What Is Flatfoot Surgical Correction?
Adult flatfoot is a collapse of the arch of the foot. Flatfoot surgery repairs the bones, ligaments, and tendons that support the arch, often through a combination of procedures. The goals of the surgery are to improve the alignment of the foot and restore more normal pressure during standing and walking. This surgery can also reduce pain and improve walking ability.
Patients with flatfoot frequently describe ankle pain and difficulty with daily activities. A foot and ankle orthopaedic surgeon should do a complete evaluation of the foot, including a medical history, physical exam, and X-rays. Surgical reconstruction of the flatfoot is performed in patients with an arch collapse that is still flexible. Non-surgical treatments such as rest, immobilization, shoe inserts, braces, and physical therapy should be tried first. If these are unsuccessful, then surgery should be considered.
Patients who have diabetes or take oral steroids should be evaluated by their primary care physician to determine if surgery is safe. Obese patients and smokers are at higher risk for blood clots and wound problems. Full recovery from flatfoot surgery can take up to a year. Patients who are unable or unwilling to complete this process should not have this surgery.
A combination of surgical procedures can be used to reconstruct the flatfoot. Generally, these procedures can be separated into those that correct deformities of the bones and those that repair ligaments and tendons. Your foot and ankle orthopaedic surgeon will choose the proper combination of procedures specifically for your foot.
Surgery of the foot can be performed under regional anesthesia, which is numbing the foot and ankle with a nerve or spinal block, or general anesthesia, which may require a breathing tube. A nerve block often is placed behind the knee to reduce pain after surgery.
Medializing Calcaneal Osteotomy
A medializing calcaneal osteotomy (heel slide) procedure is performed when the calcaneus (heel bone) has shifted out from underneath the leg. An incision is made on the outside of the heel, and the back half of the heel bone is cut and slid back underneath the leg. The heel is then fixed in place using metal screws or a plate.
Lateral Column Lengthening
Outward rotation of the foot may occur in patients with flatfoot. A lateral column lengthening procedure sometimes is performed for these patients. An incision is made on the outside of the foot, and the front half of the heel bone is cut. A bone wedge is then placed into the cut area of the heel bone. This wedge helps to lengthen the heel bone and rotate the foot back into its correct position. The wedge usually is kept in place using screws or a plate. The wedge can be taken from the patient’s hip or a cadaver.
Medial Cuneiform Dorsal Opening Wedge Osteotomy or First Tarsal-Metatarsal Fusion
Arch collapse can lead to the big toe side of the foot being raised above the ground. Your surgeon may perform a dorsal opening wedge osteotomy of the medial cuneiform bone to treat this problem. An alternative is to perform a first tarsal-metatarsal joint fusion. Both procedures involve an incision over the top of the foot. In the case of the dorsal opening wedge osteotomy, a bone wedge is placed into the top portion of the bone to push it down toward the floor. In the case of the fusion, the bone is pushed down toward the floor at the level of a joint in the middle of the foot and the bones are fused into that position. Screws or a plate can be used to keep the wedge in place or to fuse the joint.
Tendon and Ligament Procedures
The posterior tibial tendon runs underneath the arch of the foot. It is often weak or dysfunctional in patients with flatfoot. The tendon may be removed if it is thickened or torn. Usually the tendon that bends the little toes can be transferred (rerouted) to help support the arch. The stresses placed on the flatfoot can lead to tearing of the ligaments that support the arch (spring ligament) and the inside of the ankle (deltoid ligament). Your surgeon may decide to repair these structures if there is significant damage. Finally, the flatfoot condition is often associated with tightness of the Achilles tendon. This can be treated using a lengthening procedure to stretch the muscle fibers of the calf.
Double or Triple Arthrodesis
In the later stages of flatfoot, deformities frequently are stiff and arthritis may be present. Surgical correction of these severe cases requires fusion of one or more of the foot joints. This procedure is referred to as a double or triple arthrodesis depending on the number of joints fused.
Patients may go home the day of surgery or they may require an overnight hospital stay. The leg will be placed in a splint or cast and should be kept elevated for the first two weeks. At that point, sutures are removed. A new cast or a removable boot is then placed. It is important that patients do not put any weight on the corrected foot for 6-8 weeks following the operation. Patients may begin bearing weight after the first 6-8 weeks and usually progress to full weightbearing by 10-12 weeks. For some patients, weightbearing requires additional time. After 12 weeks, patients usually can transition to wearing a shoe. Inserts and ankle braces often are used. Physical therapy may be recommended.
Risks and Complications
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Complications following flatfoot surgery may include wound breakdown or incomplete healing of the bones (nonunion). These complications often can be prevented with proper wound care and rehabilitation. Occasionally, patients may notice some discomfort due to prominent hardware. Removal of hardware can be done at a later time if this is an issue. The overall complication rates for flatfoot surgery are low.
Will surgical correction of my flatfoot improve the cosmetic appearance of my foot?
Surgical correction of flatfoot is aimed primarily at reducing pain and restoring function. Although surgery likely will improve the cosmetic appearance of the foot, it is not one of the primary goals of treatment.
What activities will I be able to do following flatfoot surgery?
With proper correction and rehabilitation, many patients return to active lifestyles. Activities such as walking, biking, driving, and even golfing are well tolerated. It is less likely, however, that patients will be able to participate in very strenuous heavy impact activities requiring running, cutting, or jumping.
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