Innovative Treatments for the Foot and Ankle: An Expert Interview with Dr. Attila Vásárhelyi, M.D.

Dr. Attila Vásárhelyi, M.D., is an FMH-certified specialist in orthopedic surgery and musculoskeletal traumatology, 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 conditions, and sports-related injuries of the lower extremities.

He specializes in bone-preserving ankle prostheses as well as precise forefoot and hindfoot corrections. With many years of experience as head of the Foot and Ankle Surgery department, Dr. Vásárhelyi enjoys an excellent reputation. As an affiliated physician at the Hirslanden Klinik Linde and Aarberg Hospital, he ensures personalized, high-quality care. He is a member of renowned professional societies such as Swiss Orthopaedics, D.A.F., and EFAS, which allows him to stay up to date with the latest scientific developments. Thanks to his multilingual skills (German, English, French, Swiss German, Hungarian), he cares for patients from a wide variety of cultural backgrounds.

Dr. Vásárhelyi is one of the leading specialists in the Biel region for orthopedic surgery and offers his patients tailored and innovative solutions for the treatment of foot, ankle, hip, and knee conditions. His goal is to sustainably improve his patients’ quality of life and enable them to recover quickly and successfully.

The editorial team of the Leading Medicine Guide spoke with Dr. Vásárhelyi about minimally invasive corrections of the forefoot and hindfoot, as well as prostheses for the upper ankle joint.

Modern orthopedic surgery has made enormous strides in recent years, particularly in the treatment of foot and ankle conditions. Innovative procedures such as bone-sparing TFA 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, as well as the development of forefoot and hindfoot deformities, can be caused by various factors that often develop over time or result from injuries. 

“TARs (total ankle replacements) are primarily used today to treat advanced osteoarthritis of the ankle joint. This condition is associated with progressive degradation of the articular cartilage and the normal joint structure. Affected patients often suffer from deep-seated joint pain, limited range of motion, and a significant impairment of their ability to walk. Many of them are forced to limp and can no longer engage in sports activities as they used to. In about 90% of cases, osteoarthritis results from ligament injuries or fractures. Repeated ankle sprains are particularly common and can lead to chronic instability of the ankle joint. Other causes include fractures in the ankle region—ranging from isolated lateral malleolus fractures (fibula fractures) to complex combined or dislocated fractures in which both the lateral and medial malleoli are affected,” explains Dr. Vásàrhelyi at the beginning of our conversation.

The symptoms of ankle osteoarthritis or forefoot and hindfoot deformities usually manifest as pain, particularly during movement or when weight is placed on the affected foot. 

Ankle osteoarthritis is often accompanied by swelling, stiffness, and limited mobility of the ankle joint. Misalignments in the forefoot or hindfoot frequently result in visible deformities and lead to symptoms such as pain when walking, pressure points, or difficulty finding suitable footwear. In severe cases, misalignments can lead to improper loading of the entire musculoskeletal system, which in turn can cause further symptoms in the knees, hips, or back. 

“In today’s clinical practice, we observe that patients with ankle ligament injuries, particularly following a lateral ligament rupture, often wait a very long time before consulting a specialized foot surgeon. This is due, in part, to the fact that the conservative treatment approach—that is, without surgical intervention—has become widely accepted for ligament injuries. In many cases, it is assumed that the injury will heal well even without surgery, so patients are often not referred to a specialist. However, studies and clinical experience show that approximately 10% of those affected develop chronic instability following a ligament injury. It often takes these patients a long time to reach the right specialist who can recognize the problem. In cases where osteoarthritis has not yet developed, surgical ligament stabilization can restore good function to the ankle joint. The problem, however, is that some patients live with their instability for so long that manifest cartilage damage—that is, osteoarthritis—has already developed before they seek medical treatment. In such cases, simple ligament reconstruction may no longer be sufficient. The situation is different with ankle fractures. These are usually detected early and treated in specialized facilities—often surgically. After successful treatment, patients are often symptom-free at first. Nevertheless, some patients experience a recurrence of symptoms after a few years—typically within a period of two to ten years. Follow-up examinations then often reveal degenerative changes consistent with osteoarthritis. Once osteoarthritis reaches an advanced stage (Grade IV), an ankle prosthesis may be considered. “These patients are usually already undergoing foot surgery and are then provided with further care as part of what is known as secondary treatment,” explains Dr. Vásàrhelyi.

Bone-sparing ankle prostheses differ from traditional ankle replacement procedures primarily in that they preserve the natural bone and spare the surrounding tissue. 

Compared to hip and knee replacements, the development of ankle prostheses has been marked by limited success over many decades. The biomechanical demands on the ankle joint are particularly high: It must withstand complex sliding and rotational movements under high compressive loads—in some cases even higher than those in the hip joint. For a long time, this made it difficult to develop a permanently stable and functional prosthetic system.

Dr. Vásàrhelyi comments: “A lot has changed in the last 10 to 15 years. Thanks to digital technologies and precise biomechanical analyses, modern prostheses have been significantly improved. Today, three-component prostheses are primarily used; they are characterized by bone-sparing implantation and high functionality. A key advancement lies in patient-specific surgical planning. Before the procedure, CT scans of the affected ankle joint are taken. This data is used to perform individualized, digital 3D planning. Among other things, this process determines the correction of the leg axis, the exact size of the prosthesis, and the minimum necessary bone resection. Based on this planning, patient-specific cutting guides (known as templates) are then produced using 3D printing. During surgery, these templates are precisely positioned on the patient’s tibia and talus, enabling bone cuts with millimeter precision—exactly as planned in the digital planning phase. This procedure not only makes the surgery safer and more precise but also minimizes damage to the bone. It contributes significantly to the improved durability and functionality of modern ankle prostheses and marks a major advance over older procedures.”

As for the materials used in ankle prostheses, modern, highly advanced materials are employed today. Materials such as titanium, cobalt-chromium alloys, or special ceramic materials are frequently used. These offer high biocompatibility, meaning they are particularly well tolerated by the human body and rarely cause rejection reactions. The choice of material depends on the patient’s individual needs as well as the surgeon’s experience.

“Today’s prostheses consist of three main components that are biomechanically well-coordinated with one another and preserve as much of the natural joint function as possible. On the shin side, we implant what is known as the tibial base, a component made of a specially coated titanium alloy. This material is particularly well-tolerated and allows for stable, cementless anchoring through osseointegration. Between this upper component and the lower one, which is placed on the talus, there is a polyethylene inlay. This is a highly cross-linked plastic core made of ultra-high-molecular-weight polyethylene, which stands out for its low wear rate. “Low wear is a crucial factor for us, because wear particles can lead to loosening of the prosthesis over time, which may necessitate another surgery,” says Dr. Vásàrhelyi, adding:

“The lower component, known as the talus dome, covers the talus bone and is also made of metal with a titanium-coated surface for cementless fixation. This allows us to achieve excellent integration of the prosthesis into the surrounding bone without the need for additional cement. While earlier prostheses still required long metal pins or blocks for anchoring—which destroyed a significant amount of bone—we now use very small, short anti-rotation pins. These reliably secure the prosthesis but cause virtually no bone loss—a major advantage, especially with regard to potential future revision surgeries. We have been routinely using this modern, patient-specific prosthetic technology for about five years. This is made possible by precise, computer-assisted surgical planning based on CT data. Bone resections and axial corrections can be planned with millimeter precision and later implemented using custom-made 3D-printed surgical guides. This approach not only makes the procedure safer and more predictable for us as surgeons, but above all, it is significantly less invasive for the patients.”

Minimally invasive surgery is playing an increasingly important role in the correction of forefoot and hindfoot deformities, as it offers a less invasive 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 manipulation, the minimally invasive technique allows surgeons to access the affected area through significantly smaller incisions. This method reduces trauma to the surrounding tissue and muscles, leading to a faster recovery and less strain on the body.

“When implanting an ankle prosthesis, it is particularly important to preserve as much bone as possible. While the prosthesis naturally requires some space within the joint, bone loss is kept to a minimum. Of course, it’s not possible to avoid bone resection entirely, but today’s prostheses are designed to require only very minimal bone removal. Compared to other joint replacement procedures, such as those performed on the hip, the surgical approach to the ankle is somewhat more complex. We typically operate from the front through an incision that bypasses a large tendon. In order to be able to use the patient-specific cutting guides at all, a certain access route is required. However, experience shows that the length of the incisions can be reduced as surgeons gain more experience. A purely minimally invasive technique, as one might know it from the ‘keyhole principle,’ is not yet possible for ankle replacement—but a relatively small, well-healing incision certainly is,” says Dr. Vásàrhelyi, adding:

“Unfortunately, this minimally invasive surgical method is not yet widely established. In my region, I am one of the few who regularly use this minimally invasive technique. Many colleagues still perform traditional open surgery—because that is how they were trained, and this approach continues in practice. Patients often have no direct point of comparison and rely on their doctor’s recommendation. That is why it is very important to me to educate patients and show them that there are modern, less invasive alternatives—especially for complex cases or feet with multiple issues, where open procedures would carry significantly higher risks and be less predictable. Anyone deciding to undergo surgery should therefore not hesitate to seek a second opinion. The quality of postoperative care, long-term function, and, above all, patient satisfaction depend significantly on which method is used—and how much experience the surgeon has with it. Ankle replacements are performed much less frequently than hip or knee replacements—even in my practice. The reason for this lies in the prevalence of the condition: ankle osteoarthritis is significantly less common overall. The ankle joint is naturally very robust and typically wears down only as a result of prior injuries such as fractures or severe ligament injuries. In contrast, osteoarthritis of the hip and knee often develops without any apparent cause—facilitated by factors such as obesity or genetic predisposition. Consequently, signs of wear and tear occur more frequently in those 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 deformities. In the forefoot region, these are mostly degenerative changes such as hallux valgus—commonly known as a bunion—or deformities of the smaller toes, such as hammer toes or claw toes. These conditions affect women in particular, due in part to hormonal influences and footwear choices. Shoes that are too tight or too high lead to improper weight-bearing over the years; the connective tissue loses its tension, resulting in visible and painful changes. In the rearfoot region, we more frequently encounter heel deformities such as varus or valgus heels, which—due to developmental factors—are often combined with typical flatfoot or high-arched foot deformities.  Here, too, significant axial deviations and tendon changes can develop over the years, causing pain and gait abnormalities. Today, these deformities can be corrected in both the forefoot and hindfoot regions using minimally invasive techniques.”

After ankle surgery, the focus is on rapid rehabilitation. 

“After the procedure, the foot is protected for about three to four weeks using a brace or a walker. The goal is not so much to protect the bone as it is to allow the soft tissues to heal. Full weight-bearing on the foot is permitted—and even encouraged—from the very beginning. Patients begin targeted physical therapy as early as the first postoperative day to regain a normal gait as quickly as possible. As a rule, everyday activities can be resumed after a few weeks. However, competitive sports are only possible to a limited extent. For patients with a normal activity level—that is, daily life, work, leisure, and even moderate sports—an ankle replacement is a very good option today. We also consider a replacement for younger patients, starting in their mid-30s or 40s, if the indication is met. The decisive factor here is not age alone, but rather the functional demands and the structural conditions of the joint. “With today’s prosthetic technology, it is very well possible to lead an active, stable, and pain-free life even after severe osteoarthritis of the ankle,” says Dr. Vásárhelyi.

Individual Decisions in Ankle Joint Treatment:
Prosthesis or Fusion—When Is Which Option Appropriate?

“In addition to competitive athletes, for whom we generally tend to recommend 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 use, autoimmune diseases requiring immunosuppressive therapy, or those with pre-existing infections in the ankle region. These patients face a significantly increased risk of wound healing complications, infections, or prosthesis loosening, which is why we turn to ankle fusion as a proven alternative. The problem with diabetes lies in the often-impaired blood flow to the foot, which hinders healing and increases the risk of infection. The situation is similar for smokers: Nicotine use negatively affects microcirculation, which can lead to delayed healing or infections. “That is why strict abstinence from nicotine for several weeks before and after surgery is absolutely essential if a prosthesis is to be implanted,” explains Dr. Vásárhelyi, outlining the advantages and disadvantages of an alternative fusion procedure: “Fusion surgery generally yields good results and is a sensible and stable solution in many cases. However, in the long term, it carries the risk that adjacent joints—which must now take on more of the movement—will wear out. While the prosthesis preserves mobility and thereby protects adjacent structures, fusion can lead to what is known as a ‘chain reaction’ after several years, in which multiple joints degenerate one after another, necessitating further surgical intervention.”

Medical advancements in the field of ankle joint prosthetics are not standing still—on the contrary: an increasing degree of customization of implants is expected in the future. 

“The goal is to replicate the joint’s natural biomechanics as precisely as possible, thereby further improving both function and durability. Not only does the design of the prostheses play a role here, but also the ability to customize them for each patient—for example, through individually designed surfaces. There is also great potential in the use of artificial intelligence. With the help of AI-supported computational models, large amounts of image and motion data could be efficiently analyzed in the future to plan personalized implants or develop optimization suggestions for existing designs. Biomechanical simulations and predictive models would also be conceivable to calculate in advance how certain changes will affect joint function. “These technological advances promise an even more targeted, effective, and long-term successful treatment of joint diseases,” explains Dr. Vásárhelyi.

At the practice in Biel, foot treatments are not performed in isolation but as part of a comprehensive therapeutic approach. It is particularly important that postoperative care is carried out just as carefully and competently as the surgery itself—because “the surgery is only half the battle.”

“To this end, we have established a specialized foot care team within the physical therapy department that specifically cares for patients after surgery and is thoroughly familiar with the specific requirements of postoperative care. Close collaboration between surgery and physical therapy is essential for achieving optimal results. A particular focus is on minimally invasive corrections in the forefoot region, where we deliberately avoid the use of foreign materials. The bone cuts made—for example, on the little toe—are not fixed with screws or plates. Instead, stabilization is achieved through a special bandaging technique: the so-called minimally invasive tape bandage. This bandaging technique serves a dual purpose: on the one hand, it stabilizes the operated structures; on the other hand, it allows the physical therapist to specifically influence the position of the toes for weeks afterward. For example, in the case of the little toe—whose bone has been cut but not fixed—healing can be guided through proper taping. The bandage thus has a corrective and shaping effect—even after surgery. “The prerequisite for this type of postoperative treatment is that trained specialists regularly check, adjust, and correctly apply the bandages. This is the only way to ensure that the bones fuse in the desired position and that the functional and aesthetic results are satisfactory,” explains Dr. Vásárhelyi at the conclusion of our conversation.

Thank you very much, Dr. Vásárhelyi, for the insight into treatments for the foot and ankle!