Piñal and Associates has surgeons specialized in orthopedic surgery and joint trauma, capable of providing optimal solutions for various pathologies related to the hip, knee, ankle, and foot, such as tendinopathies, strains, dislocations, arthritis, osteoarthritis, and fractures, among others.

Additionally, the experience of Dr. Piñal and his team in microsurgical interventions enables the clinic to address cases of lower extremity reconstruction (leg and foot) following work or traffic accidents. In these situations, reparative-reconstructive surgery can mitigate partial losses of skin, tissue, or bone fragments.

The ankle is a highly important joint as it connects us to the ground for walking. It is a highly mobile area due to the convergence of various tendons, whose combined action transmits the force from the leg muscles to the foot. These characteristics make it susceptible to intense functional demands under axial load, which may exceed its capacity, leading to fractures, sprains (ligament tears), avulsions, tendinous injuries, and cartilage damage, among others.

SPRAINS

The current accessibility to advanced imaging tests, such as magnetic resonance imaging, allows us to precisely identify the injured structures. While conservative treatments are still indicated for sprains, we now know that a significant percentage of patients will experience various types of sequelae, even with proper therapy. In this context, arthroscopy provides an ideal tool to assess and treat these injuries, which significantly impact the current lifestyle, where sports are practiced to maintain a healthy life at all ages.

The classic treatment for ankle instability secondary to a sprain that does not heal properly is open repair of the incompetent ligament. Thanks to arthroscopy, this same treatment can now be performed with much less invasion, while also allowing the treatment of other injuries within the joint in the same procedure. These advantages make recovery faster and better.

In other cases, when the remaining ligament is insufficient, it can be replaced with a tendon graft, similar to what is done in the knee, recreating a ligament by passing a tendon through different bone tunnels to restore structure and function.

Another very common condition that occurs in the ankle after recurrent sprains is known as anterior impingement. The injury mechanism involves not only the rupture of the ligament but also a bone collision between the tibia and the talus. This leads to overgrowth of bone in that area, restricting movement and causing pain. This can be elegantly addressed through arthroscopy, quickly restoring function.

TENDINOPATHIES

Tendons are exposed to injuries of various natures in the ankle. The most commonly injured tendons are the Achilles, peroneal tendons, and the flexor hallucis longus (FHL).

For the Achilles tendon, treatment can be performed using tenoscopy, a procedure where the same camera used for joint arthroscopy is introduced into the tendon sheath to directly assess and treat tendon injuries. A common condition known as talalgia (pain around the Achilles tendon) often hides what is called Haglund’s disease, which is the rubbing of the distal end of the tendon against the calcaneus. Its typical appearance is a bony prominence at the back of the foot. Arthroscopy can be used to reduce this prominence and stop the tendon from rubbing.

The peroneal tendons are often injured with partial or complete tears. Tenoscopy allows for evaluation and treatment. Sometimes, these tendons become unstable in certain parts of their course from the leg to the foot. This can also be addressed with arthroscopy by deepening the groove that contains them, if necessary.

The FHL tendon helps us propel our walking by flexing the interphalangeal joint of the hallux (big toe). This tendon travels to the foot along the posterior side of the ankle and is housed in a canal where it can become compressed and rub against the bone edges of the canal. This tendon can be released through arthroscopy.

FRACTURES

Ankle fractures are a very common condition that often does not receive the attention and importance it deserves. By definition, a fracture that affects a joint must be restored in such a way that the original anatomy is faithfully recreated. While most fractures heal with the application of a cast, meaning bone consolidation, if that consolidation does not occur in an anatomically correct position, it will inevitably lead to biomechanical problems and premature joint wear, known as post-traumatic osteoarthritis. This is why it is so important to be stringent with the indication for surgery, ensuring the bone is placed in the correct position. This also allows for immediate mobilization, preventing stiffness.

Combining osteosynthesis with plates and screws with arthroscopy allows us to remove free bodies from the joint (debris from the fracture) that could hinder movement, as well as fix various bone fragments percutaneously, avoiding the complications of accessing an area that may be very swollen due to the trauma. Additionally, it ensures accurate fracture reduction for optimal joint positioning.

OSTEOARTHRITIS

Finally, when the ankle joint is degenerated due to various traumatic or non-traumatic causes, such as rheumatoid arthritis or other conditions, depending on the type of patient, a joint replacement or, if necessary, an arthrodesis (fusion of part of the damaged joint to eliminate pain at the cost of limited movement) can be performed. In this scenario, the more conservative we are in preserving the joints, the better the immediate and long-term results will be, especially for walking as close to normal as possible.

Current ankle prosthesis designs require us to be more selective with indications in order to choose the patients who will truly benefit from this treatment in the long term.

FOOT DROP

Foot drop, a condition resulting from injury to a major nerve in the leg that controls the muscles responsible for extending the ankle, toes, and hallux, is a common sequela of trauma, wounds, or surgical procedures. In cases of mild injury, recovery often occurs spontaneously over several months, during which passive movement is important to prevent stiffness. However, if the injury is severe and the nerve cannot recover despite treatment, tendon transfer surgery may be required. This procedure uses functional tendons with intact innervation to replace the non-functional ones. These surgeries are customized to balance active and inactive tendons to provide the best possible function. This approach prevents the need for a lifelong orthotic device to keep the foot at 90º, a crucial requirement for proper walking without tripping.