Patient Information Guide to Bone Fractures, 
Bone Reconstruction and Bone Fusion:

                                  Foot and Ankle

A fracture means a broken bone. Whether you have a complete or a partial fracture, you have a broken bone. A bone may be completely fractured or partially fractured in any number of ways (cross-wise, lengthwise, in the middle).

• Trauma accounts for most fractures. For example, a fall, a motor vehicle accident or a tackle during a football game can all result in a fracture.

• Osteoporosis also can contribute to fractures. Osteoporosis is a bone disease that results in the "thinning" of the bone. The bones become fragile and easily broken.

Overuse sometimes results in stress fractures. These are common among athletes.

Particular types of fractures are:

3. Transverse fracture. The fracture is at right angles to the long axis of the bone.
4. Greenstick fracture. Fracture on one side of the bone, causing a bend on the other side of the bone.
5. Comminuted fracture. A fracture that results in three or more bone fragments.

         1.                             2.                            3.                          4.                             5.

As soon as a fracture occurs, the body acts to protect the injured area, forming a protective blood clot and callus or fibrous tissue. New "threads" of bone cells start to grow on both sides of the fracture line. These threads grow toward each other. The fracture is closed and the fibrous tissue is absorbed.

Doctors use casts, splints, internal fixation by means of pins, plates, screws or other devices to hold a fracture in the correct position while the bone is healing.

External fixation methods, include plaster and fiberglass casts, cast-braces, splints and other devices.

Internal fixation methods, hold the broken pieces of bone in proper position with metal or biodegradable (implants that are not permanently in the body as they dissolve) plates, pins, or screws while the bone is healing.

The Orthopaedic trauma area deals with a wide range of very serious types of bone fractures that need immediate care. The most common conditions include fractures of the long bones (such as in the arms and legs) and the smaller bones (such as in the feet and hands). It also includes fractures to the joints (such as ankles, wrists and elbow). Treatment of these injuries is mainly done using fixation devices, which may be either internal (inside) or external (outside).

Over the past several years it has become increasingly popular surgeons to use biodegradable pins, screws and plates to stabilize fractures due to the significant advantage that these implants provide. Biodegradable implants will dissolve (degrade) over time, leaving no implant in the patients body therefore no second surgery is needed to remove the implant after the fracture has healed. A second surgery to remove implants is commonly seen when the surgeon uses metal implants.

Medical implants that are biodegradable break down gradually by a series of natural processes in the body over a period of time. Biodegradable materials are also known as (bio)resorbable, and (bio)absorbable. These implants are metabolized by the body into carbon dioxide and water which is then exhaled and excreted.

Biodegradable implants have many advantages over metal implants as they:

Hold the bone firmly while it heals and then gradually disappear. This means the patient benefits from:

• No need for another operation to remove a metal implant, which lessens the risk to the patient of another surgery and in some, cases another anaesthetic.

• Reduced overall rehabilitation time, as patients’ often have to recommence physiotherapy or take special precautions after metal implants are removed

• Implants do not remain in the body long term so patients will not have to be concerned about feeling the implant through the skin or cold metal causing an ‘aching’ feeling in cold weather.

• Implants do not interfere with X-rays, scans or airport security checks as they are not made of metal.

• Do not interfere with movement like metal screws can in the ankle

•  Reduced risk of damage to the bone, surrounding soft tissue or joint surface as after a period of time no implant is left.

• No risk of metal allergies being caused by metal implants

 Inion OTPS™ Pin is designed to treat fractures, osteotomies (where the surgeon cuts to bone to reposition it) and arthrodesis (when the bone joints are fused together, such as in the case of arthritis)

Inion OTPS™ Ankle Fixation system is the only complete biodegradable system offering screws and plates for fractured ankles and syndesmosis (please refer to foot and ankle section of brochure for further information). These plates are not currently approved for use in the USA.

All Inion OTPS™ implants are based on Inion Optima™ polymer blends (more plastic like, not metal) and have excellent handling properties

Contraindications can be infection, limited blood supply, insufficient quality or quantity of bone, load bearing greater than indicated for the specific implant and when patient cooperation cannot be guaranteed (e.g. alcoholism, drug abuse).

Complications are similar to those encountered with any other method of internal fixation:

• Premature bending, loosening, fracture or migration of the devices may result from early stress, activity or load bearing.

• Premature discontinuation of the cast or other immobilization method may cause non-union or mal-union of the fracture or osteotomy.

• Infection can lead to failure of the procedure.

• Neurovascular injuries can occur due to surgical trauma.

• Implantation of foreign materials can result in an inflammatory response or allergic reaction. Transient local fluid accumulation may occur in sterile circumstances.

As with any surgical procedure, careful postoperative management is important for optimal healing. The surgeons will give you detailed instructions for postoperative care (e.g., regarding immobilization and hygiene maintenance).

Incorrect selection, placement, positioning, or fixation of the implant can cause subsequent undesirable results or breakage of implants or instruments. The surgeon should be familiar with the devices, the method of application and the surgical procedure prior to performing the surgery (please see the product-specific instructions for use). The Inion implants are not intended to replace healthy bone or withstand the stress of full load bearing. Always use appropriate additional immobilization (e.g., suitable cast, brace, crutches and/or rigid fixation implants) postoperatively during the healing period and provide the patient with detailed instructions for postoperative care (e.g., regarding immobilization and hygiene maintenance). The patient should be warned that the implants can break or loosen as a result of early stress, activity or load bearing. Premature discontinuation of the cast or other immobilization technique may cause non-union or mal-union of the fracture or osteotomy. 

The top ankle joint is composed of three bones:                                          

• the shinbone (tibia)

• the other bone of the lower leg (fibula)

• the ankle bone (talus)

Any one of the three bones that make up the ankle joint could break as the result of a fall, a car accident or some other trauma to the ankle for example while playing sport, skiing, dancing.

Because a severe sprain can often cover up the symptoms of a broken ankle, every injury to the ankle should be examined by a physician.

Symptoms of a broken ankle include:

•  Immediate and severe pain.

• Swelling.

• Bruising.

• Hurts to touch.

• Inability to put any weight on the injured foot.

• The ankle will not look its normal shape (deformity), particularly if there is a dislocation as well as a fracture

The diagnosis of a ankle fracture is made first by a hands-on examination given by your doctor and then if an ankle fracture is suspected, your doctor will ask you to have an x-ray to determine if the bone is broken. If a fracture is seen in one of the bones of the ankle a decision will be made to determine appropriate treatment for the injury.

 The following is a general overview of the possible treatment options, your doctor might recommend for you.

If the fracture is stable and without damage to the ligaments or the joint, it may   be treated with a leg cast or brace.

If the ligaments are also torn or if the bone pieces have moved out of place or if the fracture has created a loose piece of bone irritation to the joint is highly likely. Surgery will be required to put the pieces of bone back together and in the correct place so they will heal properly. The doctor will use metal or biodegradable plates and screws to do this as they will hold the bones correctly in place while they heal.

Afterwards, your doctor will prescribe a program of rehabilitation and strengthening. Range of motion exercises are important, but keeping weight off the ankle is just as important whilst the healing process is underway.

The Inion OTPS^TM Biodegradable Fixation System is used for bone fractures of the ankle and foot.

The syndesmosis refers to a wide sheet of a ligament that connects the fibula to the tibia. If this ligament tears then the ankle becomes extremely unstable. In a serious accident that causes serious injury to the ankle then either the syndesmosis ligament tears or the fibula bone fractures, or sometimes both may happen at the same time. Following trauma to the ankle, such as an ankle fracture, the syndesmotic joint can become unstable and painful. Surgery may be needed to stabilize the syndesmotic joint to allow the ligaments to properly heal.

The syndesmosis injury causes a very serious problem, as it is very difficult to walk on; the ankle is now “loose” or unstable. It is important that your doctor looks closely at the outer side (lateral side) of the ankle to see if it is unstable and in need of metal or biodegradable screw(s) to hold the fibula to the tibia and give the syndesmosis ligament a chance to heal.

The following is a general overview of the possible treatment options, your doctor might recommend for you.

The treatment of these serious syndesmosis injuries are determined by the amount of instability (loosening) of the ankle, the location of any fracture of the fibula, and the extent of  damage to the syndesmosis. In most patients, the syndesmosis must be stabilized with a screw or screws inserted from the fibula across the tibia. The healing of the syndesmosis therefore takes place “indirectly” as long as the space between the tibia and the fibula is stable.

If there is also a bone fracture a plate and/or screws may also be used to fix this.

Every doctors after surgery management of their patient can vary but generally no weight on the ankle is permitted for 4 -6 weeks following  repair of the syndesmosis, and rehabilitation with physical therapy and exercise begins at that time. It is important to avoid any twisting of the ankle for 6-8 weeks to avoid further loosening of the syndesmosis ligament tear, as well as allow sufficient time for the deltoid ligament to heal. If a metal screw is used, this will have to removed at 10 weeks to allow the normal motion of the ankle to be restored.

  Bunions are primarily a hereditary condition and normally get worse over the years. They begin with a leaning of the big toe, gradually changing the angle of the bones over the years and slowly producing the characteristic bump, which continues to become larger. Usually the symptoms of bunions appear at later stages, although some people never have symptoms.

A bunion occurs due to multiple factors, which result in a mal-alignment of the bones with the big toe drifting toward the second toe. You will more than likely see the bunion first before they become painful. 

Bunions are often described as a bump on the side of the big toe. But a bunion is more than that. The visible bump actually reflects changes in the bone structure of the front part of the foot. With a bunion, the big toe leans toward the second toe, rather than pointing straight ahead. This throws the bones out of alignment, producing the bunion's "bump."

A bunion is a bone problem.  It is not a skin problem or a cyst. As you walk more the symptoms become worse. Pain is often the result of rubbing of the enlarged bunion against the inner side of a shoe. There may be pain from within the actual bunion joint.  Pain can be present when the great toe presses against the second toe.

Bunions are most often caused by an inherited  faulty mechanical structure of the foot.  It is not the bunion itself that is inherited,
but certain foot types that make a person prone to developing a bunion

Symptoms occur most often when wearing shoes that crowd the toes—
shoes with a tight toe box or high heels. This may explain why women are more  likely to have symptoms than men. In addition, spending long periods of time  on your feet can aggravate the symptoms of bunions.

Symptoms, which occur on the bunion, may include:

• Pain or soreness

• Inflammation and redness

• A burning feeling

• Perhaps some numbness

• Calluses(thickening of skin) on the big toe, sores between the toes, ingrown toe nail, and restricted motion of the toe.

Although your doctor will be able to clearly see the bunion, to ensure that he or she fully evaluates your condition, an x-ray will be done to determine the degree of the deformity and assess the changes that have occurred.

 The following is a general overview of the possible treatment options, your doctor might recommend for you.

Early treatments are aimed at easing the pain of bunions. Sometimes observation of the bunion is all that's needed.

Non-surgical treatment:

• Changes in shoes. Wearing the right kind of shoes is very important.

• Padding. Pads placed over the area of the bunion can help minimize pain. You can get bunion pads from your local pharmacy.

• Medications. Nonsteroidal anti-inflammatory medication may be prescribed by the doctor.

• Icing. Applying an ice pack several times a day helps reduce inflammation and pain.

• Orthotic devices. In some cases, custom orthotic devices may be provided by the doctor.

• Modify your daily activity. Avoid activity that causes bunion pain, including standing for long periods of time.

Surgical treatment: 

Bunion surgery is necessary if:

• There is severe foot pain that limits your activities.

• Severe inflammation of the big toe is present.

• Significant deformity of the toe (the moving of the big toe towards the small toes is usually called Hallux Valgus). Sometimes you will hear bunion surgery called Hallux Valgus Procedure.

• The big toe joint is stiff and does not bend so that it interferes with walking.

• You are no longer responding to conservative methods like anti inflammatory medications, padding over bunion, different shoes.

A variety of surgical procedures are performed these days to treat bunions. The procedures are designed to remove or correct the "bump" of bone, correct any changes in the bone structure of the foot, as well as correct soft tissue changes that may also have occurred over the years due to the presence of the bunion.

Some of the procedures include:

Simple bunionectomy just, literally, cuts off the lump of bone (it does not realign the big toe) tendons and ligaments around the big toe can be out of balance, so this may be surgically corrected (this is often used in conjunction with other procedures)

An osteotomy is when a wedge of bone is taken out of the big toe and or metatarsal to 'straighten' the big toe (screws, plates or wires are used  to hold the bones in place while they heal) the damaged joint surfaces
 can be removed and the joint fused together.

Afterward the surgery your doctor will prescribe a program of rehabilitation. The usual recovery period after bunion surgery is 6 weeks to 6 months, depending on the amount of soft tissue and bone involved. Complete healing may take as long as 1 year.

 A toe fracture is when you break your toe, either partially or completely

• Severe pain and swelling;

• Visible deformity;

• Numbness or coldness in the toe if the blood supply is impaired.

There are two main categories of toe fractures:

• Direct blow to the toe, as when kicking or being stepped on.

• Indirect stress to the toe. Indirect stress may be caused by twisting.

Stress fractures frequently occur in the bones of the forefoot that extend from your toes to the middle of your foot. Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in training (such as running or walking for longer distances or times). Ballet dancers are particularly venerable to stress fractures due to the high demand places on their feet.

• Pain and swelling

• Sometimes bruising

• Pain when you walk

• If the pain, swelling, and discoloration continue for more than two or three days, or if pain interferes with walking, see a doctor as soon as possible.

Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for three to four weeks. Gradually, you will be able to return to activity.

The bone ends of a displaced fracture must be realigned and the bone kept immobile until healing takes place. If you have a broken toe, the doctor may just tape the injured toe to the toe next to it for support. This is done with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed.

If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace, or a rigid, flat-bottom type shoe. It could take six to eight weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, the doctor may request another set of X-rays to ensure that the bones remain properly aligned. As symptoms subside, you can put some weight on the leg. Stop if the pain returns.

Surgery may be required to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success. The doctor will use pins to fix the bone pieces back into their correct place and make sure that the toe is correctly aligned. It is rare but if the toe(s) have been crushed miniature metal or biodegradable plates may be required to properly fix the bone.