Ankle

• Overuse or Intense Physical Activity: Engaging in activities that involve repetitive or excessive strain on the Achilles tendon, such as running, jumping, or sudden increases in physical activity, can lead to tendonitis.
• Tight or Weak Calf Muscles: Imbalances in the calf muscles, including tightness or weakness, can contribute to increased stress on the Achilles tendon.
• Improper Footwear: Wearing shoes with inadequate support or that don’t properly fit can contribute to the development of Achilles tendonitis.
• Poor Biomechanics: Abnormalities in foot structure or walking/running gait can place additional stress on the Achilles tendon.

The symptoms of Achilles tendonitis may include:

• Pain and Stiffness: Pain and stiffness along the Achilles tendon, especially in the morning or after periods of inactivity.
• Swelling: Swelling or thickening of the tendon.
• Tenderness: Tenderness or pain when touching the Achilles tendon.
• Difficulty Walking or Climbing Stairs: Increased discomfort during activities that involve pushing off with the foot, such as walking, running, or climbing stairs.

Treatment typically involves a combination of rest, ice, compression, and elevation (R.I.C.E.), along with the following measures:

• Rest: Avoid activities that exacerbate the symptoms and give the tendon time to heal.
• Ice: Apply ice to the affected area to reduce inflammation and alleviate pain.
• Compression: Use compression bandages or wraps to support the injured tendon and reduce swelling.
• Elevation: Elevate the affected leg to further reduce swelling.
• Physical Therapy: Specific exercises and stretches (particularly eccentric strengthening) can help improve flexibility, strengthen the calf muscles, and promote healing.
• Platelet Rich Plasma (PRP) injections: PRP injections have been shown to be an effective treatment for Achilles tendonitis, particularly in cases which have failed to respond to the above measures.

In more severe cases, a healthcare professional may recommend surgical management, but this is a last resort when all else has failed. 

It’s crucial to consult with a healthcare provider for an accurate diagnosis and appropriate treatment plan tailored to individual circumstances. Early intervention and proper care can contribute to a faster and more complete recovery.

 

• Achilles Tendon Rupture: One of the most common reasons for Achilles tendon repair is a rupture. This typically occurs when there is a sudden and forceful contraction of the calf muscles, often during activities like running or jumping. This can lead to a tear or complete rupture of the Achilles tendon, causing pain, swelling, and difficulty walking.
• Tendonitis: Chronic inflammation of the Achilles tendon, known as Achilles tendonitis, can result from overuse, improper footwear, or other factors. If conservative treatments like rest, ice, and physical therapy do not alleviate the condition, surgery might be considered to repair any damaged or degenerated tissue.
• Degenerative Changes: Over time, the Achilles tendon can undergo degenerative changes, especially in older individuals. This can lead to a weakening of the tendon, making it more susceptible to injury. Surgical intervention may be recommended to address degenerative issues and reinforce the tendon.
• Chronic Tendinopathy: Some individuals may experience chronic Achilles tendinopathy, characterized by persistent pain, swelling, and dysfunction of the tendon. If conservative treatments fail to provide relief, surgical repair may be considered to address the underlying issues within the tendon.
• Infection or Trauma: In rare cases, severe trauma or infection affecting the Achilles tendon may require surgical intervention. This could involve repairing damaged tissue, removing infected areas, or addressing other complications to restore the tendon’s function.

Achilles tendon repair surgery typically involves reattaching the torn or damaged portions of the tendon, and the specific procedure may vary depending on the extent and nature of the injury. Rehabilitation and physical therapy are crucial components of the recovery process to regain strength, flexibility, and function in the affected leg.

Dr. Neary performs the majority of Achilles tendon repairs in a minimally invasive fashion. By taking a minimally invasive approach, this allows preservation of the biology and blood flow to the tendon. This results in decreased scarring, faster healing, and improved sliding and gliding of the tendon long term.

Types of minimally invasive Achilles repair:

Ankle Instability/Ligament Reconstruction 

The lateral ankle ligaments include both ATFL and CFL that stabilize the outside of the ankle :

Ankle instability refers to a condition in which the ligaments and structures that support the ankle joint are weakened or damaged, leading to a decreased ability to maintain stability during weight-bearing activities. It often results from a previous ankle sprain or repeated injuries to the ankle ligaments. There are two main types of ankle instability:

Functional Ankle Instability:

• Cause: Functional instability is often the result of repeated ankle sprains that cause damage to the ligaments and lead to a loss of proprioception (the sense of joint position).
• Symptoms: Individuals with functional ankle instability may experience a feeling of “giving way” or instability in the ankle, especially during activities that involve changes in direction or uneven surfaces. Swelling, pain, and a sense of joint laxity may also be present.

Mechanical Ankle Instability:

• Cause: Mechanical instability is typically associated with anatomical changes in the structures supporting the ankle, such as stretched or torn ligaments. It may result from a single severe ankle sprain or repeated injuries over time.
• Symptoms: Mechanical instability is characterized by persistent feelings of looseness or instability in the ankle joint, regardless of the activity. Pain and swelling may be present, and the ankle may be prone to giving way during weight-bearing tasks.

Common Causes and Risk Factors:

• Ankle Sprains: The most common cause of ankle instability is a previous ankle sprain, especially if the initial injury was not adequately treated or rehabilitated.
• Inadequate Rehabilitation: Failing to undergo proper rehabilitation following an ankle sprain can contribute to muscle weakness and reduced proprioception, increasing the risk of instability.
• Genetics: Some individuals may be predisposed to ligament laxity, making them more susceptible to ankle instability.
• Improper Footwear or Biomechanics: Wearing inappropriate footwear or having biomechanical issues with the feet, such as overpronation, can contribute to ankle instability.

Treatment Options:

• Physical Therapy: Strengthening exercises, balance training, and proprioceptive exercises can help improve stability and reduce the risk of future sprains.
• Bracing or Taping: Supportive braces or taping techniques may be used to provide additional stability to the ankle joint during activities.
• Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to manage pain and inflammation.
• Surgery: In severe cases where conservative measures are not effective, surgical intervention may be considered to repair or reconstruct damaged ligaments.

When it comes to surgery, fixing ankle instability is crucial for several reasons, as instability in the ankle joint can lead to various issues that affect mobility, function, and overall quality of life. Here are some key reasons why addressing ankle instability is important:

• Prevention of Further Injury: An unstable ankle is more susceptible to repeated sprains and injuries. Chronic ankle instability increases the risk of rolling or twisting the ankle, which can result in additional ligament damage, fractures, or other injuries. Addressing instability helps prevent these recurrent injuries.
• Improved Function and Mobility: An unstable ankle can significantly impact daily activities, including walking, running, and even simple movements. Restoring stability through proper treatment and rehabilitation can enhance overall ankle function and mobility, allowing individuals to engage in activities without the fear of instability-related problems.
• Reduced Pain and Discomfort: Ankle instability often leads to pain, discomfort, and swelling. Addressing the underlying causes, such as ligament damage or muscle weakness, can help alleviate these symptoms and improve the overall comfort of the affected individual.
• Prevention of Joint Degeneration: Chronic ankle instability can contribute to joint degeneration over time. Instability alters the biomechanics of the ankle joint, leading to increased stress on surrounding tissues and potentially causing long-term damage. Addressing instability helps maintain joint health and reduces the risk of degenerative conditions like arthritis.
• Enhanced Balance and Proprioception: Ankle instability can compromise balance and proprioception—the body’s ability to sense its position in space. Restoring stability through rehabilitation exercises and other interventions improves balance and proprioception, reducing the risk of falls and related injuries.
• Improved Quality of Life: Persistent ankle instability can have a significant impact on an individual’s quality of life. It may limit participation in sports, recreational activities, and even daily tasks. Addressing instability allows individuals to lead more active and fulfilling lives without the constraints imposed by an unstable ankle.
• Optimal Joint Function: Ankle stability is essential for maintaining optimal joint function. When the ligaments and muscles around the ankle work together harmoniously, the joint functions properly, providing support and facilitating smooth movement.

Dr. Neary approaches ankle ligament repair with the goal of achieving long term stability and minimizing the risk of recurrent instability down the road. The majority of ligament reconstructions are augmented with a device called the Arthrex InternalBrace. The InternalBrace is essentially a seatbelt for the ligament and provides a hard stop to stretching of the ligament down the road. This provides additional stability to the ligament repair, allows accelerated recovery, and significantly decreases recurrent instability down the road.

Ankle Sprains 

An ankle sprain is a common injury that occurs when the ligaments that support the ankle joint are stretched or torn, usually due to a sudden twist, turn, or roll of the foot. Ligaments are tough, fibrous bands that connect bones to one another, providing stability to the joints. Ankle sprains can range from mild to severe, depending on the extent of ligament damage. Here’s a breakdown of ankle sprains:

1. Grade I (Mild) Ankle Sprain:

• Description: In a mild sprain, ligaments are stretched but not torn.
• Symptoms:
  • Mild pain
  • Minimal swelling
  • Slight difficulty bearing weight
• Recovery: Typically, individuals recover within a few days to a couple of weeks with rest, ice, compression, and elevation (R.I.C.E), and sometimes the use of a brace or compression bandage.

2. Grade II (Moderate) Ankle Sprain:

• Description: This involves a partial tear of the ligament.
• Symptoms:
  • Moderate pain
  • Swelling
  • Bruising
  • Difficulty bearing weight and walking
• Recovery: Healing time is longer than with a mild sprain, often taking several weeks. Treatment may involve a combination of R.I.C.E, physical therapy, and bracing.

3. Grade III (Severe) Ankle Sprain:

• Description: This is a complete tear or rupture of the ligament.
• Symptoms:
  • Severe pain
  • Significant swelling
  • Extensive bruising
  • An inability to bear weight or walk
• Recovery: A severe sprain may require several weeks to months for complete healing. Treatment may involve immobilization with a cast or walking boot, followed by physical therapy. In some cases, surgical intervention may be necessary to repair the torn ligament.

Common Causes of Ankle Sprains:

• Inversion Injury: Most ankle sprains occur when the foot rolls inward, causing the outer ligaments to stretch or tear.
• Awkward Landings: Jumping or landing on an uneven surface can lead to ankle sprains.
• Sports Injuries: Athletes, especially those involved in sports with quick changes in direction or high impact, are at an increased risk.
• Tripping or Falling: Accidental falls, slips, or missteps can result in ankle sprains.

Treatment:

• • Rest: Allow the injured ankle to rest and avoid putting weight on it.
  • Ice: Apply ice to reduce swelling and alleviate pain.
  • Compression: Use a compression bandage or brace to support the injured area.
  • Elevation: Elevate the ankle to help minimize swelling.
  • Medication: Over-the-counter pain relievers and anti-inflammatory medications may be recommended.

• Physical Therapy

• Brace wear

It’s essential to seek medical attention for a proper diagnosis and to determine the appropriate course of treatment based on the severity of the ankle sprain. Early and proper management can contribute to a faster and more complete recovery.

Ankle Arthritis 

Ankle arthritis is a condition characterized by inflammation and degeneration of the ankle joint, leading to pain, stiffness, and reduced mobility. The ankle joint consists of the tibia, fibula, and talus, and it allows for the up-and-down motion of the foot. Arthritis in the ankle can affect the smooth movement of the joint, causing discomfort and functional limitations. The two most common types of arthritis that can affect the ankle are osteoarthritis and rheumatoid arthritis.

1. Osteoarthritis (OA):

• Cause: Osteoarthritis is typically associated with the wear and tear of the joint over time. It occurs when the protective cartilage that covers the ends of the bones in the ankle gradually wears away, leading to bone-on-bone contact.
• Symptoms:
  • Pain, particularly during weight-bearing activities
  • Stiffness and limited range of motion
  • Swelling and tenderness around the joint
  • Gradual onset of symptoms
• Treatment: Conservative treatments include pain management, anti-inflammatory medications, physical therapy, steroid injections, and lifestyle modifications. In advanced cases, surgical options such as ankle fusion or ankle replacement may be considered.

2. Rheumatoid Arthritis (RA):

• Cause: Rheumatoid arthritis is an autoimmune disorder where the immune system attacks the synovium, the lining of the joint. This leads to inflammation, cartilage damage, and, ultimately, joint destruction.
• Symptoms:
  • Joint pain, swelling, and warmth
  • Morning stiffness that lasts for more than an hour
  • Fatigue, fever, and general malaise
  • Symmetrical involvement of joints
• Treatment: Management involves disease-modifying antirheumatic drugs (DMARDs), anti-inflammatory medications, steroid injections, and sometimes biologic agents. Joint-preserving surgeries or joint replacement may be considered in severe cases.

Other Forms of Arthritis:

• Post-Traumatic Arthritis: This can develop after a significant ankle injury, such as a fracture or severe sprain, leading to damage to the joint surfaces.
• Inflammatory Arthritis: Autoimmune conditions such as lupus, psoriatic arthritis, or ankylosing spondylitis can also affect the ankle joint.

Diagnosis and Management:

• Clinical Evaluation: A healthcare professional will assess symptoms, medical history, and perform a physical examination.
• Imaging Studies: X-rays, CT scans, or MRI may be used to visualize joint damage.
• Treatment Options: Depending on the severity and type of arthritis, treatment may include medications, physical therapy, joint injections, and, in some cases, surgical interventions like arthroscopy, ankle fusion, or total ankle replacement.

Early diagnosis and appropriate management are crucial for minimizing pain and preserving joint function in individuals with ankle arthritis. Dr. Neary can provide tailored recommendations based on the specific type and severity of the arthritis.

Ankle Replacement 

Total ankle replacement, also known as total ankle arthroplasty, is a surgical procedure designed to treat end-stage ankle arthritis or severe ankle joint dysfunction. The procedure involves removing the damaged surfaces of the ankle joint and replacing them with artificial components. Total ankle replacement aims to alleviate pain, restore function, and improve mobility in individuals with debilitating ankle conditions. Here are key aspects of total ankle replacement:

Indications for Total Ankle Replacement:

• Osteoarthritis: Advanced degenerative changes in the ankle joint due to osteoarthritis.
• Rheumatoid Arthritis: Inflammatory arthritis affecting the ankle joint.
• Post-Traumatic Arthritis: Arthritis that develops after severe ankle fractures or other traumatic injuries.
• Failed Ankle Fusion: In cases where previous attempts at ankle fusion (arthrodesis) have not been successful or have led to complications.

Components of Total Ankle Replacement:

• Tibial Component: The part that replaces the top of the tibia (shinbone).
• Talar Component: The part that replaces the surface of the talus (anklebone).
• Polyethylene Insert: A plastic component placed between the tibial and talar components, providing a smooth, low-friction surface for joint movement.

Recovery and Rehabilitation:

• Postoperative Care: Patients typically can discharge home the same day of surgery, but occasionally will require an overnight stay in the hospital.
• Immobilization: Initially, the ankle may be immobilized with a splint or cast. After the first postop appointment, patients are transitioned to a boot. 
• Physical Therapy: Rehabilitation plays a crucial role in the recovery process, focusing on restoring strength, flexibility, and proper gait. Formal PT starts after 6 weeks, but range of motion exercises are started after the first postop visit. 
• Weight-Bearing Progression: Most patients are nonweightbearing for the first 6 weeks. 6 weeks after surgery, full weightbearing is allowed and physical therapy will be prescribed. 

Success and Long-Term Outcomes:

Total ankle replacement has evolved over the years, and modern (more recent) implants have shown significantly improved outcomes compared to earlier versions. Success rates and patient satisfaction have increased, especially in cases where the procedure is performed on appropriate candidates with realistic expectations.

However, not everyone is a suitable candidate for total ankle replacement, and the decision for surgery should be made in consultation with Dr. Neary. Factors such as age, activity level, ankle alignment, and overall health are considered when determining the appropriateness of this procedure for an individual. 

Dr. Neary utilizes patient specific guides and instrumentation to perform ankle replacement. Patient-specific ankle replacement involves the use of custom-designed implants tailored to the individual patient’s anatomy. This approach aims to optimize the fit and alignment of the artificial components, improving the overall success and longevity of the ankle replacement. Here’s an overview of the process:

Preoperative Planning:

• Imaging: High-resolution imaging techniques, such as CT scans or MRI, are used to create detailed three-dimensional images of the patient’s ankle joint.
• Digital Reconstruction: Computer-aided design (CAD) software is employed to digitally reconstruct the patient’s anatomy based on the imaging data. This allows for precise visualization and analysis of the joint structure.
• Custom Implant Design: Using the digital model, custom implants are designed to closely match the patient’s unique anatomy. This includes the tibial and talar components, as well as any necessary additional features to address specific deformities or irregularities.

Surgical Procedure:

• Implant Fabrication: The custom-designed implants are manufactured using advanced manufacturing techniques, such as 3D printing or computer numerical control (CNC) machining. The materials used for the implants are typically metal alloys or medical-grade polymers.
• Surgical Planning: Dr. Neary uses the digital model and custom implants to plan the surgical procedure in advance. This includes determining the optimal placement of the components and addressing any specific challenges presented by the patient’s anatomy.
• Custom Guides: Patient-specific surgical guides are often created to assist Dr. Neary during the procedure. These guides are designed to fit precisely onto the patient’s bones, providing guidance for accurate implant placement.
• Surgical Implantation: During the surgery, the custom implants and guides are used to replace the damaged portions of the ankle joint. Dr. Neary follows the preoperative plan, guided by the patient-specific tools and implants.

Benefits of Patient-Specific Ankle Replacement:

• Improved Fit: Custom-designed implants aim to closely match the patient’s anatomy, reducing the risk of complications related to poor implant fit or alignment.
• Optimized Joint Function: The precise alignment achieved with patient-specific implants can contribute to improved joint function and biomechanics.
• Reduced Tissue Trauma: The use of custom guides allows for more precise and efficient surgery, potentially minimizing soft tissue damage during the procedure.
• Enhanced Surgical Accuracy: Patient-specific planning and guides can improve the accuracy of implant placement, which may lead to better outcomes and reduced risk of complications.
• Personalized Approach: Dr. Neary tailors the approach to the individual patient’s anatomy, addressing specific challenges or abnormalities that may not be adequately addressed with standard implants.

Dr. Neary uses the Stryker Total Ankle system for ankle replacement. The system utilizes Prophecy patient specific technology, and has implant options for both primary and revision total ankle replacements.

Ankle Fusion 

Ankle fusion, also known as ankle arthrodesis, is a surgical procedure that involves fusing the bones of the ankle joint. This procedure is typically considered for individuals with advanced arthritis or severe ankle joint dysfunction when conservative treatments have failed to provide relief. Ankle fusion aims to eliminate pain and stabilize the joint by creating a solid union between the tibia (shinbone) and the talus (ankle bone). Here are key aspects of ankle fusion:

Indications for Ankle Fusion:

• Advanced Arthritis: Severe osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis affecting the ankle joint.
• Failed Conservative Treatment: When non-surgical interventions, such as medications, physical therapy, steroid injections, and bracing, have not effectively managed symptoms.
• Joint Instability: Cases of significant ligamentous instability or joint deformity.
• Failed Total Ankle Replacement: In some instances where a previous total ankle replacement has failed or led to complications.

Recovery and Rehabilitation:

• Immobilization: Patients typically remain nonweightbearing for approximately 6 weeks, and immobilization involves the use of a cast, walking boot, or brace.
• Follow-up Imaging: X-rays or other imaging studies are conducted periodically to assess the progress of bone fusion.
• Gradual Weight-Bearing: Weight-bearing is usually gradually reintroduced as the bones fuse, starting at approximately 6 weeks after surgery.
• Physical Therapy: Rehabilitation exercises may be prescribed to restore strength and flexibility in the surrounding muscles and joints after the joint is fully healed (12 weeks postoperatively).

Benefits of Ankle Fusion:

• Pain Relief: Ankle fusion effectively eliminates pain associated with arthritis or joint instability.
• Joint Stability: Fusion creates a stable, immobile joint, reducing the risk of further damage.
• Improved Function: While ankle motion is sacrificed, many individuals find that they can adapt to altered walking mechanics and resume a relatively normal level of activity due to increased compensatory motion through the remainder of the hindfoot and midfoot joints. 
• Long-Term Durability: Ankle fusion is a durable solution, and once the bones have fused, the joint typically remains stable over the course of a lifetime. 

Considerations:

• Loss of Motion: Ankle fusion eliminates motion at the ankle joint, and patients may experience altered gait and limited range of motion.
• Adjacent Joint Stress: Increased stress on nearby joints, such as the subtalar joint or the joints of the foot, may occur over time.
• Non-Reversible: Ankle fusion is a non-reversible procedure. Once the fusion is complete, restoring normal joint motion is not possible.
• Patient Selection: The decision to undergo ankle fusion should be made after careful consideration of the patient’s overall health, lifestyle, and expectations. 

While ankle fusion may limit joint motion, it can provide effective pain relief and improved stability for individuals with severe ankle conditions. Advances in surgical techniques and rehabilitation protocols continue to enhance outcomes for those undergoing ankle fusion surgery.

 

Ankle Fractures (Broken Ankle) 

Treatment for ankle fractures depends on the severity of the break and may involve casting, splinting, or surgery to realign and fixate the broken bones. The goal is to heal the fracture, restore stability, and regain ankle function.

Ankle Arthroscopy 

Ankle arthroscopy is a minimally invasive surgery using a camera and small instruments to diagnose and treat problems inside the ankle joint. This procedure can address issues such as bone spurs, cartilage damage, and infections, offering a quicker recovery compared to open surgery.

Ankle Cartilage Preservation 

This involves surgical techniques aimed at repairing or regenerating damaged cartilage in the ankle. Techniques may include microfracture, autologous cartilage implantation, or osteochondral grafts, aiming to alleviate pain and improve joint function.

Peroneal Tendon Injuries 

Treatment for injuries to the peroneal tendons, which run along the outside of the ankle, can range from physical therapy and bracing to surgery. The goal is to relieve pain, repair any tendon damage, and restore normal ankle function.

Ankle Deformity Correction 

Surgical correction of ankle deformities aims to realign the bones, repair damaged joints, and improve function. This is crucial for patients with congenital, developmental, or post-traumatic deformities, enhancing stability and mobility while reducing discomfort.