What is flatfoot reconstruction?
Flatfoot reconstruction is a combination of surgical procedures that repair the foot’s ligaments and tendons and correct deformities of the bones to restore and support the arch. These adjustments can reduce pain and help the patient return to an active life.
Complication rates for flatfoot reconstruction are low. However, the procedure carries the risks of any surgery, including infection, bleeding, blood clots, nerve or blood vessel damage, and anesthesia-related problems. Other complications include a failure of the bones or the surgical wound to completely heal.
Sometimes, a patient may be bothered by the hardware left in the foot to stabilize the bones. If this occurs, it is usually possible to remove the hardware after healing is complete.
Types of flatfoot reconstruction
In many cases, flatfoot can be corrected by nonsurgical treatment, especially when detected early. Types of nonsurgical flatfoot treatment include:
- Rest and immobilization—Decreasing or completely stopping any activities that aggravate the arch of the foot can help the healing process tremendously. Total bed rest is sometimes required to allow the correction of flatfoot.
- Ice therapy—Placing an ice pack on the foot and ankle for 20 minutes at a time can alleviate pain, swelling and inflammation.
- Anti-inflammatory medication—Aspirin, ibuprofen and naproxen are common over-the-counter anti-inflammatory medications used to control pain and inflammation.
- Orthotic inserts—An insole can be added to your shoe for arch support.
- Orthopedic footwear—A leg brace or orthopedic shoe may be recommended by your doctor to reduce pressure and impact on the affected foot. Protecting your foot and ankle from further use can allow the arch and surrounding ligaments to heal properly.
- Cortisone injections—Cortisone is a steroidal medication that can be injected directly into the tissue in the arch to reduce swelling, inflammation and pain.
- Physical therapy—A physical therapist can show you new techniques and ways to perform activities than can reduce impact on and damage to the foot and ankle. Physical therapy is often combined with one or more of the other nonsurgical treatments.
Since there are many different causes of flatfoot, the types of flatfoot reconstruction surgery are best categorized by the original condition:
Posterior tibial tendon dysfunction
Posterior tibial tendon dysfunction is a condition in which the tendon connecting the calf muscle to the inner foot is torn or inflamed. Consequently, the damaged tendon can no longer serve its main function of supporting the arch of the foot. Flatfoot is the main result of this type of condition and can be treated by the following flatfoot reconstruction surgeries:
- Lengthening of the Achilles tendon—Otherwise known as gastrocnemius recession, this procedure is used to lengthen the calf muscles. This surgery treats flatfoot and prevents it from returning. This procedure is often combined with other surgeries to correct posterior tibial tendon dysfunction.
- Cleaning the tendon—Also known as tenosynovectomy, this procedure is used in the earlier and less severe stages of posterior tibial tendon dysfunction. It is performed before the arch collapses and while the tendon is only mildly affected. The inflamed tissue is cleaned away and removed from the remaining healthy tendon.
- Tendon transfer—This procedure is done to correct flatfoot and reform the lost arch in the foot. During the procedure, the diseased tendon is removed and replaced by tendon from another area of the foot. If the tendon is only partially damaged, the inflamed part is cleaned and removed, then attached to a new tendon.
- Cutting and shifting bones—Also called an osteotomy, this procedure consists of cutting and reconstructing bones in the foot to rebuild the arch. The heel bone and the midfoot are the most likely to be reshaped to achieve this desired result. A bone graft may be used to fuse the bones or to lengthen the outside of the foot. Temporary instrumentation such as screws and plates may also be used to hold the bones together while they heal.
Rheumatoid arthritis of the foot and ankle
This is a chronic inflammatory disease that attacks the ligaments and cartilage in the foot and ankle. Flatfoot can sometimes be a painful side effect of this condition and can be treated with the following surgeries:
- Fusion—When caused by arthritis, the flat foot is usually stiff and is not flexible enough to be treated with tendon transfer or bone cutting procedures. Fusion of the joints in the back of the foot can realign the foot, remove any arthritis and make the shape of the foot normal again. During the procedure, all of the cartilage is removed from the joint and replaced with bone graft material to fuse the joints together. Fusing of the joint creates one solid bone to eliminate any pain from the previously moving joint. Instrumentation can be used to further secure the bones while they fuse together.
- Triple arthrodesis—In this surgery, all three joints in the hindfoot are fused together with bone graft material and/or instrumentation.
When the ligaments of the foot are injured, the joints can fall out of proper alignment. Injuries are more common in the midfoot but can also occur in the hindfoot as well. Eventually, the torn ligaments will no longer be able to provide support, which can then lead to complete collapse of the arch. Surgeries for flatfoot resulting from injury include:
- Internal fixation—This surgical procedure involves realignment of the bones using metal instrumentation such as plates and screws. This hardware is usually removed three to five months after surgery.
- Subtalar implant—In the case of a misplaced talus bone, a subtalar implant is used to restore height to the arch in the foot. This implant is a small, soft-threaded titanium device that is inserted into the side of the hindfoot section. The placement of the subtalar implant prevents rolling of the ankle and provides arch support. Tissue can grow normally around the implant, which also helps to hold it in place.
Diabetic collapse (Charcot foot)
People with diabetic foot can suffer from a more severe version of flatfoot because, as a result of nerve damage, the diabetic often does not feel any pain from the collapse of the arch. The condition can progress further than normal and can result in a severely deformed foot that is difficult to fix with any surgery. Fusion surgery and surgery that lengthens the Achilles tendon (Achilles tendon repair) are two common procedures used to correct flatfoot caused by diabetes. There are various other procedures used to treat the many deformities in the foot resulting from diabetic collapse:
- Surgery for bony prominence—This type of surgery is used to remove the large, bony bump that occurs on the bottom of the foot.
- Stable deformity—For this condition, the bony prominence is shaved away.
- Unstable deformity—Simple removal of the bony prominence is not available because the bones surrounding it are too loose. These bones can easily move around and allow a new prominence to develop. Fusion and repositioning of the bones is needed to correct this side effect of diabetic collapse.
- Fractures—When these occur in the softer bone of patients with diabetes, the fractures are often more difficult to repair. Fusion will require more screws and plates for added stability and bone support.
- Ankle deformity—Diabetic collapse of the ankle can lead to flatfoot, and generally requires surgical fusion of both the ankle and the joint below the ankle to hold the foot straight.
What to expect
Because a variety of tendon, ligament and bone problems can work together to cause a flatfoot deformity, your doctor will do a complete evaluation of your foot to determine the procedures required in your case.
Your doctor is likely to do procedures to correct bones, tendons and ligaments, all of which may be impacted by a collapsed arch. For instance, it may be necessary to insert a bone wedge into the heel bone in order to adjust its positioning and correct an outward rotation of the foot. It is not uncommon for the big-toe side of the foot to be lifted off the ground in someone with flatfoot. To remedy this, the surgeon may cut and reshape one of the bones of the mid-foot, or may fuse a joint in the same area. In either case, the surgeon may use screws or a plate to maintain the proper position of the bones.
Because tendons and ligaments may have stretched, torn or thickened in response to the stresses created by the flatfoot deformity, your surgeon may perform some repairs on them, as well. If the posterior tibial tendon, which runs under the foot’s main arch, is too damaged, the surgeon may remove it and re-route another tendon to do its job. The ligaments that support the arch may also be repaired. Other procedures may be done, as well.
The surgery may be done under regional or general anesthesia. You may be able to go home the same day or may need to spend a night in the hospital.
After surgery, your leg will be in a cast or splint. You should keep it elevated as much as possible for the first two weeks to reduce swelling and speed healing. It is important not to put weight on the foot for six to eight weeks; at that point, you can start gradually introducing weight-bearing activities. Your doctor may recommend using inserts or an ankle brace, and may also prescribe physical therapy.