Since surgical bunion correction was first described, there have been more than 100 different procedures developed to treat the deformity commonly known as hallux valgus.

Two of the most utilized procedures, Lapidus-type fusion and minimally invasive bunion surgery, have taken center stage in recent years due to advances in surgeon skill and technology, which have allowed physicians to treat the entire 3D plane of hallux valgus deformity.

But surgical bunion correction still has a long way to go, according to Dr. Ellis. 

“Bunion surgeries have been going on for years, and the fact that there are so many means there is not a perfect solution,” Dr. Ellis, said. “Most bunion corrections are good, but not perfect in terms of achieving and maintaining correction and patients being happy with the surgery.”

Read the full article at healio.com. 

“Because of the way the bunion correction is performed with MISB, there is a thought that it may not help stabilize the foot in the same way that the more extensive, open procedures performed at the midfoot do,” said study senior author Anne Holland Johnson, MD, a foot and ankle surgeon at HSS. “When someone has a flatfoot deformity, which is essentially a fallen arch, the idea is that fixing the bunion through this minimally invasive technique could make the flatfoot worse because we cut the bones closer to the toe. What we found is that it was quite the opposite—that fixing the bunion in a minimally invasive way caused no changes in the overall flatfoot dimensions.”

“Bunion” is an umbrella term describing a variety of painful deformities at the base of the big toe. In the most common type of bunion, called hallux valgus, the big toe turns inward from its normal position and angles toward the second toe. Hallux valgus often presents with secondary structural deformities such as flatfoot, which can be symptomatic or asymptomatic (causing no symptoms).

All techniques for treating bunions involve cutting the bones and repositioning them with metal screws. The minimally invasive chevron and akin bunionectomy (MISB) fixes the bunion by cutting the bones through tiny incisions in the skin. “The advantages of doing the surgery through small incisions include minimal to no pain after the surgery; immediate weight bearing, so you can walk normally on the foot; and faster return to day-to-day activities and sports,” said Dr. Johnson.

The researchers conducted a retrospective study using a patient registry at HSS. In the registry, they identified patients who were over 18 years of age and were diagnosed with a bunion deformity between 2016 and 2021. Of this cohort, patients were included in the study if they underwent a MISB procedure to correct a hallux valgus deformity; reported their outcomes for at least one year and up to two years, as recorded by a patient-reported outcomes tool known as PROMIS; and had x-rays before and three months after surgery, at minimum. Using preoperative x-rays, the team identified individuals who had evidence of flatfoot; using a chart review, they also identified those with an asymptomatic flatfoot. These reviews yielded a study group of 35 patients with asymptomatic flatfoot and 47 patients without flatfoot.

“We collected PROMIS surveys on all our patients. These are a series of questionnaires that have been validated for use in foot and ankle research and ask the patient about their function, pain, and mental health,” said Rami Mizher, lead author of the study and a research assistant in the Department of Foot and Ankle Surgery at HSS. The researchers found that MISB resulted in similar improvements in the two groups in physical function, pain interference (how often the pain interferes with daily life), pain intensity, and global physical health (overall patient health), as measured by the PROMIS survey. There were no significant preoperative to postoperative changes in PROMIS global mental health and depression measures in either group.

A chart review showed there was no difference in complications in the two study groups.

The researchers also examined pre- and post-operative x-rays to clinically assess how well the surgery corrected the bunion deformity and if it changed any of the flatfoot-related measurements. In both groups, there was a similar correction of the bunion deformity. In terms of the flatfoot outcomes, the researchers looked at three different parameters: calcaneal pitch, or the height of the foot arch; Meary’s angle, which measures how much a foot sags; and talonavicular coverage angle, which measures how much the foot turns outward. The first two measures didn’t have any significant changes, while the talonavicular coverage angle improved in the flatfoot group.

“Our research shows that you can fix the bunion with this comparatively easier procedure and not make the flatfoot worse,” said Dr. Johnson. “It proves that minimally invasive bunion correction is a viable option for patients with flatfoot.”

 Authors: Rami Mizher, BS; Lavan Rajan, BA; Jaeyoung Kim, MD; Syian Srikumar, BS; Elizabeth Cody, MD; Anne Holland Johnson, MD; Scott Ellis, MD (HSS)

Kaler, who is from Long Island, says the surgery changed her life. She can now engage in activities most people take for granted – walking normally without pain, wearing shoes she likes, being able to do her job, working in her backyard.

“You have no idea how grateful I am. Before the surgery, my left ankle was collapsing, it could barely support my weight,” says Kaler, a slim 5 foot 7. “All my shoes were worn out on one side.” Her ankle was so unstable, she lived in fear that she would fall or break it, despite the rigid plastic brace she wore from her foot to her knee, day in and day out. She could only wear one type of shoe that she needed to replace every three months.

As a child, Kaler recalls constantly twisting her ankle. Her parents took her to several doctors, and she was given a shoe insert to help with her high foot arches. Years later, arthritis set in, and the pain worsened and became more debilitating. Cortisone shots could only do so much, and she resumed the search for a long-lasting solution. Four doctors said nothing could be done. One orthopedic surgeon said the problem might be corrected with four separate surgeries, which she declined.

Then she learned about total ankle replacement during an appointment with a doctor at HSS Long Island. It’s a complex surgery performed by relatively few orthopedic surgeons, and she was referred to Dr. Demetracopoulos, director of the HSS Total Ankle Replacement Center at the main hospital in Manhattan.

“One of the few centers of its kind, we have a team of foot and ankle specialists, anesthesiologists, radiologists, nurses and physical therapists who have extensive experience in ankle replacement,” he explains. “We strive to provide the best possible care for each of our patients and have grown our volume to become one of the top institutions nationwide in ankle replacement.”

Kaler says her consultation with Dr. Demetracopoulos gave her hope, and she would not be disappointed. She had the surgery in April 2021. “He saved my life. I never cry, but I cried in front of him, I was so grateful,” she says.  

“Ankle replacement is considered when patients are no longer able to manage arthritis pain with nonsurgical treatments such as physical therapy, appropriate footwear, an ankle brace or anti-inflammatory medication,” Dr. Demetracopoulos explains. “They have consistent pain that limits their activities and affects their quality of life.”

Like other types of joint replacements, the surgery involves replacing the damaged bone and cartilage in the ankle with a prosthesis. The implant, made of metal and plastic, has the shape of a natural joint and seeks to provide normal, pain-free movement.

The last 15 years have brought vast improvements in ankle replacement implants, technology and surgical techniques, making it a viable option for many patients suffering from severe arthritis, says Scott Ellis, MD, another orthopedic surgeon specializing in foot and ankle surgery at HSS.

One of the most noteworthy advances in ankle replacement is patient-specific instrumentation, or PSI, Dr. Ellis says. It entails obtaining a CT scan of the patient’s ankle and developing a customized presurgical plan tailored to the individual’s anatomy. “PSI has been a game changer. It enables us to choose an implant that is the perfect size and map out a very precise surgery for optimal alignment and positioning,” he says. 

For people considering an ankle replacement, the first step is a thorough assessment of the ankle and the foot, and a discussion of patient goals and expectations. Imaging and other tests determine if a patient is a candidate. For someone whose ankle is very stiff with limited mobility or a severe deformity, a fusion of the ankle bones might be a better option and is also very successful in relieving pain, the HSS experts say. An ankle fusion would also be a better option for someone with weakened bones or osteoporosis. The benefit of ankle replacement over fusion is better movement after surgery.

Sometimes an ankle replacement needs to be combined with another procedure, as it was in Kaler’s case. “Hers was a complex surgery. She had a type of foot that predisposed her to ankle instability,” Dr. Demetracopoulos explained. “In addition to treating her arthritis with the ankle replacement, we needed to treat the instability by repairing the ligaments in her ankle and by correcting the alignment in her foot, so it was in the right position.” 

Kaler says she experienced no pain after surgery, which Dr. Demetracopoulos attributes to advances in nerve block anesthesia and pain management protocols after the procedure. He notes that each patient experiences pain differently, though.  

The HSS doctors expect 90 percent of ankle replacements to last 10 years. If the implant wears out, patients could be candidates for a revision ankle replacement or an ankle fusion. The physicians follow and monitor patients in a joint replacement registry at HSS. “One of our core missions at HSS is not only to deliver the care and do the best surgery we can for our patients, but to collect data over time that we can share with other surgeons and clinicians,” Dr. Demetracopoulos says.  

Kaler says the surgery has enabled her to regain her confidence. She can now drive her stick-shift Mini Cooper and carry out her demanding job responsibilities at a major home improvement store. “I’m all over the place, to the point where my friends and colleagues are saying, ‘slow down,’” she adds, making up for lost time and living life to the fullest.

A new study by researchers at Hospital for Special Surgery (HSS) in New York City provides attainable goals for return to sports and related physical activities for patients who have undergone procedures to correct progressive collapsing foot deformity (PCFD), a severe musculoskeletal pathology that can drastically inhibit a patient’s daily function. The findings were presented today at the American Academy of Orthopaedic Surgeons (AAOS) 2022 Annual Meeting.

“This procedure is the epitome of big surgery,” said Scott J. Ellis, MD, an orthopaedic foot and ankle surgeon at HSS and the senior researcher on the study. “It is associated with a long recovery period, and patients are quite immobile even before they reach the operating room. As a result, even surgeons want to know: Is this going to be worth it?”

Dr. Ellis added, “PCFD is a debilitating condition marked by several progressive deformities that require a combination of extensive reconstructive procedures, from cutting and reshaping bones in the foot to rerouting tendons in the fallen arch. Although patients can expect to eventually resume at least light to moderate physical activity, the recovery period can take many months to a year or more, and some of the most vigorous sports may not be possible.”

This study is the first attempt to quantify the recovery period for individual activities. The HSS research team, led by clinical research scientist Robert Fuller, analyzed patient-reported data from 82 patients, aged 18 to 60 years, who had undergone reconstructive foot surgery at the hospital between February 2016 and May 2019. About three-fourths of the patients were women, and the average time since surgery was approximately 3 years (range, 2 to 5.4 years).

Patients were asked about their ability to return to 21 physical activities, such as yoga, biking, walking and running, as well as their overall level of function, pain and other outcomes using the HSS Orthopaedic Foot and Ankle Registry, a rich repository of data that helps clinicians and researchers better guide treatment decisions.  

According to the findings, patients said that half of the 21 activities had become easier for them to perform after surgery, while 33% experienced no difference and 17% said the activities had become more challenging. Improvements in physical function (P=0021), pain (P=0.001) and global physical health (P=0.001) were associated with statistically significant increases in patient satisfaction with respect to sports and physical activities.

No patients surveyed said they had stopped doing activities they had performed before surgery, but many said they had taken up new activities—mainly low-impact pursuits such as walking, biking and swimming. Overall, 74 of the 82 patients (90%) reported being somewhat to very satisfied with their ability to be active, while just eight (10%) said they were unsatisfied with the results of the surgery in that regard.

The most exciting part of the study, Fuller said, was that the researchers were able to collect enough data on individual physical activities that they can now advise patients not only on the types of activities they can expect to carry out, but also on the length of time they can expect to be off their feet after surgery.

“We think this study gives us the ability to say to a patient, ‘If you're interested in doing yoga again, you can expect to return in about six to nine months and be back to full form in about a year,’” Fuller said. “It can help provide clarity for a lot of people showing these surgeries can be life-changing in terms of getting them active again, but a substantial amount of people will face some extended recovery.” Indeed, the researchers found that 22% of patients said they never reached their maximum preoperative level of participation in physical activities, and 26% said the difficulties they experienced in performing activities had increased after surgery.

Not surprisingly, Fuller said, people who undergo foot reconstruction can resume low-impact activities—faster than those who practice more demanding sports such as dancing, jogging, skiing or basketball. However, “we observed great progress in both high- and low-impact activities,” he added.

Although the new research highlights the effectiveness of the reconstructive procedure, Fuller and Dr. Ellis said more work is needed to help standardize good outcomes for patients. At HSS, Dr. Ellis and his colleagues are using new technologies such as weight-bearing CT scanning to help identify which bones in the affected foot are collapsing and which ligaments are failing to better understand the anatomy of the deformities and optimize the surgical plan. They also are incorporating a computer modeling technique called finite element analysis to simulate how the foot will appear after the bones and other tissues are cut.

 “We plan to use the data from this study to provide patients with realistic expectations and timelines regarding their return to sports activities after collapsing flatfoot reconstruction, and as a resource for patients at the time when surgery is being discussed,” Dr. Ellis concluded.

The findings, published in the journal Foot and Ankle International and presented today at the American Academy of Orthopaedic Surgeons (AAOS) 2021 annual meeting, found that patients with the most severe impairment, both physical and, to a somewhat lesser degree, emotional, before reconstructive surgery reported the most gains after the procedure.

Adult-acquired flatfoot deformity, more recently known as progressive collapsing foot deformity (PCFD) or “fallen arches,” is relatively common with age. The condition, which affects at least 3% of women over age 40 and more than 10% of people over age 65, results from weakening, stretching or other alterations to the tendons and ligaments in the foot and can lead to severe pain and significantly restricted mobility. Women are more prone to the problem than men; and being overweight is considered an increased risk factor.

A mix of stretching, physical therapy and the use of orthotic devices may help people with milder cases. But for the more severe cases of PCFD, surgeons can operate to reshape and restore function to the affected extremity.

“Once the foot starts collapsing, it never uncollapses, and the worry is that over time the ligaments will continue to stretch, the foot will flatten, and the pain will increase,” said Scott J. Ellis, MD, a foot and ankle surgeon at HSS and senior author of the study. Although nonsurgical or conservative management appears to help prevent the progression of PCFD, Dr. Ellis noted that hasn’t been conclusively proven. “Roughly half of patients will need surgery. If the foot continues to hurt and limits quality of life and function, and there’s pain from walking, travel and other activities, then we say it’s time to perform surgery.”

Determining which patients stand to benefit most from foot reconstruction — and who would do better with more conservative management — has been unclear.

For the new study, Dr. Ellis and his colleagues sought to determine if instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) could help physicians predict which patients would experience the most improvement from foot surgery. PROMIS has multiple components, including scores for physical function, pain scale and depression, and is considered an objective measure of a patient’s physical and mental health specific to a given condition.

The HSS team, including Matt Conti, MD, a chief resident and the first author on the paper, identified 71 men and women (75 feet in total) who underwent surgery for PCFD between February 2016 and April 2018, and for whom PROMIS data were also available. The average follow-up time for the patients was roughly 27 months.

Patients with the lowest PROMIS scores for physical function (PROMIS-PF) before surgery — indicating the most severe impairment — were most likely to experience clinically meaningful improvements two years after the procedure, according to the researchers. Those with a PROMIS-PF score of 45.7 had roughly a 14% chance of improvement, while patients with a score below 40.9 had nearly a 98% chance of clinical gains.

Armed with the new information, surgeons now have a more objective way of informing patients of their chances of a successful operation. “When a patient walks in the door, you can get an idea of where they stand on that scale, and we know based on our study where patients need to land to achieve clinically meaningful improvements from the surgery,” Dr. Ellis said. “It could be a real-time decision with the patient and something they could follow over time to allow them to see the trajectory of their recovery and where they are heading.”

Every patient scheduled for surgery at HSS completes the PROMIS survey, and the results become part of the electronic medical record. As a result, HSS has built one of the nation’s most robust and detailed databases of patient-reported outcomes, enabling its physicians and researchers to optimize the care they provide. “A similar study could be conducted across a whole different host of conditions,” Dr. Ellis concluded.

“An in-depth understanding of what factors contribute to preoperative patient expectations is especially critical in foot and ankle surgeries, as there are a wide variety of surgeries in our subspecialty, each of which comes with different expectations,” said Scott J. Ellis, MD, a foot and ankle orthopedic surgeon at HSS and author of the study.

Patient expectations of orthopaedic procedures have been demonstrated to be strongly associated with clinical outcomes and postoperative satisfaction. While efforts to quantify the difference between patient and surgeon expectations have been undertaken in spine and total knee arthroplasty, among other subspecialties, few attempts have been made to measure this in foot and ankle surgery.

In reviewing the operative schedules of seven foot and ankle surgeons at HSS, Dr. Ellis and his colleagues hypothesized that patients would have greater expectations for their outcomes than their surgeons, that there would be greater differences in preoperative expectations between patients and surgeons in major versus minor foot or ankle surgery, and that greater differences between patient and surgeon expectations would be associated with worse preoperative physical and mental health.

“Although most surgeons do their best to engage in open conversations with their patients about what they can expect from surgery, many find it difficult to tell patients that they are not going to be as good as new postoperatively,” said Dr. Ellis. “It is challenging to get patients past the belief that surgeons have a magic wand.”

Working with researchers from Weill Cornell Medicine, the HSS team examined data from 202 patients, administering a 23-item survey that assessed expectations regarding pain, physical function, shoe wear, appearance, work, social activity and psychological factors. Surgeons were given the same survey and asked how much improvement they expected their patient to gain in those areas.

In addition, patients completed Patient-Rated Outcomes Measurement Information System (PROMIS) computer adaptive tests in Physical Function, Pain Interference, Pain Intensity, Depression and Global Health prior to their procedures.

“We determined that 66.3% of patients had higher expectations than their surgeons, 21.3% had concordant expectations, and 12.4% had lower expectations,” said Dr. Ellis. “In addition, the study showed that the majority of patients who had worse preoperative PROMIS scores had higher postoperative expectations. We also found that depressed and anxious individuals had greater expectations than their surgeons, as did patients with a higher body mass index.”

Going forward, said Dr. Ellis, future research should delve into other potential factors such as medical literacy and patients’ knowledge of their condition, as well as the bond between surgeon and patient. “Ideally, we could construct a study that could follow patients out to one or two years so as to determine amongst those whose expectations were met, how they were fulfilled. In the meantime, we suggest that a preoperative educational class for foot and ankle patients would go a long way towards a rapprochement between patients and surgeons when it comes to expectations.”

The group, led by Constantine Demetracopoulos, MD, foot and ankle surgeon at HSS, received the honor for their paper, "Influence of Tibial Component Position on Altered Kinematics Following Total Ankle Arthroplasty During Simulated Gait." The article describes experiments to determine how surgical replacement of the joint can affect patient mobility after the procedure.

The surgeon team consisted of Drs. Jonathan Deland, Scott Ellis, and Guilherme Saito, who performed the study in conjunction with Daniel Sturnick in the Biomechanics Department at HSS. The research team utilized a unique robotic gait simulator, which is able to reproduce normal walking gait using human cadavers. The simulator was developed through a generous donation by Herbert Black, owner and CEO of American Iron and Metal Company, under the leadership of Dr. Jonathan Deland, foot and ankle surgeon at HSS.

The findings from the study could help surgeons fine-tune their techniques during ankle replacement to reduce the risk that patients experience complications later on, said Dr. Demetracopoulos. It may also help companies that make artificial joints design implants that are more anatomically friendly and less prone to wear.

"For patients who have ankle arthritis and have an ankle replacement, how we do the replacement and how we position the replacement device is critical to matching the kinematics of normal gait and the success of the procedure," Dr. Demetracopoulos said.

Total ankle arthroscopy (TAA), or ankle replacement surgery, is an option for patients with severe arthritis of the joint. For the procedure, surgeons replace the patient’s diseased ankle with a prosthetic joint composed of metal and plastic. Although the procedure is becoming more common, it is much less so than knee or hip replacement procedures, which number in the hundreds of thousands per year each. As a result, relatively little is known about the best ways to perform the procedure, particularly when it comes to positioning the replacement parts in the bone, or how variations in surgical techniques may affect outcomes.

Ankle replacement surgery is thought to provide patients greater flexibility and motion in the joint than an alternative procedure, ankle fusion. However, despite the significant improvement in pain and mobility following ankle replacement, whether an ankle prosthesis can restore normal walking gait remains unclear. 

For the new study, Dr. Demetracopoulos and his colleagues sought to learn how placement of the ankle implants during TAA affects range of motion. To do so, they implanted artificial ankles (Salto Talaris, Integra LifeSciences) into eight leg sections obtained from cadavers. (The use of cadavers allowed the researchers to more accurately assess ankle motion before and after implant surgery, and also avoided having to expose living patients to excessive radiation from imaging tests.)

To monitor motion, Dr. Demetracopoulos’ group surgically grafted ligaments and tendons from the original joint to sensors. The legs were mounted on a robotic platform with computer software that tracked movement of the ankle in three dimensions: up/down bending of the ankle, side-to-side tilting, and rotation of the bones. "As you bend your ankle up and down, the bone is doing a little bit of all three: From the very top to the very bottom, it’s bending down, it’s tilting and it’s rotating. It doesn’t move like a hinge," Dr. Demetracopoulos explained.

Using the robotic platform to simulate a walking gait, the HSS team found that ankle motion appeared to be restored in two degrees of movement--up/down and side to side tilting. However, rotational motion was significantly greater than before the procedure.  

"We were able to show that the technique of how the replacement is positioned is what drives that rotation," Dr. Demetracopoulos said.

The HSS researchers say the asymmetrical design of the implant used in the study—one of the oldest devices to reach the market that is currently still in use— may play a role in their findings. Newer implant designs may be less prone to such rotational motion, and the group is in the process of trying to evaluate those devices.

"I want to help secure the future financial support for all the AOFAS programs that benefited me and my trainees so much in the past. I have been the recipient of several AOFAS research grants, did the AOFAS Traveling Fellowship Program, and have multiple residents that have participated in the Resident Scholarship Program. I also want to ensure that my friends and colleagues who have been able to participate in the Overseas Outreach Project to Vietnam can continue to do so, and potentially help at new sites including Haiti, Kenya, and China," said Dr. Ellis in a statement.

This article originally appeared at news-journal.com.

Additional Coverage:

• Becker's Spine Review: HSS surgeon named president of Orthopaedic Foot & Ankle Foundation: 3 things to know

Researchers from Hospital for Special Surgery (HSS) presented study findings today at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS) that were the first to compare the outcomes of reconstructions on older patients to those of a younger group.

The study evaluated patients over 65 with stage II AAFD to see if there are worse clinical outcomes or an increased number of subsequent surgical procedures following flatfoot reconstruction when compared to younger patients.

"Overall, flatfoot reconstruction provides better long-term outcomes and mobility of the foot when compared to foot fusions," said Scott J. Ellis, MD, foot and ankle surgeon at HSS and senior study author. "However, there is a chance that reconstruction could fail, and to avoid a long, arduous recovery with multiple surgeries, patients older than 65 commonly skip reconstruction and opt for a fusion."

"My colleagues and I wanted to investigate if this was still a viable option for elderly patients in the hopes of maintaining flexibility in their foot," Dr. Ellis added.

Over 130 HSS patients were assessed in three groups based on their age: less than 45 years old (young); 45 to 65 years old (middle-aged); and 65 years and older (old).               

This study measured clinical outcomes using the Foot and Ankle Outcome Score (FAOS) and compared preoperative and postoperative scores at a minimum of two years. Findings indicated that patients in the older group did not demonstrate any differences in their outcomes compared with patients in the young and middle-aged groups.

Additionally, older patients were not more likely to undergo a subsequent removal of hardware or revision procedures than patients in the younger cohorts.

"Our initial hypothesis was that there would be increased complications for patients in the older group. However, we saw positive, consistent surgical outcomes across all age groups," said Dr. Ellis. "Depending on the severity of the condition, we believe a flatfoot reconstruction is a great option for patients regardless of their age. For the right patient, it can be the last surgery that they need."

Dr. Ellis believes that older patients have not often been offered a flatfoot reconstruction by their surgeons since there has not been enough research to critically review surgical outcomes. The loss of mobility with a fusion is something patients need to consider and discuss with their surgeon along with their expectations.

"This is strong evidence to support that flatfoot reconstruction can be an option for everyone, but we need to continue to follow patient clinical outcomes over an extended period of time to provide more data for this sparsely investigated topic," Dr. Ellis stated.