Flatfoot Reconstruction

Hindfoot Fusion

What does Reconstruction of the Flatfoot involve?

This operation is designed to help recreate the arch of your foot and also correct the heel so that it is placed in the correct position. There are several procedures which may be done to correct the overall flatfoot but usually two main components to this surgery are:

• Posterior tibial tendon reconstruction/transfer
• Calcaneal osteotomy (Heel bone cut)

Posterior tibial tendon reconstruction/transfer:

For detailed information on what causes a flatfoot and the posterior tibial tendon, please refer to the ‘flatfeet’ section under ‘foot and ankle conditions’ on this website.

The posterior tibial tendon is responsible for maintaining the arch of the foot. When the tendon ruptures, the arch of the foot becomes flat, and no support is present on the inside of the ankle.As it is not possible to repair the torn tendon,a new tendon must replace the torn one. Therefore, the tendon that moves the toes called the flexor digitorum longus tendon is transferred to replace the function of the tibialis posterior tendon and help recreate the arch of the foot. This involves a skin incision on the inner side of the foot to gain access to the tendons. The tendon transfer is then performed and the transferred tendon is anchored to a bone in the midfoot under tension to help recreate the arch.

Calcaneal osteotomy (heel bone cut):

In order to improve the arch of the foot, and protect the tendon transfer, something else has to be done to the back of the foot, because the tendon transfer is not strong enough to support the foot and keep it corrected. This involves making a cut in the heel bone and sliding the heel bone to improve the overall alignment of the heel. This is then held with a screw. The incision for this part of the operation is placed at the outer aspect of the heel bone.

Type of procedure

This is an inpatient procedure and you will most likely be discharged in a day or two.

Type of anaesthesia

The operation will be undertaken under a general anaesthetic supplemented with an injection around the ankle to numb the foot (nerve block). The effect of this block will last for a few hours after surgery.

How long will the surgery take?

The surgery normally takes about one and a half to two hours.

Risks of surgery

Any orthopaedic surgery carries some inherent risks and it is the surgeons responsibility to fully inform you regarding the benefits and risks of this procedure. Mr Shariff will go through this in detail with you to help you make an informed decision.

This is a fairly routine procedure with risk of:

Infection

If this occurs it is usually a superficial infection around the wound site.It settles with a course of oral antibiotics. Deep infection is rare. Overall risk is 1%.

Pins & needles or patch of numbness:

Small nerve branches which supply sensation to the skin may be bruised or cut when the skin incision is made. This may cause pins and needles or a patch of numbness around the scar or the top of the foot. This feeling generally resolves within a few weeks to a couple of months. Overall risk is 5%.

Clots – Deep vein thrombosis

Extremely rare in foot and ankle surgery (<5%). However you will be given blood thinning injections after surgery for 4 weeks to minimise this risk.

Recurrence:

In some instances, the arch may flatten out with time. A fusion may then be required although this is not usually necessary.

Recovery from surgery

What can I expect immediately after the surgery whilst in hospital?

When you wake up, it is normal to have numbness in the operated foot as the anaesthetic block will take a few hours to wear off. You will have a bulky dressing to your foot and a below knee back slab (which is half a plaster) applied. You will not be allowed to walk on the operated foot for atleast 6 weeks. The physiotherapists will make sure that you are safe on your feet before discharge and you will be provided crutches. You will also be given painkillers to take home. It is normal to experience moderate pain after surgery and you can keep this to a minimum by taking regular painkillers.

Specific recovery protocol:

Day 1 – 7

Ensure that you keep your foot elevated on pillows to help reduce swelling.

Foot wrapped in bulky bandage and below knee backslab

Not allowed to put any weight through operated leg.

Elevate leg and take pain medication

Expect numbness in foot 12-24 hours then moderate pain

Bloody drainage through bandage expected.

Do not change bandage.

Day 14

You will have a follow up visit in clinic.

You will have an Xray on arrival prior to seeing Mr Shariff

Your wound will be inspected. You will have sutures that will need to be removed.

You will be put into a removable boot at this stage.

6 weeks

Cast/boot removed

X-rays taken

Use the boot for about 4 more weeks

Full weight bearing is allowed at the 6 week stage

The boot can be removed at night, and for gentle movement exercises.

Swimming is permitted, but with limited pressure on the foot

12 weeks

You can expect swelling to last for about 6 months, but you will notice that it gradually starts to settle.

You will have started to wear normal foot wear by this time.

You will almost certainly need insoles which will be custom made for you

Post operative clinic visit schedule

2 weeks after surgery – wound check and advice regarding basic hygiene

6 weeks after surgery – X-rays and advice regarding exercise

3 months after surgery – clinical exam

6 months – final follow up and discharge

When can I begin to walk?

You are not allowed to put weight on the operated leg for atleast 6 weeks.However you will be allowed to mobilise with crutches

0 – 2 weeks – below knee backslab

3 – 10 weeks – removable boot, normal shoes thereafter.

How do I look after my surgical wound site?

Your wound should be healed 2 weeks after surgery. If you notice any redness around the wound site, get in touch with your consultant as you may have a wound infection. Do not pick on any scabs and allow them to fall off. You will be taught some massage techniques to lighten your scar.

How do I shower or wash?

Do not get your wound wet until it heals completely. You can use a waterproof cover or plastic bag over your foot when you have a shower. Only expose your wound to water after it has healed completely.

When can I get back to driving?

It is the responsibility of the driver to ensure that he/she is in control of the vehicle at all times. As a general rule, you are ready to drive when you are able to perform an emergency braking manoeuver without pain. This usually is 6 weeks after surgery.

When can I get back to work?

Returning to work is very much dependent on the specific type of job and individual. As a rule of thumb –

Office based sedentary work – 3 weeks

Manual labour – 16 weeks

When can I get back to sport?

It depends on the kind of exercise, but as a general rule of thumb you can get back to sports like golf 3 months after surgery.