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General Information

Foot Anatomy

The foot is a complex part of the body. It is not just at the end of our legs to stop them fraying! (Quote Nick Geary, Wirral Foot and ankle unit) If is healthy and pain free it allows us to stand Walk, run and jump. There are 26 bones in the foot, 33 joints and more than 100 muscles tendons and ligaments. Approximately one quarter of all the bones in the human body are in the human foot.

The structures of the foot change with age. The padding tissues become thinner and muscles loose their strength. Tendons and ligaments loose their elasticity and joints wear out and become degenerative. Injuries to the foot can cause serious problems and poorly fitting shoes can worsen many problems.

Problems with the foot can be treated in a number of ways from insoles, shoe modifications and sometimes surgery. If non-operative treatments are prescribed you will often be referred to the appliance department in the hospital to see an Orthotist who is an expert in assessing the suitability for treatments such as insoles and will often make them and then fit them.

If surgery is undertaken it is important to understand what the risks and benefits of surgery are and these will be explained to you during your consultation and during signing of a consent form.
Everyone has a different shaped foot but there are five main types of foot. The different shapes predispose to different conditions and pathology

1, Grecian (Morton’s) foot. The second and third metatarsals are relatively long in relation to the first and fifth. This can lead to increased pressure and pain under the longer metatarsals, which is called metatarsalgia. Approximately 22% of the population have this shape of foot.

2, Egyptian foot. Long first ray relative to the central metatarsals. This can predispose the first metatarsal phalangeal joint to become arthritic (Hallux rigidis). Approximately 69% of the population have this shape of foot.

3, Simian foot. Metatarsus primus varus, which means that the 1st metatarsal is deviated towards the opposite foot. This causes less weight to be taken through the 1st ray, as the joint at the base of the 1st metatarsal tends to be hypermobile. As a result more weight and force is transferred to the other metatarsals and this can result in pain. (Transfer metatarsalgia).

4, Peasant foot. The metatarsals are all of similar length resulting in a broad square foot. The foot is very stable making it an ideal platform for dancing. Approximately 9% of the population have this shape of foot.

5, Models foot. This foot is long and slender with an exaggerated cascade from the 1st to the 5th metatarsal.
(Ref Viladot A. Patologia del Antepie. Barcelona: Ediciones Toray, 1957.

Interesting Foot Facts

Foot facts

1, Bones; A third of all the bones in the body are in our feet. Each foot has 26 bones and 33 joints, 19 muscles, 10 tendons, and 107 ligaments.

2, During a lifetime the average person will walk more than 250,000 miles. That’s the same distance from the Earth to the moon. This is between 8000 and 10,000 steps a day. Each mile you walk your feet strike the ground a total of 1800 times.

3, Foot problems occur four times more often in women than in men.

4, 20% of people have a second toe that is the longest toe in the foot.

5, The average foot expands 5% in volume as the day goes on.

6, Runners hit the ground with a force two and a half times their body weight.

7, A two and a half inch high heeled shoe increases the load on the forefoot by 75%.

8, Toenails and fingernails grow fastest in hot weather, when pregnant and in teenage years.

9, Philosopher’s thoughts – The ancient Greek philosopher Socrates once claimed “When our feet hurt, we hurt all over”.

10, Achilles heel – The Achilles tendon located in the heel of the foot was named after one of the most famous mythical characters from Ovid’s ‘Illiad’. In an attempt to immortalize her son, Thetis (Achilles’ Mother) dipped Achilles into the River Styx, holding him by his ankle. Therefore his ankle became the only part of his body capable of sustaining a mortal wound. This is why he strongest tendon in the foot acquired the name of Achilles tendon.

11, Diabetes – 60 – 70% of diabetics have mild to severe forms of nerve damage in the feet impairing sensation in the feet.

12, Measuring feet – Shoe sizes in the UK are based on a measurement of barleycorns. This unit of measurement was devised by King Edward II in 1324. A grain of barley is a third of an inch. So each increase in shoe size adds a third of an inch to the length of the shoe. The average foot gets 2 sizes larger when you stand up. The ancient Romans were the first to have a distinct left and right shoe. Before this shoes could be worn on either foot. The largest feet in the world belong to a Mr Matthew McGrory who lives in America whose feet are a whopping size 28½ (US size). The 7ft4in resident of Florida, USA has to fork out a massive $22,745 for a pair of shoes to fit his unusually large feet.

13, Big feet – Can you tell the size of a mans manhood from the size of his feet? Well a study performed by nurses at St Mary’s Hospital and University College Hospital in London looked at this.

They measured the foot size and penis length of 104 men and found no link between the two. Previous studies which had shown a correlation relied on asking the male subjects for their penis length rather than performing a direct measurement !

14, Sex appeal – Research has shown that women with size 5 feet are more attractive to men ! Women who have size 5 feet include, Victoria Beckham, Sophia Loren. Half of men admit to looking at women’s feet on the first date and a third made a character judgement based on the state of them. Six out of ten women admit to trying to hide their feet because they were self conscious.

15, Animals feet – Animals can walk on the whole foot (Plantigrades) such as humans, bears, baboons, alligators and frogs. Or they can walk on their toes (Digitigrade) such as dogs, cats, birds and dinosaurs.
Butterflies taste with their feet, gannets incubate eggs with webbed feet and elephants use their feet to hear as they pick up vibrations through the soles of their feet.
The word pedigree is derived from the French phrase pied de gru “The foot of a crane” because the descent lines of family trees look like birds feet.

16, 100 feet – A centipede has never been found to have 100 feet. 96 feet is the closest. This is unusual because most species actually have an odd number of pairs of legs ranging from 15 and 191 pairs, or 30 and 382 legs.

17, Sweaty feet – Squirrels and dogs have sweaty feet. The sweat glands are between the footpads and paws and when they get hot or excited they leave wet tracks. They also use sweat left by their feet to mark territories. Each human foot produces a cup of sweat a day. During exercise this can be as much a pint of sweat. There are 250,000 sweat glands in the human feet.

You will usually have a general anaesthetic but may also have a popliteal local anaesthetic block to help with post op pain. (See general information on having surgery on the foot and ankle)

Often you will be able to mobilise weight bearing as tolerated but it is advisable to rest as much as possible in the first two weeks post op to keep the swelling down and to get the wounds fully healed with the minimum of complications.

Occasionally however if a lot of procedures have been done inside the ankle you may be asked to non-weight bear. You will usually be given crutches to help with your mobility. If you have a ligament repair or reconstruction you will usually be placed in a below knee plaster (POP) for 6 weeks and after this time you will be placed into a removable ankle brace and will commence physiotherapy.

Complications

The aim of surgery is to reduce pain, improve function and correct any deformity in the foot. Generally surgery is considered if the condition you suffer from fails to get better with the various non operative treatments on offer. So the indication for surgery is the failure to get better by any other means.

There are many potential complications of surgery and the exact incidence of these will depend on the individual operation being carried out. Your surgeon is highly trained and makes every effort to minimise these risks and complications. Any surgeon who however says he has a zero complication rate is either lying or not performing enough surgery.
General complications

Infection: Any operation has a risk of infection. If you are a smoker or if you are diabetic the risk increases. If you are having surgery where a metal implant is inserted into your foot such as a screw or joint replacement you will have antibiotics as prophylaxis whilst you are an in patient.

Most infections are superficial and can often be treated by dressing care and the use of antiseptics agents. Occasionally antibiotics are required and very rarely re-admission to hospital is required for more intensive treatment. In the current NHS infections such as MRSA (“The Superbug”) are constantly in the news. The elective surgical centres usually screen patients being admitted for MRSA and if you are positive you will be treated and your surgery may be postponed until you are free of the infection.

Wound problems: Whenever you have surgery you will always be left with a scar. Modern surgical techniques have improved the cosmetic appearance of surgical scars. Minimising swelling in the first few weeks after surgery is essential to prevent delayed wound healing and ways of reducing this are discussed elsewhere. Scars will take time to settle and may be red and raised for up to 18 months following surgery. Once the scar has faded to match the colour of the surrounding skin it has fully matured. At this time the swelling post surgery will be as good as its ever going to get.

Deep venous thrombosis (DVT) or blood clots and pulmonary embolism (PE): These two complications are rare following foot surgery but certain people are at increased risk. These include people with a previous history of a blood clot, smokers, people taking the oral contraceptive pill, and anyone who will be in a plaster cast (POT) or immobilised after the surgery. If anyone has these risk factors you may be started on an injection of heparin (Clexane or Fragmin) and this can either be self administered by the patient or be given by a district nurse as sometimes this will need to be continued for up to six weeks post op. If you are on clexane you will be asked to have a blood test one week after starting the clean / fragmin and this can often be done at the GP surgery. This is to make sure you don’t have a rare complication from the clean / fragmin called heparin induced thrombocytopenia (HIT).
Nerve damage: Nerves can be damaged during surgery or can be stretched or compressed by postoperative swelling. This may result in reduced sensation or absent sensation. Most of the time this will recover but it can take several months. If nerve is cut during an operation the cut end of the nerve may swell and can be very tender. This is known as a neuroma and if symptomatic this may require further surgical treatment.

Failure of the bone to unite (Non-union): This can occur whenever you have an operation to fuse a bone or joint or when we cut a bone and fix it in a different position (osteotomy). The risks increase if you have other medical conditions such as diabetes, or if you have poor circulation in your legs. If you are a smoker your risks of this complication are increased significantly. The reason for this is the nicotine in cigarettes causes the blood vessels in the foot to narrow, thus reducing the blood supply.

The best way to reduce this risk is to stop smoking. If you do stop you must not use nicotine patches to help you, as the nicotine released by these will have the same effect as smoking.

Smoking and Surgery

The effects of smoking on foot and ankle surgery
Smoking whilst recovering from foot and ankle surgery increases some of the complications of surgery. The carrying capacity of oxygen in the blood is lower in smokers and therefore less oxygen is available to the operative site. The nicotine in the cigarettes causes narrowing of the small blood vessels throughout the body and, at the operative site, further reducing the amount of oxygen reaching the operative site.

The foot is not as well supplied with blood vessels as some other parts of the body and is particularly sensitive to anything which may reduce the blood supply. A good blood supply to carry nutrients and oxygen to the operative wound is essential.

Any factor which reduces the blood supply will potentially compromise healing. The chemicals in cigarettes also have a direct toxic (poisonous) effect on the cells which are necessary for healing of the bones, soft tissues and wounds. For an osteotomy (breaking and realigning of bones), and fusion (removal of worn joint and permanent stiffening of the joint) to be successful bone cells must be able to produce bone which then leads to union (joining of the cut or prepared bone surfaces). These bone cells are affected by chemicals in cigarettes, in particular nicotine.

If the bones fail to heal, this is called a non union and further surgery may be required which is often more involved and potentially more complicated. Bones cells from elsewhere (Bone graft) may need to be used to help the local bones to heal and unite. This bone graft can be harvested from different parts of your skeleton (shin bone, heel bone or pelvis).

There have been reports of poor healing and infection resistant to treatment resulting ultimately in amputation of the leg. This is a rare occurrence but the risk is higher in patients who smoke.

To minimise complications of the surgery it would be advisable to reduce the amount you smoke or preferable to stop completely.
Please consult your general practitioner for help to stop smoking.

References:
Haverstock BD, Mandracchia VJ: Cigarette smoking and bone healing: implications in foot and ankle surgery. J Foot Ankle Surg. 1998 Jan-Feb;37(1):69-74;
Sherwin MA, Gastwirth CM: Detrimental effects of cigarette smoking on lower extremity wound healing. J Foot Surg. 1990 Jan-Feb;29(1):84-7.
Silverstein P: Smoking and wound healing. Am J Med. 1992 Jul 15;93(1A):22S-24S.
Sorensen LT, Karlsmark T, Gottrup F: Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003 Jul;238(1):1-5.
Kwiatkowski TC, Hanley EN Jr, Ramp WK: Cigarette smoking and its orthopedic consequences. Am J Orthop. 1996 Sep;25(9):590-7.
W-Dahl A, Toksvig-Larsen S: Cigarette smoking delays bone healing: a prospective study of 200 patients operated on by the hemicallotasis technique. Acta Orthop Scand. 2004 Jun;75(3):347-51.
Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine. 2000 Oct 15;25(20):2608-15.

Information About Having Surgery On Your Foot

1 What to expect when having an operation on your foot or ankle.
You will be consented for your operation at your clinic visit by your Consultant or a member of his team. You will then be attend a pre-op assessment clinic prior to your hospital admission where you will be asked questions regarding your general health, any previous hospital admissions, past illnesses, medications you are currently on and any allergies that you may have. Some additional tests may be required at this stage such as blood tests, x-rays, heart recordings (ECG). All of this is to ensure that you are fit for the proposed surgery so that any problems can be dealt with prior to your admission.

2 Day case admission
Patients who are having surgery as a day case will be admitted on the morning of their operation and will be discharged home on the same day. You will seen by the Consultant or a member of his team on the ward, and they will check that there have been no changes to your condition since you were last seen and will then mark the limb or limbs to be operated on with a skin marker pen. You will have opportunity at this point to clarify any questions you may have about your operation or postoperative treatment.

3 In-patient stay
Patients will be admitted the day of the operation and will seen by the Consultant or a member of his team whilst on the ward. They will check that there have been no changes to your condition since you were last seen and will then mark the limb or limbs to be operated on with a skin marker pen. You will have opportunity at this point to clarify any questions you may have about your operation or postoperative treatment.

4 Anaesthetics
LOCAL: Local anaesthetic means that you will be awake during your operation.
GENERAL: General anaesthetic means that you will be asleep during your operation. GENERAL and LOCAL BLOCK: Often in foot and ankle surgery we perform the surgery with a combination of a general anaesthetic and a local anaesthetic block.

The local anaesthetic block will usually be given once you are asleep and will be either be top of your thigh / buttock (Sciatic block), behind your knee (Popliteal block), or around your ankle (Ankle block).

The duration of the block will depend on which one is used. The aim of any block is to give you pain relief once you wake up from the general anaesthetic so that you are comfortable. Your leg or foot should feel numb when the block is working. Don’t worry this is a normal feeling. Once the block wares off you will require more conventional painkillers in either injection or tablet form. An ankle block lasts 12 hours on average and a popliteal block 24 hours. See information sheet on ankle block.

5 Postoperative recovery
You may be required to stay on bed rest for a few days until you are able to mobilise. The timing of this will depend on the sort of surgery you have had and we will usually be able to give you an idea of how long you will need to be on bed rest before you come into hospital. The reason for bed rest and elevation is to minimise the soft tissue swelling of the foot and ankle.

If your foot swells a lot it will put pressure on the wounds and may cause problems with the would healing so to minimise wound complications such as delayed wound healing and infection we advise elevation.

If you require a plaster cast (POT) as part of you post-operative treatment we often put you in a plaster back slab (A incomplete plaster) at the time of surgery and once the swelling has settled we will place you in a full plaster, and this is often done 2 weeks post op when you are seen in clinic for removal of the stitches.

Many operations don’t require a plaster cast and a postoperative shoe may be used. Most forefoot operations such as bunion surgery and lesser toe surgery will use this type of shoe. Examples of the postoperative shoes can be seen below.

Often if long-term immobilisation is required a walker boot will be used rather than a plaster cast. The boot currently being used is the Rebound® Air Walkermade by Ossur. A video showing how to apply the boot can be found here.

Once home it is important that you elevate you leg as much as possible. This is to minimise the swelling for the reasons outlined above.

If you are sitting down, you want to use a foot stool with some cushions so that you foot is at least at the same level as your waist. You don’t want you leg to be hanging down, as gravity will increase the swelling. As a general rule we say “TEA, TOILET, and TOAST” (Quote from Mike Hennessy, Wirral Foot and Ankle Unit).

This means that you can get up to make a cup of tea, go to the toilet and make a slice of toast. The rest of the time rest and elevate the limb. These rules are most important in the first 2 – 3 weeks after surgery.

After this stage the wounds should have healed and your stitches will be out and the complications of swelling are not as serious, it may just hurt more if it swells. At this point you should always sit when you can and elevate your leg but you can mobilise more. Generally it takes “ 3 months to be FAIR, 6 months to be GOOD and 12 months to be RIGHT.”

Going home
You will need to arrange for someone to drive you home and you should have someone at home with you for the first 24 hours.

6 Follow up after discharge
Most patients will be seen two weeks after the surgery for a wound review and removal of stitches. You will see the Consultant or a member of his team at this visit. After this clinic visit further follow-ups and the timing of these will depend on the type of surgery you have had.

If you have a plaster cast (POT) on your leg, this will be removed so that the stitches can be removed and then if required for a further length of time a new plaster cast (POT) will be applied.

7 Preparation for your operation
You will usually attend a pre assessment clinic before your operation. This will check that you are fit for the operation and if there are any investigations are required such as chest x-rays, heart tracing (ECG) they will be organised from this clinic. If more detailed investigations are required your date for surgery may have to be postponed until you are ready.

Occasionally you may have to be sent back to your GP especially if input is required from another specialist doctor such as a heart specialist. The aim of the pre assessment process is to make sure that your operation goes ahead under the safest of circumstances.

8 Medications
It is necessary to stop some medications prior to elective surgery and these are listed below. Otherwise all other medication should be continued but if you are unsure you should contact the hospital for clarification.
Oral contraceptive pill / Hormone replacement therapy (HRT). Stop 4 weeks before surgery.

Aspirin Stop 7 days before surgery
(Unless taking because of past history of heart disease in which case individual advice will be given). Clopidogrel Stop 7 days before surgery (Unless taking because of past history of heart disease in which case specific advice will be given.

Rheumatoid medication Most can be continued but the new “Biological” agents (Anti TNF drugs) will need to be stopped
2 – 4 weeks before surgery and restarted once the wounds have healed and the stitches are out.

Specific timing will depend on the drug and guidance will be given.
Warfarin Will need to stop before surgery but exact timings and details will be discussed
with you prior to your admission. This will depend on the reason you are on
warfarin.

9 Before you come into hospital you should
Have a bath or shower at home on the day of your admission.
Remove any make-up, nail varnish and jewellery. Rings and earrings that you prefer not to remove can usually be covered with sticky tape.

Follow the fasting instructions given in your admission letter. Typically you must not eat or drink for six hours before the operation. You can usually drink clear fluids up to two hours before surgery. This does not include anything with milk in. You are best sticking to water if you need a drink up to two hours before surgery. You should avoid any alcohol in the 24 hours before your admission.

Ankle Block

An ankle block is usually performed once you are asleep with the general anaesthetic. Local anaesthetic is injected around your ankle to stop the nerves that carry pain signals to the brain. The aim of the block is to help with your post operative pain relief in the first 24 – 48 hours after surgery.

This tends to be the most painful time period after your surgery. Typically it takes 15 – 30 minutes to work so in most cases the block will be working once you wake up from your anaesthetic.

Because the local anaesthetic blocks the pain signals it will also make your foot numb. The foot can be numb for between 5 – 15 hours (12 hours on average). The pain killing (analgesic) effect can however last for much longer, 6 – 30 hours.
If you are being treated as a day case you will be discharged home with an ankle block that is still working. (i.e Your foot is still numb).

It is essential that you only mobilise with the protective post op shoe in place otherwise you could damage your foot. Because you will not have normal feeling in your foot you may not be aware if you were to stand for example on a sharp object. Ideally you should rest until the sensation in your foot returns to normal. As soon as you start to feel the sensation return to normal you will require additional pain killers and you should take these regularly.

In the first 2 weeks after surgery you should elevate your foot as much as possible. You will have been told the phrase “Tea, toast and toilet”
If the feeling in your foot does not return to normal after three days you should contact the ward for advice.

Mr S W Sturdee
Consultant Orthopaedic and Trauma Surgeon
West Yorkshire Foot and Ankle Clinic