Dr. Attila Vásárhelyi is an FMH specialist in orthopaedic surgery and traumatology of the musculoskeletal system with particular expertise in foot and ankle surgery as well as hip and knee arthroplasty. At his practice in Biel/Switzerland, he offers innovative, minimally invasive procedures for the treatment of complex deformities, degenerative diseases and sports-related injuries to the lower extremities.
He specializes in bone-sparing OSG prostheses and precise forefoot and hindfoot corrections. With many years of experience as head of foot and ankle surgery, Dr. Vásárhelyi enjoys an excellent reputation. As an attending physician at Hirslanden Klinik Linde and Aarberg Hospital, he guarantees individual, high-quality care. He is a member of renowned specialist societies such as Swiss Orthopaedics, D.A.F. and EFAS and thus always keeps up to date with the latest scientific developments. Thanks to his multilingualism (German, English, French, Swiss German, Hungarian), he treats patients from a wide range of cultural backgrounds.
Dr. Vásárhelyi is one of the leading addresses in the Biel region for orthopaedic surgery and offers his patients tailor-made and innovative solutions for the treatment of foot, ankle, hip and knee disorders. His aim is to sustainably improve his patients' quality of life and enable them to recover quickly and successfully.
The editors of the Leading Medicine Guide were able to speak to Dr. Vásárhelyi about minimally invasive corrections of the forefoot and hindfoot and about prostheses for the upper ankle joint. (1).jpg "Dr. med. Attila Vásárhelyi")
Modern orthopaedic surgery has made enormous progress in recent years, particularly in the treatment of foot and ankle disorders. Innovative procedures such as bone-sparing OSG prostheses and minimally invasive corrections of the forefoot and hindfoot offer patients new hope for a pain-free future and an improved quality of life.
The need for an ankle joint prosthesis (upper ankle joint prosthesis) and the development of forefoot and hindfoot malalignments can be caused by various factors, which often develop over time or as a result of injuries.
“Nowadays, ankle joint prostheses (prostheses of the upper ankle joint) are mainly used in cases of advanced osteoarthritis of the ankle joint. This disease is associated with a progressive breakdown of the joint cartilage and the normal joint structure. Affected patients often suffer from deep-seated joint pain, restricted movement and a significant impairment of their ability to walk. Many of them have to walk with a limp and can no longer pursue sporting activities as usual. In around 90% of cases, osteoarthritis develops as a result of ligament injuries or fractures. Repeated twisting trauma is particularly common and can lead to chronic instability of the ankle joint. Another cause is fractures in the ankle joint area - for example, isolated fractures of the outer ankle (fibula fractures) through to complex combination or dislocation fractures in which both the outer and inner ankle are affected,” explains Dr. Vásàrhelyi at the beginning of our conversation.
The symptoms of osteoarthritis of the ankle joint or malalignment of the forefoot and hindfoot are usually manifested by pain, especially when moving or putting weight on the affected foot.
Osteoarthritis of the ankle joint is often accompanied by swelling, stiffness and limited mobility of the ankle joint. Deformities are often visible in malaligned forefoot or hindfoot, resulting in symptoms such as pain when walking, pressure points or difficulty finding suitable footwear. In severe cases, deformities can lead to incorrect loading of the entire musculoskeletal system, which in turn can lead to further complaints in the knees, hips or back.
“In today's clinical practice, we observe that patients with ligament injuries to the ankle, especially after an external ligament rupture, often only consult a specialized foot surgeon at a very late stage. One of the reasons for this is that the conservative treatment approach - i.e. without surgical treatment - has become widely accepted for ligament injuries. In many cases, it is assumed that the injury will heal well without surgery, so that referral to a specialist is often not necessary. However, studies and clinical experience show that around 10% of those affected develop chronic instability following a ligament injury. These patients often take a long time to reach the right specialist who recognizes the problem. In cases where osteoarthritis has not yet developed, good ankle function can be restored through surgical ligament stabilization. However, it is problematic that some sufferers live with their instability until there is already manifest cartilage damage - i.e. osteoarthritis - before they seek medical treatment. In such cases, a simple ligament reconstruction may no longer be sufficient. The situation is different in the case of ankle fractures. These are usually detected early and treated in specialized facilities - often surgically. After successful treatment, patients are often initially symptom-free. However, after a few years - typically between two and ten years - some of those affected experience symptoms again. Check-ups then often reveal degenerative changes in the form of osteoarthritis. From an advanced degree of osteoarthritis (grade IV), treatment with an OSG prosthesis is considered. These patients are usually already undergoing foot surgery and then receive further treatment as part of secondary treatment,” explains Dr. Vásàrhelyi.
Bone-sparing ankle joint prostheses (upper ankle joint prostheses) differ from traditional ankle joint replacement procedures mainly in that they preserve the natural bone and protect the surrounding tissue.
Compared to hip and knee endoprostheses, the development of ankle prostheses has been characterized by limited success over many decades. The biomechanical demands on the ankle joint are particularly high: it has to withstand complex sliding and rotational movements under high compressive loads - sometimes even higher than in the hip joint. For a long time, this made it difficult to develop a permanently stable and functional prosthesis system.
Dr. Vásàrhelyi comments on this: “A lot has happened in the last 10 to 15 years. Digital technologies and precise biomechanical analyses have significantly improved modern prostheses. Today, three-component prostheses are mainly used, which are characterized by bone-saving implantation and high functionality. A decisive advance lies in patient-specific surgical planning. CT scans of the affected ankle joint are taken before the operation. This data is used to carry out individual, digital 3D planning. Among other things, the correction of the leg axis, the exact size of the prosthesis and the minimum bone resection required are determined. Based on this planning, patient-specific cutting templates (so-called gauges) are then produced using 3D printing. These templates are placed precisely on the patient's tibia and talus during the operation and enable bone cuts to be made with millimeter precision - exactly as they were intended in the digital planning. This procedure not only makes the operation safer and more precise, but also more bone-friendly. It makes a decisive contribution to the improved durability and functionality of modern ankle prostheses and marks a significant advance over older procedures."
Modern, highly developed materials are used today for the material of OSG prostheses. Materials such as titanium, cobalt-chrome alloys or special ceramic materials are frequently used. These offer a high level of biocompatibility, which means that they are particularly compatible with the human body and rarely cause rejection reactions. The choice of material depends on the individual needs of the patient and the experience of the surgeon.
“Today's prostheses consist of three main components that are biomechanically very well matched to each other and retain as much of the natural joint function as possible. On the tibia side, we implant the so-called tibia base, a component made from a specially coated titanium alloy. This material is particularly well tolerated and enables stable, cement-free anchoring by growing into the bone. A polyethylene inlay is placed between this upper component and the lower component, which is applied to the talus. This is a highly cross-linked plastic core made of ultra-high molecular weight polyethylene, which is characterized by its low abrasion tendency. Low abrasion is a decisive factor for us, as abrasion particles can lead to loosening of the prosthesis over time, which may necessitate another operation,” says Dr. Vásàrhelyi, adding:
“The lower component, the so-called talus dome, covers the talus and is also made of metal with a titanium-coated surface for cement-free fixation. This allows us to achieve very good integration of the prosthesis into the surrounding bone without the need for additional cements. While earlier prostheses still required long metal pins or blocks in the area of the prosthesis anchorage, which destroyed a lot of bone material, we now work with very small, short anti-rotation pins. These secure the prosthesis reliably, but cause hardly any bone loss - a great advantage, especially with regard to possible subsequent revision procedures. We have been routinely using this modern, patient-specific prosthesis technology for around five years. This is made possible by precise, computer-assisted surgical planning based on CT data. The bone resections and axis corrections can be planned with millimeter precision and later implemented with the help of individually manufactured 3D-printed cutting templates. This approach not only makes the procedure safer and easier to plan for us as surgeons, but above all much gentler on the patient."
Minimally invasive surgery is playing an increasingly important role in the correction of forefoot and hindfoot deformities, as it offers a gentler treatment option that significantly improves both the healing process and the postoperative outcome.
Compared to traditional open surgical procedures, which require larger incisions and more extensive tissue surgery, the minimally invasive technique allows surgeons to reach the affected area with significantly smaller incisions. This method reduces trauma to the surrounding tissue and muscles, resulting in a faster recovery and less stress on the body.
“When implanting an ankle joint prosthesis, it is particularly important to protect the bone as much as possible. Although the prosthesis naturally requires some space in the joint, bone loss is reduced to a minimum. Of course, bone resection is not entirely possible, but today's prostheses are designed in such a way that they require very little bone removal. Compared to other joint replacement procedures, such as hip replacement, the surgical approach to the ankle joint is somewhat more complex. We usually operate from the front through an incision that passes a large tendon. A certain access route is required so that we can use the patient-specific cutting guides at all. However, experience shows that the incision lengths can be shortened with increasing routine. A purely minimally invasive technique, as we might know it from the 'keyhole principle', is not yet possible with an ankle prosthesis - but a relatively small, well-healing approach is,” says Dr. Vásàrhelyi and continues:
“Unfortunately, this minimally invasive surgical method is not yet established across the board. In my region, I am one of the few people who regularly use this minimally invasive technique. Many colleagues still perform classic open surgery - because that's how they were trained and this approach continues in practice. Patients often have no direct comparison and rely on their doctor's recommendation. That's why it's very important to me to educate patients and show them that there are modern, gentler alternatives - especially for complex or multiple affected feet, where open procedures would be associated with significantly higher risk and a less predictable course. Anyone who decides to have surgery should therefore not hesitate to seek a second opinion. The quality of the follow-up treatment, the long-term function and, above all, the patient's satisfaction depend largely on which method is used - and how much experience the surgeon has with it. Ankle prostheses are used much less frequently than hip or knee prostheses - even in my practice. The reason for this lies in the frequency of the disease: ankle arthrosis is much rarer overall. The ankle joint is naturally a very robust joint and usually only wears out in the event of previous injuries such as broken bones or severe ligament injuries. In contrast, osteoarthritis of the hip and knee often occurs without any recognizable cause - favoured by factors such as obesity or genetic predisposition. Accordingly, signs of wear and tear occur more frequently in these areas. Even in specialized centers, the number of ankle replacements is therefore comparatively low."
“In addition to treating the ankle joint, we also frequently focus on correcting forefoot and hindfoot misalignments. In the area of the forefoot, this usually involves degenerative changes such as hallux valgus, i.e. bunions, or small toe malpositions such as hammer or claw toes. These affect women in particular, which is partly due to hormonal influences and the choice of footwear. Shoes that are too tight or too high lead to incorrect loading over the years, the connective tissue loses tension and visible and painful changes occur. In the hindfoot area, we frequently encounter heel deformities such as varus or valgus heels, which are often combined with typical flat or hollow foot deformities due to developmental factors. Here too, significant axial deviations and tendon changes can occur over the years, causing pain and gait disorders. These malpositions can now be corrected using minimally invasive techniques in both the forefoot and hindfoot areas."
After an ankle operation, the focus is on rapid rehabilitation.
“After the operation, the foot is protected for around three to four weeks with an orthosis, a walker. This is less about protecting the bone and more about healing the soft tissue. Full weight-bearing on the foot is permitted and even encouraged from the outset. Patients begin targeted physiotherapy on the first postoperative day in order to regain a normal gait pattern as quickly as possible. As a rule, everyday activities can be resumed after a few weeks. However, competitive sports activities are only possible to a limited extent. For patients with a normal level of activity - i.e. everyday life, work, leisure and even moderate sport - an ankle joint prosthesis is now a very good option. We also consider a prosthesis for younger patients, such as those in their mid-30s or 40s, if the indication is given. The decisive factor here is not just age, but rather the functional requirements and structural conditions in the joint. With today's prosthesis technology, an active, stable and pain-free life can be achieved very well even after severe osteoarthritis in the ankle joint,” says Dr. Vásárhelyi.
Individual decisions for ankle treatments:
Prosthesis or fusion - When is which option appropriate?
“In addition to competitive athletes, for whom we generally recommend a fusion, there are other groups for whom a prosthesis is not an option. These include patients with significant soft tissue damage, severe or poorly controlled diabetes, long-term nicotine consumption, autoimmune diseases with immunosuppressive therapy or those with pre-existing infections in the ankle area. In these patients, there is a significantly increased risk of wound healing disorders, infections or prosthesis loosening, which is why we use ankle fusion as a proven alternative. The problem with diabetes is that blood flow to the foot is often restricted, which makes healing more difficult and increases the risk of infection. The situation is similar for smokers: Nicotine consumption has a negative effect on microcirculation, which can lead to delayed healing or infections. For this reason, it is essential that smokers abstain from smoking for weeks before and after the operation if a prosthesis is to be implanted,” says Dr. Vásárhelyi, explaining the advantages and disadvantages of alternative fusion surgery: “Stiffening surgery delivers good results overall and is a sensible and stable solution in many cases. However, in the long term, it entails the risk that neighboring joints, which now have to take over more of the movement, will wear out. While the prosthesis maintains mobility and thus protects neighboring structures, a fusion can lead to a so-called chain reaction after years, in which several joints degenerate one after the other and make further surgical measures necessary."
Medical development in the field of ankle prosthetics is not standing still - on the contrary: increasing individualization of implants is expected in the future.
“The aim is to reproduce the natural biomechanics of the joint as precisely as possible and thereby further improve both function and durability. It is not only the design of the prostheses that plays a role here, but also the possibility of adapting them to the specific needs of the patient - for example through individually designed surfaces. There is also great potential in the use of artificial intelligence. With the help of AI-supported calculation models, large amounts of image and movement data could be efficiently evaluated in the future in order to plan personalized implants or develop optimization suggestions for existing designs. Biomechanical simulations and prognosis models could also be used to predict how certain changes will affect joint function. These technological advances promise an even more targeted, effective and successful long-term treatment of joint diseases,” Dr. Vásárhelyi visualizes.
At the practice in Biel, foot treatments are not carried out in isolation, but as part of a comprehensive overall therapeutic concept. It is particularly important that the follow-up treatment is carried out just as carefully and competently as the operation itself - because “the operation is only half the battle”.
“To this end, we have set up a specialized foot team within the physiotherapy department, which looks after patients after surgery and knows the specific requirements of follow-up treatment. Close cooperation between surgery and physiotherapy is key to achieving optimal results. There is a particular focus on minimally invasive corrections in the forefoot area, where the use of foreign material is deliberately avoided. The bone incisions made - for example on the little toe - are not fixed with screws or plates. Instead, they are stabilized using a special bandaging technique known as minimally invasive tape bandaging. This bandaging technique fulfils a dual function: on the one hand, it stabilizes the operated structures and, on the other, it allows the physiotherapist to influence the position of the toes in a targeted manner for weeks to come. For example, the healing of a little toe whose bone has been cut but not fixed can be guided by correct taping. The bandage thus has a corrective and shaping effect - even after the operation. The prerequisite for this type of follow-up treatment is that trained specialists regularly check, adjust and correctly apply the bandages. This is the only way to ensure that the bones grow together in the desired position and that the functional and aesthetic result is convincing,” explains Dr. Vásárhelyi at the end of our conversation.
Thank you very much, Dr. Vásáhelyi, for the insight into foot and ankle treatments!
