Flatfoot reconstruction: what the operation involves

When reconstruction is considered

For background, see adult-acquired flatfoot. Non-surgical treatment is always tried first and often controls symptoms in the early stages.^[1] Surgery should be considered if pain doesn’t get better after several months of appropriate treatment,^[2] or when the deformity is progressing and delay would let it stiffen or spread to the ankle.^[3]

How the operation is planned

The surgical plan follows the deformity. Before surgery, weight-bearing X-rays, and sometimes CT or MRI, show which joints are involved, how flexible the foot is, and whether the ankle is affected.^[2,4] A consensus classification, progressive collapsing foot deformity, describes the deformity in more detail than the older stages, and helps surgeons plan and compare results.^[5]

The building blocks of reconstruction

Most reconstructions combine several of these:

• Tendon transfer. When the posterior tibial tendon is diseased, a neighboring tendon — commonly the flexor digitorum longus — is moved to take over its role.^[1,6]
• Heel-bone (calcaneal) osteotomy. Cutting and shifting the heel bone inward moves the heel back under the leg and takes strain off the inner side of the foot.^[6]
• Lateral column lengthening. A bone cut on the outer side of the foot to help correct a foot that points outward.
• Ligament repair or reconstruction. The spring ligament, which supports the arch, can be repaired or reinforced.^[2]
• Calf lengthening. Releasing a tight calf muscle (see gastrocnemius recession) or lengthening the Achilles tendon takes strain off the midfoot. Studies show improved motion after these procedures, but no study has directly compared flatfoot reconstruction done with and without them, so their exact contribution is unproven.^[7]
• Subtalar arthroereisis. A small implant is placed in the space between the heel bone and ankle bone to limit collapse; a systematic review of nine studies (mostly stage II) reported improved clinical and X-ray scores with a low complication rate, and called for higher-quality studies.^[8]
• Joint fusion (arthrodesis). For a rigid, arthritic hindfoot, a triple arthrodesis fuses three joints of the hindfoot in a corrected position.^[1]
• Ankle procedures. If the ankle joint is involved, the plan may include deltoid ligament reconstruction and ankle fusion or replacement.^[1,2]

There is limited evidence as to which combination is optimal, and surgical indications and techniques are still being researched.^[1]

What results can you expect?

Reported results for flexible flatfoot reconstruction are generally good. In a long-term study of 31 patients who had a flexor digitorum longus transfer and heel-bone osteotomy for stage II disease, followed for an average of 15 years, scores improved significantly and 27 (87%) were pain-free and functioning well.^[6] Results depend on the deformity, the operation and the patient, and outcomes for severe or rigid deformities are less predictable.

Complications include incomplete pain relief, failure of a bone cut or fusion to heal (nonunion), wound infection and stiffness. Smoking and diabetes raise the risk.^[2]

Recovery

Recovery is a long process. A typical plan involves a period in a cast or boot without weight on the foot, followed by graduated weight-bearing in a boot, physical therapy and then supportive footwear, and it commonly takes six months or more before healing is complete.^[2] Your surgeon will give you the schedule for your specific operation. See recovery after foot and ankle surgery.

Questions to ask before deciding

• Which stage do I have, and can the deformity still be corrected by hand?
• Which parts of the operation do you recommend for my foot, and why?
• How long will I be non-weight-bearing, and how long until I can drive, work and exercise?
• What are the chances I’ll need further surgery, and what are the alternatives?

When to seek care