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Robert Weinstein

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Surgeon, Author, Educator and Inventor Dr. Robert Weinstein discusses all things foot and ankle health related. From common conditions and their conservative treatments to complex reconstructive surgical challenges, every topic will be explained in plain language for all audiences.

4d ago

Surgery for the Rigid Flatfoot

This episode is designed for anyone interested in foot and ankle health, including patients considering flatfoot surgery, athletes dealing with progressive deformity, medical students, residents, podiatrists, orthopedic surgeons, and anyone interested in understanding how complex reconstructive foot surgery actually works. The rigid flatfoot is not simply an arch that has fallen. It is a three-dimensional structural deformity involving the bones, joints, tendons, and ligaments of the entire foot and ankle. The goal of reconstruction isn't simply to make the arch look better. It is to create a plantigrade, stable, well-aligned, functional, and substantially less painful foot. Arthrodesis is a cornerstone of reconstructing the rigid or grossly unstable flatfoot. This involves fusion or permanent stiffening of one or more joints to achieve stability and reduce pain and dysfunction. In the case of severe adaptation or arthritis this approach has the highest likelihood of long term success. Isolated talonavicular or subtalar joint fusion are often performed, in conjunction with gastrocnemius lengthening or corrective osteotomies. However this would be entertained in earlier presentations of a painful non-reducible flatfoot. In later stages, a double or triple arthrodesis is commonly chosen for its predictability in restoring all of the major deformity components and long term stability. Often, the surgeon is tasked with developing a treatment plan based on clinical and radiographic evidence. This approach - a single recipe for a set of circumstances - is in my opinion archaic. Modern reconstruction should not follow a recipe, rather careful assessment of the condition and patient expectations and choosing the least destructive procedures to get there. A well trained foot and ankle surgeon should be nimble enough to make decisions after careful inventory both pre- and intra-operatively. And if the deformity magnitude is extreme, staging may be appropriate. Oftentimes a single procedure can be effective. For example, with profound peri-talar subluxation without adjacent joint arthritis an isolated talonavicular joint arthrodesis may be all that is required. This procedure will realign the TN joint to restore stability, reduce forefoot abduction, and effectively stabilize the calcaneus underneath the leg by way of retrograde stiffening. I have performed calcaneocuboid distraction arthrodesis in isolation for the same purpose when this joint alone is degenerated. Swinging the forefoot around on the talar head and stabilizing the lateral column from further luxation can be achieved this way, while preserving subtalar motion required for traversing uneven terrains. I have also planned for isolated joint fusion and ended up fusing multiple joints and rerouting tendons and ligaments in the end. No two flatfeet are alike, so they cannot be approached that way. The most important principle of all: Don't reconstruct the flatfoot from a recipe. Reconstruct the deformity. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Aug 7

Surgery for the High Arch - Pes Cavus

Pes cavus (high arch) is notoriously difficult to approach since there are so many manifestations. It may be masked since there are a variety of ways the foot and leg will compensate, and often the presenting symptoms seemingly have nothing to do with the deformity. A classic example is the chronic ankle sprainer. While the injury is in the ankle, the set up for the injury is rigidity in the foot structure. Another example is multiple hammered toes. The patient sees their curled toes, but the reason is mechanical instability across a structurally high arch leading to imbalance and downstream contractures. Notably, many of these patients suffer from neurological issues, which may not have even been discovered yet. Part of the workup for pes cavus is a thorough neurological inventory - reflexes, range of motion, muscle strength, gait observation, and occasionally EMG/NCV studies or even back MRI. The practitioner has to keep all options open for reconstruction. The goal is a stable, plantigrade foot. Lowering the arch height may be the visual objective, but restoring balance and stability is the surgical objective. This is why so much time is placed in clinical and radiographic evaluation - to formulate the best treatment plan, which is often multi-dimensional. Tendon transfers are commonly performed as part of a comprehensive surgical reconstruction. This involves changing lever arm directions and power. Assisting weaker muscles or weakening over powering muscles is the goal. When we think about the foot moving about the ankle, the lever arm and power of the tendon becomes important - tendons attaching further from the axis exert greater torque about that axis, and tendons of greater diameter exert more force than tendons of smaller diameter. Therefore it is a careful balance of force enhancement and force reduction along with force vectors that is very much an art on the part of the surgeon. Bone work is done to create a stable platform across which the tendons can function. When a structural deformity exists (for example a rigidly plantarflexed first ray) then tendon transfer alone will not achieve the goal of stability. This is when osteotomy or arthrodesis is used. In cases of neurological deficit we almost always choose arthrodesis, for its predictable long term success and maintaining a sufficient structure upon which to balance and ambulate. At least for as long as possible, and some of the neurological conditions are progressive and degenerative. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Jul 31

Total Ankle Replacement

End stage of arthritis in the distal lower extremity has almost always dictated fusion of a joint. Until relatively recently this was the case in the ankle. However, due to its essential role in normal gait, surgeons have long sought ways to replace rather than fuse this joint. Replacement joints have existed for decades. Early versions were fraught with complications and required revision and conversion to fusion very often. Like many procedures, refinement in design of the implant, instrumentation, and patient selection has resulted in newer versions that have fairly decent and predictable durability. The ideal patient has lower functional demands, although physically active. Adequate bone stock, a lower BMI, and adherence to strict post operative protocols round out the characteristics for a patient who will likely benefit. Morbid obesity, uncontrolled systemic comorbidities, peripheral vascular disease, neuropathy, and patients who cannot follow through with strict rehab protocols will likely have less than optimal outcomes, often requiring revision or conversion early on in their recovery. The decision to replace rather than fuse is highly individualized. Regardless of patient health, they must understand that the likelihood of some further intervention is high. This is due to the wear characteristics of the polyethylene component and high load going through the relatively small ankle joint surface area. Despite this, maintenance of sagittal plane motion becomes a deciding factor along with age, adjacent joint health, and overall desire for a more normal gait (not entirely 'normal') for a longer period of time. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Jul 24

Hammertoe Surgery

Boradly speaking, there are three types of digital contractures or hammertoes: Flexor Stabilization: This is the most common mechanism, often driven by overpronation (flat feet). As the foot flattens, it unlocks the midfoot, causing the flexor tendons (the muscles underneath the foot) to fire earlier and longer to stabilize the foot. These overactive flexors overpower the smaller stabilizing muscles, forcing the toe to buckle downward at the proximal interphalangeal (PIP) joint. Extensor Substitution: Common in individuals with high arches (pes cavus), this mechanism occurs when the extensor muscles (top of the foot) overpower the lumbricals and interossei muscles. The extensor tendons "bowstring" over the toe, pulling the base of the toe upward (hyperextension) at the metatarsophalangeal (MTP) joint, which in turn forces the tip of the toe downward. Flexor Substitution. This is the least common mechanism and usually results from calf muscle weakness or nerve issues. In this case, the deep flexor muscles take over to help the foot push off the ground, overpowering the stabilizing muscles and causing the toe to curl. The formation of hammertoes occurs in phases, beginning with a flexible deformity with mild muscle and tendon contracture, and often primarily a functional condition seen in weight bearing and ambulating. Later the deformities become rigid, where the affected tendons and joint capsules shorten and tighten permanently. The bones in the joint can luxate, meaning the toe cannot be straightened manually. This rigid phase leads to painful corns on the top of the toe or calluses on the ball of the foot from friction against footwear. Correction methods centers around the biomechanical cause, the rigidity of the deformity, adjacent joint stability, and likelihood of recurrence. Broadly speaking, either arthroplasty or arthrodesis is performed. For retention of flexibility arthroplasty is utilized, but for long term success more often than not arthrodesis is performed. This involves removing the articular cartilage and retention of the bone ends together through the bone healing phases. Satisfaction with these procedures approaches 90%, with the most likely complication being recurrence, especially when either arthroplasty is performed or when adjacent deformity or instability is not addressed. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Jul 17

Nonunions

The "Diamond Model" (or Diamond Concept) of bone healing is a theoretical framework in orthopedic surgery and regenerative medicine that outlines five interdependent factors needed for successful fracture repair and non-union treatment: Osteogenic cells, Osteoinductive mediators, Osteoconductive scaffold, Mechanical stability, and adequate Vascularity. The first four are connected by vascularity - without blood flow no healing can occur. When evaluating a nonunion, this framework gives us a checklist upon which to determine the cause of the nonunion. A failure in any of the pillars of the model will result in a failed fusion or fracture to heal. Some conditions present specific challenges to bone healing that are not obvious. For example, obesity is widely known as a risk factor for nonunion. But it is not enough to just categorize high BMI solely; the obese individual poses challenges due to mechanical stability being inadequate, chronic inflammation where adipose tissue releases pro-inflammatory cytokines creating an environment favoring osteoclastic activity, and metabolic abnormalities such as insulin resistance and vitamin D deficiency. For me the key to a successful outcome of surgery or conservative treatment of fractures is mitigating risk factors when possible, or circumventing them altogether. However when faced with a nonunion, the surgeon has to answer the two questions - how can I improve mechanics around the nonunion site and how can I improve the tissue/organ/whole body biology? Without answering these the nonunion will likely persist leading to even further morbidity. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Jul 10

Reconstruction of the Flexible Flatfoot

Instead of understanding a flexible flatfoot as a single condition, it should be understood that it is in fact multiple simultaneously occurring conditions resulting in mechanical failure. And since there are multiple components: The surgeon should ask themselves "What component of the deformity am I correcting?" Every operation has a purpose. Every procedure corrects a different deforming force. That framework helps both patients and residents understand why flatfoot reconstruction is often a combination of several procedures rather than a single operation. And for patients, why they emerge from an operating room with incisions on the medial and lateral sides of their foot along with the back of their leg thinking I am just "giving them an arch." Careful assessment of the dominant planes of deformity clue the surgeon into where the pathology lies. For example, strictly sagittal plane dominance may be a result of spasticity in the heel cord only. This is often the case in pediatric presentations. Likewise, frontal plane dominance may occur in the forefoot, the hind foot, or both. Consequently procedures designed to correct on these planes may be required at one or both levels depending on extent of deformity. Some procedures have a powerful impact in multiple planes. For example the Evans osteotomy will effect transverse plane (forefoot abduction) and frontal plane (forefoot supinatus) simultaneously. This is why we often use these procedures to complete a correction, so as to minimize the total surgical disruption and recovery time. It should also be noted that correcting a flatfoot is not necessarily about arch restoration, which is an obvious external sign of success. It's about creating a mechanically stable propulsive foot that is pain free. We can't make someone an olympic-level runner simply by raising an arch, but we can improve the mechanics that lead to a failure of the arch mechanism. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Jul 4

Cartilage Structure and Function

There are three types of cartilage in the human body, although the one we most commonly pay attention to is hyaline cartilage since this makes up the articulation between bones. The gliding and shock absorbing function of type 2 collagen makes hyaline cartilage particularly suited for absorbing force. It is arranged in a very specific manner to absorb forces and maintain structural integrity under load. When damage occurs to this tissue, the integrity becomes compromised, and similar to the laminated structure of a car tire, begins a disintegration process. Delamination will occur in phases, and often correlates to the radiographic and clinical findings a patient will present with. As a surgeon, my job is to determine the origin of the degradation (whether normal age related or traumatically induced) and assume certain prognostic factors, like stage and rate of degradation that is likely and secondary or collateral effects of this degenerative process. There is no one-size-fits-all approach to joint degeneration. Since this is a slow process in most cases there is time for decisions related to interventions, whether conservative or surgical. When surgery is considered, there are joint sparing and joint eliminating procedures, the choice of which is highly dependent on the knowledge and skillset of the surgeon evaluating the condition. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
Jun 27

Ankle OCD

Symptomatic OLTs represent one of the most common causes of persistent pain following ankle injury. The condition is often missed due to the volume of ankle sprains seen in clinics that are routinely imaged with plain film X-ray only. These lesions not only do not appear on xray unless there is obvious bone involvement but sometimes evolve over time after the initial insult. Therefore the foot and ankle surgeon must keep this pathology in mind when pain persists beyond a reasonable amount of time in recovery. Lesion patterns sometimes can correlate with the mechanism of injury. Inversion sprains which are the most common type of injury, tend to produce more shallow, anterior located lesions if there is a dorsiflexion component, while deeper posteromedial lesions occur if the foot is plantarflexed at the time of injury. Cartilage damage is particularly challenging in that the body does not have a capacity to heal hyaline cartilage. Thus when damage occurs it can lead to symptomatology that persists well beyond the bodies repair of the surrounding tissues. This is why careful attention to the timeline after injury is so important. There is no universal clinical presentation for these lesions. Therefore MRI is essential when OLT is suspected. Larger lesions almost always require some type of intervention, especially with cartilage or cartilage-bone displacement. These tend to be more challenging, both in the type of repair required and the access to the joint to repair properly. Malleolar osteotomy is occasionally performed for access since direct cartilage replacement is likely the procedure of choice. Smaller lesions can often be treated either arthroscopically or in retrograde manner, tunneling to the lesion from underneath and performing a repair in a way that does not introduce larger injury to the joint surface. The content of this podcast is for educational and informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.

Surgeon, Author, Educator and Inventor Dr. Robert Weinstein discusses all things foot and ankle health related. From common conditions and their conservative treatments to complex reconstructive surgical challenges, every topic will be explained in plain language for all audiences.

Creator

Robert Weinstein
Years Active

2026
Episodes

37
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Clean
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