The ankle is made up of three bones:

• the tibia (shin bone), which forms the inside, front, and back of the ankle
• the fibula, which forms the outside of the ankle
• the talus, a small bone that sits between the tibia and fibula and the heel bone

The ends of these bones are called malleoli. The tibia has a medial (inside) malleoli and a posterior malleoli. The fibula forms the lateral (outside) malleoli.

Ankle Fracture

A fracture is a partial or complete break in a bone. In the ankle, fractures involve the far (distal) ends of the tibia and/or the fibula. Some distal tibia fractures can involve the rear (posterior) part of the bone, which also are known as posterior malleolar fractures. Ankle fractures can range from less serious avulsion injuries (small pieces of bone that have been pulled off) to severe, shattering-type breaks. Some fractures also may involve injuries to important ankle ligaments that keep the ankle in its normal position. Ankle fractures are commonly caused by the ankle twisting inward or outward.

Symptoms

One or all of these signs and symptoms may accompany an ankle fracture:

• Pain at the site of the fracture, which can extend from the foot to the knee
• Swelling, which may occur along the length of the leg or be more localized at the ankle
• Blisters, which should be treated promptly
• Bruising
• Decreased ability to walk. It is possible to walk or bear weight upon the ankle with less severe fractures. Never rely on walking as a test of whether the ankle is fractured.
• Bones protruding through the skin. This condition is known as an open ankle fracture. These types of ankle fractures require immediate treatment to avoid problems like infection.

Most patients with ankle fractures are treated in an emergency room or a doctor’s office. An X-ray of the damaged ankle may be taken to determine what the fracture looks like, which bones are broken, how separated or displaced the bones are, and the condition of the bone itself. The X-ray will help determine the proper course of treatment.

The goal of amputation is to remove unhealthy tissue and create a remaining leg that is less painful and more useful. Just like many reconstructive orthopedic surgeries, the surgical goal is to improve a patient’s pain and function. Amputation can improve quality of life for many patients.

Below-Knee Amputation

A below-knee amputation (BKA) is an amputation often performed for foot and ankle problems. The BKA often leads to the use of an artificial leg that can allow a patient to walk. A BKA is performed roughly in the area between the ankle and knee. This amputation provides good results for a wide range of patients with many different diseases and injuries.

Diagnosis

Your foot and ankle orthopedic surgeon may perform a BKA if you are severely injured or have a severe infection. After a severe injury to the lower leg, an amputation may be recommended immediately or after attempts to save the limb leaves the patient with significant pain or functional limitations. Other reasons for amputation can include non-healing ulcers, chronic pain, birth defects, and tumor. The decision to amputate involves many factors and is done after a thorough discussion between you and your orthopedic surgeon.

There are many medical reasons why a patient may not be a good candidate for a BKA. Below are some of the more common reasons.

• Poor blood flow: Patients with poor blood flow should not undergo an operation without proper evaluation before surgery. Adequate blood flow is necessary for wound healing. This may mean a referral to a vascular specialist before surgery is considered.
• Medical problems: Severe heart or lung disease, a poor immune system, or bleeding problems may be reasons to not have surgery.
• Infections or tumors that extend above the knee: In cases where an infection or tumor goes above the knee joint, a higher level of amputation may be required.
• Scar tissue or skin and muscle loss: A patient with scarring, tissue grafting, or tissue loss may not be a candidate for a BKA. Such patients may not have adequate skin or muscle to heal a wound or to use an artificial leg.
• Limited knee function or knee pain: Patients who cannot straighten their knee or have pain and giving way at the knee may find it difficult to use an artificial leg.
• Patients who already do not walk or stand due to other reasons may not benefit from a BKA.

Treatment

If amputation is being considered, a team approach should be used. This often means meeting with numerous specialists. This may include your foot and ankle orthopedic surgeon; your medical doctor, who can make sure you are healthy for surgery; a prosthetist, someone who specializes in making artificial limbs; a physical therapist; and a rehab doctor. Support groups and patients with similar problems who have undergone amputation can be excellent resources before and after surgery.

During surgery, the leg is amputated at a level that removes as much damaged tissue as possible. There is no single length of amputation that will work for all patients. In general, several inches of leg bone below the knee are required in order for an artificial leg to be properly fit. There is not an advantage to a very long residual leg as it does not improve the ability to fit and wear an artificial leg.

Specific Technique

There are many different techniques for performing a BKA. Each surgery is customized for the individual patient. Most patients are completely asleep for the procedure. On occasion, a spinal anesthetic or a nerve block with a sedative may be appropriate.

An incision is made below the desired level of the amputation. The calf muscles and skin are cut in a way that creates a “flap.” The leg bones are cut with a saw. Some surgeons may fuse the end of the two bones (tibia and fibula) together, called an Ertl technique. The calf muscle is then folded up over the ends of the bones and held with sutures. The skin is closed with sutures or staples. Some surgeons may place a temporary drain to help prevent blood from pooling under the flap. A compressive dressing or a cast is applied to minimize swelling. Sometimes a cast is applied for added protection. The surgery usually lasts two to three hours. Patients spend some time in a recovery area and are then transferred to a hospital floor.

Recovery

Most patients will be admitted to the hospital for at least one night following the procedure. Many are able to return home as long as they have help at home and are able to walk with crutches or a walker. Some patients who need more assistance with walking or have multiple medical problems may benefit from a stay in a rehabilitation facility until they are ready to return home.

The incision will heal over a period of 2-6 weeks. This can depend on patient factors such as blood flow, quality of skin and soft tissue, and medical conditions such as diabetes. Swelling is common and may last for months if not years.

Swelling often is treated with a compression stocking or “shrinker.” Decreased swelling is critical for proper use of an artificial leg. If a limb is swollen when the prosthesis is fitted, it will be loose when the swelling improves. Similarly, a swollen limb won’t fit into an artificial leg. Complete healing may take up to a year. The artificial leg is continually adjusted during that time to make sure of a proper fit.

Most surgeons will want the incision to be completely healed before allowing a patient to walk with an artificial leg. Most patients are fitted with a temporary artificial leg within the first three months. Activities are increased slowly over time. A permanent artificial leg may not be made for 6-12 months after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. After amputation patients may have continued nerve pain, phantom limb pain, or bone spur overgrowth at the end of the limb (heterotopic ossification). Any of these problems may require additional operations. Disability can result from any of these problems.

FAQs

What kind of activities can I expect to be able to do after a below-knee amputation?

This depends on your level of activity before surgery. Patients often are able to return to the level of activity they had prior to amputation. An amputation may even allow a higher level of activity such as brisk walking or running. Younger patients without other medical problems or joint ailments may have the best results. Different prosthetic styles are available depending on an individual’s functional demands.

What are the keys to having a successful below-knee amputation?

Knowing what to expect is important. Even a perfectly performed surgery may be seen as a failure if a patient has the wrong expectations. This is one of the reasons why it is important to learn about the procedure and talk to as many patients and practitioners as possible before the operation. Speaking with a patient who is of similar age and has undergone an amputation for similar reasons can be extremely helpful.

What can I do before surgery to stay strong?

Prior to your operation it is important to maintain hip and knee strength. This can be accomplished with straight leg raises and knee extension exercises. These exercises should be continued during your recovery.

What kinds of things can help healing?

It is important to protect the limb and incision after surgery. If you are given a brace or cast to wear, you should wear this exactly as directed. It takes only one accidental bump to open the incision. If this happens, it could delay healing by several weeks or even months. It may even require additional surgery.

If you are a smoker, you should stop. Smoking has been associated with numerous complications. These include wound healing problems, bone healing problems, heart and lung disease, pain, and even arthritis. The risks of surgery are sometimes so high that some surgeons will hold off on performing an amputation until a patient has stopped smoking entirely. Proper nutrition and medical management of chronic disease, particularly diabetes, also is helpful.

Bunions

Most bunions can be treated without an operation, but sometimes surgical procedures are needed to relieve pain and deformity. Unfortunately, in some cases bunion repairs fail and the pain or deformity returns. There are multiple factors that can contribute to this challenging scenario. Bunions can recur because of medical conditions or non-healing of the bone after surgery. In some cases, there are technical aspects that can be improved to achieve the desired result with additional surgery.

The goal of correcting a failed bunion repair, using a procedure called revision surgery, is to relieve pain and deformity of the first toe that remains after the initial surgery. Sometimes arthritis develops after bunion surgery. This may require a different procedure than the first. It is important to figure out why the first surgery failed to prevent another failure.

Symptoms

Revision surgery is for those with deformity and pain after bunion surgery. The pain may be the same or different from that experienced before the first surgery. Your foot and ankle orthopedic surgeon will examine deformities of bones and joints and their various angles around the first toe.

Revision bunion surgery is not advised for patients with poor blood flow or certain nerve conditions. Bunions should not be revised if they are painless and do not cause problems. No bunion surgery should be performed solely to make the foot look better.

Treatment

Revision surgery typically takes a little longer to perform than the first procedure because it can be more complicated due to scar tissue and altered anatomy. Incisions are made around the first toe and by the arch of the foot. Special instructions may include wrapping, protection with boots or braces, and limited activity. Usually this is an outpatient procedure, meaning you can go home the same day as surgery.

There are numerous accepted methods of correcting a bunion. Some are treated with a bone cut of the first toe, while others require a fusion. Hardware in the form of plates and/or screws may be used to maintain corrections or hold fusions solid.

Recovery

Recovery will take at least as long as the first surgery. After surgery, you will be placed in a brace or shoe. You will have to avoid putting weight on the foot or only put weight on the heel for a period of time determined by your surgeon. Sutures usually are removed two weeks after surgery.

Sesamoids

Sesamoids are bones that develop within a tendon. The one most people are familiar with is in the kneecap, however they most commonly occur in the foot and hand. Two sesamoids, each about the size of a corn kernel, typically are found near the underside of the big toe.

Symptoms

Pain from a sesamoid injury is focused under the big toe on the ball of the foot. With sesamoiditis or a stress fracture, pain may develop gradually, whereas with a fracture, the pain will be immediate after trauma. Swelling and bruising may or may not be present. There may be difficulty and pain when bending and straightening the big toe.

Causes

Sesamoids act like pulleys, increasing the ability of the tendons to transmit muscle forces. The sesamoids in the forefoot also assist with weight bearing and help elevate the bones of the big toe. Like other bones, sesamoids can break in a traumatic injury. They also can develop a stress fracture from overuse. In addition, the tendons surrounding the sesamoids can become irritated or inflamed. This is called sesamoiditis and is a form of tendinitis or tendinosis. It is common among ballet dancers, runners, and professional athletes.

Diagnosis

During your examination, your foot and ankle orthopedic surgeon will look for tenderness at the sesamoid bones. Your doctor may manipulate the bone slightly or ask you to bend and straighten the toe. He or she also may bend the big toe up toward the top of the foot to see if the pain intensifies.

Your surgeon will request X-rays of the forefoot to ensure a proper diagnosis. In many people, the sesamoid bone nearer the center of the foot (the medial sesamoid) has two parts (bipartite). Because the edges of a bipartite medial sesamoid are generally smooth, and the edges of a fractured sesamoid are generally jagged, an X-ray is useful in making an appropriate diagnosis. Your physician also may request X-rays of the other foot to compare the bone structure. If the X-rays appear normal, the physician may suggest additional tests such as an MRI or CT scan.

Treatment

Treatment for sesamoiditis usually is nonoperative and successful, but can be frustrating in how long it takes for symptoms to resolve. If conservative measures fail, your physician may recommend surgery to remove the sesamoid bone. First, your specialist will recommend the following:

• Stop the activity that causes the pain.
• Take acetaminophen or ibuprofen to relieve the pain.
• Rest and ice the sole of your foot. Do not apply ice directly to the skin; use an ice pack or wrap the ice in a towel.
• Wear soft-soled, low-heeled shoes.
• Use a felt cushioning pad around the sesamoid to relieve stress.
• Return to activity gradually and continue to wear a cushioning pad of dense foam rubber under the sesamoids to support them. Avoid activities that put your weight on the balls of the feet.
• Tape the big toe so that it remains bent slightly downward.

In rare occasions, a steroid injection may be appropriate.

If symptoms persist, you may need to wear a removable boot or a cast for 4-6 weeks. Sesamoids tend to heal slowly.

If you have fractured a sesamoid bone, your foot and ankle orthopedic surgeon may recommend conservative treatments before resorting to surgery. You will need to wear a stiff-soled shoe, a boot, or possibly a cast, and your physician may tape the joint to limit movement of the big toe. You also may have to wear a J-shaped pad around the area of the sesamoid to relieve pressure as the fracture heals. Pain relievers such as acetaminophen or ibuprofen may be recommended as well, but know that it may take several months for the discomfort to subside.

In some cases, a fractured sesamoid requires surgery. In this case, repair sometimes can be performed, but often removal of part or all of the sesamoid will be needed.

Recovery

Healing of the sesamoid typically is slow and can take up to six months. The process can be frustrating but is usually successful.

Risks

Failure of healing, avascular necrosis, development of arthritis at the joint between the sesamoid and the first metatarsal, and continued pain are the risks associated with sesamoid injuries. If these should develop, excision of part or all of the sesamoid can usually resolve symptoms.

Osteochondral Lesions

Osteochondral lesions are injuries to the talus (the bottom bone of the ankle joint) that involve both the bone and the overlying cartilage. They may also be called osteochondritis dessicans or osteochondral fractures. These injuries may include softening of the cartilage layers, cyst-like lesions within the bone below the cartilage, or fracture of the cartilage and bone layers. Throughout this article, these injuries will be referred to as osteochondral lesions of the talus (OLT).

Anatomy

The talus is the bottom bone of the ankle joint. Much of this bone is covered with cartilage. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. The blood supply to the talus is not as rich as many other bones in the body, and as a result, injuries to the talus sometimes are more difficult to heal than similar injuries in other bones.

Symptoms

OLTs usually occur after an injury to the ankle, either a single traumatic injury or as a result of repeated trauma. Common symptoms include prolonged pain, swelling, catching, and/or instability of the ankle joint. Symptoms can be vague. After an injury such as an ankle sprain, the initial pain and swelling should decrease with appropriate attention (rest, elevation). Persistent pain in spite of appropriate treatment after several months may raise concern for an OLT.

You may feel pain primarily at the lateral (outside) or medial (inside) point of the ankle joint. Severe locking or catching symptoms, where the ankle freezes up and will not bend, may indicate that there is a large osteochondral lesion or even a loose piece of cartilage or free bone within the joint.

Causes

The majority of OLTs, as many as 85%, occur after a traumatic injury to the ankle joint. Ankle sprains are a common cause of OLTs. With this type of injury, a section of the talus surface may impact another part of the ankle joint (tibia or fibula) and injure the talus. Some patients, however, have no history of an injury to their ankle.

Diagnosis

Foot and ankle orthopedic surgeons diagnose OLTs with a combination of clinical and special studies. Your surgeon may have a suspicion that you have this type of injury from the history you provide and their physical examination. Imaging is necessary to confirm the diagnosis. Occasionally, regular X-rays can show an OLT but frequently additional imaging is needed, such as a CT scan or an MRI.

Treatments

Once the diagnosis has been confirmed, treatment may be surgical or non-surgical, depending on the nature of the OLT, presence of other injuries, and patient characteristics.

Non-surgical Treatment

Non-surgical treatment is appropriate for certain lesions and usually involves immobilization and restricted weightbearing. This may be followed with gradual progression of weightbearing and physical therapy. The goal of non-surgical treatment is to allow the injured cartilage and bone to heal. Patients may have an OLT that is present and doesn’t cause pain or limitations or a lesion that becomes painful but improves. In these cases, no additional treatment is necessary. It was once believed that all OLTs progress and worsen with time. This has been shown to no longer be true.

Surgical Treatment

Other lesions may be more appropriately treated with surgery. The goals of surgery are to restore the normal shape and gliding surface of the talus in order to re-establish normal mechanics and joint forces. The hope is to minimize symptoms and limit the risk of developing arthritis.

Depending on the characteristics and location of the OLT, surgery may done arthroscopically or by opening the skin. Arthroscopy uses a camera and small instruments to view and work within the joint through small incisions. It may not be possible to properly treat certain lesions arthroscopically due to the size or location of the lesion. Treatments may include debridement (removing injured cartilage and bone), fixation of the injured fragment, microfracture or drilling of the lesion, bone grafting the bone cyst below the cartilage, and/or transfer or grafting of bone and cartilage. You and your foot and ankle orthopedic surgeon can discuss these treatment options and decide which one is best. Often, there may be several treatment options.

If you have any underlying conditions that may predispose to an OLT such as ankle instability, ankle impingement, a high arched (cavovarus) foot, or tight calf muscles, it may be necessary to correct these problems at the time of surgery as well.

Recovery

Recovery after OLT treatment varies depending upon the nature of the lesion and the treatment. Most treatments require a period of immobilization and restricted weightbearing that can range from several weeks to several months. More involved procedures that include bone grafting or cartilage transfer may require a longer period of recovery.

The results of non-surgical treatment of OLTs have been disappointing. Most studies show that full resolution of the pain from an OLT occurs in less than half of cases. Studies examining the outcomes after surgical debridement and microfracture (drilling) of OLTs have shown that more than 70% of patients have a good or excellent outcome. Procedures that transfer bone or cartilage to an OLT also have good outcomes. In general, the best results can be expected for smaller lesions.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications, such as infection or wound healing problems, are uncommon after arthroscopic ankle surgery. More complex procedures with an open surgical approach or bone or cartilage transfer may have additional risks. In addition to standard surgical risks, additional complications may include the failure of any transplanted tissue (bone or cartilage). Despite surgery going as well as possible, there is still a chance the pain will persist requiring additional treatment in the future.