corrected with this procedurepresent a greater challenge – onethat Dr. Deland and his colleaguesseek to solve with an innovativeapproach in which they lengthen thebone in the outside of the foot tohelp restore the arch. “You accom-plish this by adding bone,” notes Dr. Deland. “The size of that piece ofbone is critical in how well thepatient is going to do. If you put intoo little, you can undercorrect it. If you put in too much, you can overcorrect it and make the foot toostiff.” Dr. Deland has developed aunique approach using special trialwedges he designed that are insertedin one-millimeter increments untilthe proper correction is achieved.

The work of the foot and ankle sur-geons often takes them into the LeonRoot, MD, Motion Analysis Laboratory,directed by Howard J. Hillstrom, PhD.

Fine-Tuning a DiagnosisNerve damage is a frequent problem of

persons with diabetes, especially with

the feet, because it prevents

patients from feeling pain and

realizing they have injuries. This

can lead to painful foot ulcers

and even amputation. To meas-

ure the nerve reflexes of diabet-

ic patients, Walther H.O. Bohne,

MD, (at right) uses a tuning fork

test, that has been proven to be

a useful and reliable way to

diagnose diabetic nerve disease.

of metatarsalgia,” says Dr. Deland,“we correct the alignment of the toe,including the bunion if there is one,and shorten the prominent bones.This requires very precise judgment.If we can take pressure patterns inthe OR using a device that stimulatesweight bearing, we can determine theamount of correction needed for thebest possible outcome.”

Treating Trauma“Most acute injuries to the foot andankle – unless they are open fracturesor dislocations – are not surgicalemergencies,” says David S. Levine,MD. In fact, cautions Dr. Levine, themajority of injuries to the foot andankle should not be surgically treatedimmediately because they are oftenassociated with significant swelling.“We have a great respect for, andneed, to be careful of these injuries,”he says. “We call it ‘respecting thesoft-tissue envelope.’ If we add toomuch surgical trauma on top of theinjury too soon, wound healing maynot occur.”

Dr. Levine and his colleagues callon the Hospital’s imaging capabilities(CT or MRI scanning) to learn abouta fracture’s complexity, as well as its soft-tissue injury, well beforeentering the OR to fix the fracture.“The main reason we perform sur-gery following traumatic injury is to

Stride Right“While foot problems, in

and of themselves, are

not life threatening, they

are lifestyle threatening,”

says Rock Positano, DPM,

MSc, MPH. “We take for

granted how important feet are

to everyday living. The ability to work,

exercise, and go out are completely

dependent upon how our feet function.

And, as strange as it may seem, foot

problems can affect virtually any part of

the body. “For instance, a flat foot or

high-arched foot

mechanically changes

the way a person’s foot

hits the ground and may

be helped

with an

orthotic (at

left),” he says. “If

the foot is not able to absorb

the shock properly, the joint

reaction force is transmitted up

to the knee, hip, and back.”

The uniquely designed Motion AnalysisLab is one of the largest of its kind inthe country and includes a 32-foot-long platform containing force platesthat can be arranged for evaluating arange of foot problems and otherpathologies. Says Dr. Hillstrom, whodesigned the facility, “You can bringthem close together for small stridelengths for three- or five-year-olds, orplace them apart for a seven-foot-tallbasketball player.”

The lab also has technologies to dis-cern flexibility in the first metatarsaljoint, the height of the arch, and otheraspects of foot structure. In one NIH-funded project, Dr. Hillstrom is lookingat forefoot geometry and how thecurve that is formed by the ball of thefoot relates to its function.

The Diabetic FootWalther H.O. Bohne, MD, offers spe-cialized expertise in the diabetic foot.“Since most patients with diabeteslose some of the sensation in thelower extremities, they are at risk forinjuring the sole of their foot withoutrealizing it,” says Dr. Bohne. “Thisbegins a cascade of events that leadsto deeper wounds and infection.These patients can go on to developan ulcer, which if left untreated, candeepen and involve the bone, puttingthem at risk for amputation.”

In addition, notes Dr. Bohne,patients with diabetes can developCharcot’s arthropathy – a complica-tion that involves fragmentation of thesmall bones in the foot. The condition,however, often goes undiagnosedbecause patients are unaware of aproblem until swelling appears. “Thebony prominences from the fragmentscan cause excessive pressure andbreak down the skin leading to ulcers.As soon as the diabetic patient seesunexplained swelling in the foot, he orshe should seek the immediate atten-tion of a physician who understandsand can treat the orthopedic conse-quences of diabetes.”

According to Dr. Bohne, educationis the key in preventing the severeconsequences of diabetic foot condi-tions. And, he cautions, at the veryleast, a person who has diabetesshould never walk barefooted andalways wear slippers or shoes with asolid sole to prevent anything frompenetrating the skin.

The Right Start Cerebral palsy is a neurological disor-der that results in abnormal muscletone in children. “This can result inmuscle imbalance that causes thefoot to deform,” says Leon Root, MD.“Weakness in the muscle in the frontof the leg can cause the child to walkon his toes.” In the young child, the

use of braces and therapy may con-trol the way the child walks, but ifthe child continues to walk abnormal-ly despite conservative treatment,surgery is performed to rebalance themuscles around the foot and ankle inorder to obtain normal weight-bear-ing position of the feet.

Clubfoot is a congenital deformitythat causes a child’s foot to be twist-ed and pointed downward. “If leftuntreated, the foot would not beamenable to proper walking, running,or normal functions,” says David M.Scher, MD, Director, Clubfoot Clinic.“The beauty of treating a clubfoot isthat when attended to in a timelymanner – usually the first two weeksof life – we can take advantage of the properties of the immature mus-culoskeletal system by manipulatingthe foot to stretch the joints, liga-ments, and tendons and actuallyremold the bones back into a normalposition. In two months or less, we’reable to make the foot functionallynormal for life.”

Non-Surgical Solutions “Leonardo DaVinci once said that the foot is the pedestal of the body.Everything starts at the foot andankle and works its way up,” saysRock Positano, DPM, MSc, MPH,Director of the Joe DiMaggio Non-

7

Surgical Foot and Ankle Service – thefirst of its kind at a major orthopedicteaching hospital.

Heel and Achilles tendon pain,ankle sprains, shin splints, bunions,metatarsal pain, neuroma, and tendonproblems are among the many condi-tions evaluated and treated by Dr.Positano, who is the author of threemajor textbooks on non-surgical foottreatments. “Most patients who cometo our practice have biomechanicalissues, and we often prescribe a footorthoses to achieve better alignmentand decrease the amount of forcethat the foot has to endure.”

“We are able to custom fabricateorthoses to the needs of the patienton site with direct input from ourphysicians,” says Glenn Garrison,Director of Prosthetics and Orthotics.“This collaboration with the clinicianprovides for a much better, higherquality of care for the patient.”

Physical therapy also plays a keyrole. “Therapy is designed to calmdown inflammation, diminish swelling,and restore normal motion andmechanics, and improve propriocep-tion of the foot and ankle,” says ToddGage, PT. “The entire kinetic chainmust be evaluated. In order to effec-tively treat the foot and ankle, youmust evaluate the adjacent segmentsto restore normal mechanics of theentire lower extremity.”

“If physical therapy, foot orthoses,and injections do not produce thedesired result,” says Dr. Positano,“then it’s a seamless transition to the next phase of care – our surgicalcolleagues are right next door.”

An Inflammatory Effect Problems of the foot and ankle maybe the result of an inflammatory orautoimmune disease such as rheuma-toid arthritis. “These conditions cancause joint inflammation,” notesStephen A. Paget, MD, Physician-in-Chief, and Chairman, Division ofRheumatology.

Sergio Schwartzman, MD, special-izes in spondyloarthropathies – agroup of inflammatory diseases thattends to affect the spine as well asthe joints of the lower extremity.When these diseases affect peripheraljoints, patients may have inflamma-tion that results in pain and swelling.“These diseases are not always obvi-ous,” says Dr. Schwartzman, a rheuma-tologist. “It is important to rememberthat all autoimmune diseases canaffect the foot and ankle.”

Picture Perfect Successful treatment for any foot and ankle disorder depends on theextraordinary imaging capabilities ofthe Department of Radiology and

Imaging directed by Helene Pavlov,MD, FACR, Radiologist-in-Chief. “An X-ray provides an overview ofthe boney architecture and alignmentand soft tissue anatomy,” she says.“An MRI can further pinpoint a specific abnormality. The imaging isvery sensitive and specific, and thedetail is exquisite.”

“Ultrasound, which employs highfrequency sound waves to produceimages, is an excellent method forassessing soft tissue swelling or asmall cyst on the foot,” says RonaldAdler, PhD, MD, Chief, Division ofUltrasound and Body CT. “The periar-ticular soft tissues can be exquisitelydetailed, and the real-time aspect ofultrasound is helpful in that we candisplay how joints and tendons movethrough a series of maneuvers.”

Radiologists also use ultrasoundfor therapeutic procedures, particu-larly ultrasound-guided injection.“The synovial sheaths that surroundthe tendons of the ankle, as well as the bursa, can be specifically identified when inflamed, and cortisone injections can be carefully targeted to the site required,” says Dr. Adler. “We are able to see thejoint and soft tissues surrounding the abnormality, as well as nervesand arteries, and can avoid thosestructures when we do the injectionunder ultrasound guidance.” n

Tending toTendons Andrew T. Elliott, MD,

one of seven orthope-

dic surgeons with the

Foot and Ankle Service,

has an interest in

degenerative tendon

disorders. Zarela Martinez (right) came

to him when she was unable to walk

due to a posterior tibial tendon insuffi-

ciency. Dr. Elliott performed reconstruc-

tive surgery that enabled her to return

to her very active life as a restaurateur.

8

Forward ThinkingWhile there are a number of strategies

to treat osteochondral injuries, John J.

Kennedy, MD, Director of Research in

the Foot and Ankle Service, and

colleagues in sports medicine, are at

the forefront of computerized

navigation to identify and treat

these lesions. Dr. Kennedy,

with Dr. Deland and others, is

investigating clinical out-

comes of existing treatments

and pursuing novel future

treatments in the laboratory.

Back on Her Feet,Thanks to Special SurgeryFollowing surgery for atendon injury, ZarelaMartinez is now back ather Eastside Mexicanrestaurant – Zarela –and greeting guests.“The worst part aboutrecovery was that Icouldn’t cook,” she says.“I had to eat takeout –it was horrifying!”

Best-selling author Mary HigginsClark is used to unraveling clues inthe plot lines of her 25 suspense

novels that have sold more than 85 millioncopies in the United States alone. Butwhen it came to her health, solving themystery of an ankle problem proved a lotmore daunting.

Nearly two decades ago, Ms. Clark hadundergone a triple bone fusion on herankle. From the very beginning, she says,she knew that “something wasn’t right.”But she suffered for another five yearsuntil a friend recommended that she cometo Hospital for Special Surgery and seeJonathan T. Deland, MD, Chief of the Footand Ankle Service.

At her first visit, Ms. Clark recalls hisexact words: “‘It’s elective surgery, but ifyou don’t do it, at some point you willnever walk again.’ And I said, ‘I don’t callthat elective!’”

Dr. Deland performed revision surgerythat included a triple bone fusion to preserve as much as possible her ability to walk. As Ms. Clark says simply, “I knowabsolutely that he saved my ankle.”

With a history of foot problems, shecontinued to experience a number ofissues with both of her feet – coming backeach time to Special Surgery for care.“Genetically, I have really rotten arches,and they led to other troubles,” says Ms. Clark. “I also broke my leg with dam-age to the ligaments from, if you canbelieve this, slipping on the tiniest piece ofa banana.” Once again, she notes, Dr.Deland “saved my foot.”

A native New Yorker, Ms. Clark wasraised in the Bronx, and began her work-ing career in an advertising agency beforebecoming a stewardess with Pan AmAirlines. She started writing short storiesfollowing her marriage to Warren Clark. Ittook six years and 40 rejections before shesold her first piece, Stowaway, in 1956 for$100. After her husband’s untimely deathin 1964, she went to work writing radio

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Managing EditorLinda Errante

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Major PhotographyRobert Essel

IllustrationsFeet in fold-out: Anatomical Chart Company

Hammertoe and Bunion: Nucleus Medical Art

Development DepartmentHospital for Special Surgery535 East 70th St, Suite 842WNew York, NY 10021tel: 212.606.1196www.hss.edu/giving

Hospital for Special Surgery is an affiliate of NewYork-PresbyterianHealthcare System and Weill MedicalCollege of Cornell University.

scripts to support her family of five chil-dren and began her foray into full-lengthnovels. Some 40 years later, she is still aprolific writer, having just publishedanother holiday suspense novel, SantaCruise, co-authored with her daughter,Carol Higgins Clark, and in April 2007, her26th novel, I Heard That Song Before,will be published by Simon & Schuster.

A contributor to Dr. Deland’s researchand clinical programs, Ms. Clark has high praise for him and the staff of SpecialSurgery that enabled her to ‘stay on her feet.’

“Dr. Deland is a wonderful, caring sur-geon, and certainly the staff is wonderful,too,” she says. “I think that in both judg-ment and skills in the operating room, heis top-drawer…he’s marvelous.”

According to Ms. Clark and the thou-sands of patients treated by the Hospital’sfoot and ankle specialists, there’s no mystery of what it takes to provide thehighest quality care. n

Contacting Special Surgery

Finding a PhysicianOur Physician Referral Service can help find you the right doctor for your medical needs. Call 800.796.0783

Visit Our Web SiteNeed more information on musculoskeletal health and our medical services? Visit www.hss.edu

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Giving to HSSTo support the Hospital’s pioneering work in research,patient care, and education, call 212.606.1196 or visitwww.hss.edu/giving

Mary Higgins Clark

Best Foot Forward