Flat Foot Reconstruction
The symptom of flat feet manifests from many different causes. A surgeon intervenes in non-responsive cases of flat feet by addressing the root issue. Root issues commonly linked to flat feet include a dysfunctional posterior tibial tendon, rheumatoid arthritis, injury to the midfoot or hindfoot, and diabetic collapse. Each root issue has a different approach to surgical correction and many issues have options depending on the patient’s specific anatomical considerations.
Posterior tibial tendon
Patients subject to tendonitis, or a tear, of the posterior tibial tendon can have reduced arch support leading to flat feet. The posterior tibial tendon attaches the calf muscle, or gastrocnemius, to many bones in the foot to support the natural arch. Damage to the tendon results in reduced functionality that responds well to surgical intervention. Surgical intervention for a flat foot caused by dysfunction of the posterior tibial tendon may include some or all the following techniques:
Tenosynovectomy
When caught early, before the collapse of the arch, removing and damaged portions of the posterior tibial tendon and sparing healthy portions can prevent further progression of the tendon dysfunction thereby preventing the arch collapse.
Tendon Transfer
Surgeons repair cases of flat foot caused by tendon dysfunction that has fully manifested into arch collapse with the removal of the dysfunctional tendon and replacement with healthy tendon harvested from elsewhere in the body.
Lengthening of the Achilles Tendon
Surgeons consider three methods for lengthening the Achilles tendon: A series of slices that allow the tendon to stretch farther, loosening muscle fibers of the gastrocnemius near the tendon attachment point, and making a “Z” shaped cut into the tendon to stretch it to the desired length and then securing it back together. This procedure reduces the tightness of the muscles associated with flat feet to alleviate associated muscle spasms and pain.
Osteotomy
Surgeons can rebuild the arch of the foot by cutting, to reshape at their discretion, the bones of the midfoot and heel to restore the arch of the foot. They may also use bone graft for fusion or lengthening if needed. The surgeon uses the osteotomy technique, such as a Cotton Osteotomy, to reshape the foot to a stable and more functional final form.
Rheumatoid arthritis of the foot and ankle
Rheumatoid arthritis systemically degrades the joints of the body and can cause a foot arch to collapse when affecting the bones of the foot. Due to the painful nature and joint stiffness of flat foot caused by rheumatoid arthritis a surgeon would consider fusing some or all the joints in the hindfoot.
Joint Fusion
The surgeon removes all the cartilage of the target joint and replaces it with bone graft before using hardware to hold the desired shape during recovery. The goal of the fusion is to realign the foot into a more functional shape and to reduce the amount of pain the patient experiences.
Complete hindfoot fusion
Triple arthrodesis fuses the three hindfoot bones below the ankle to reduce pain, eliminate the foot deformity, and add stability. A surgeon reserves triple arthrodesis for the worst cases due to the tradeoff of losing range of motion. Most patients in a position to consider complete fusion experience enough pain and inconvenience before intervention to gladly take the trade and consider it an upgrade.
Flat foot due to ligament injury
The ligaments of the foot hold the many bones of the complex skeletal structure in place. Ligaments, when damaged, loose the ability to offer structural support and may result in arch collapse resulting in a flat foot. A surgeon can reconstruct the arch by placing the bones into their correct places and temporarily fixing them to each other with hardware while the ligaments heal over the upcoming months. After the ligaments have healed the surgeon will remove the hardware allowing the ligaments to once again carry the proper load and alignment. For cases with a misplaced talus bone due to ligament damage surgeons consider a subtalar implant. This implant restores proper alignment and prevents new injury from rolling the ankle. Over time soft tissues heal and will encroach around the implant leading to added stability.
Diabetic arch collapse (Charcot foot)
Diabetes places patients with neuropathy at increased risk for the damages caused by flatfoot due to them not receiving the pain signals that would cause non-diabetics to seek treatment. Continued use of the foot leads to large amounts of damage and deformity leaving surgeons with little option beyond fusion and lengthening the Achilles tendon to combat muscular issues. Consideration for other surgical procedures such as removing any bony prominence that has formed on the bottom of the foot can work for patients with stable deformities. Fractures, unstable deformities, and ankle collapse indicated for the surgeon to choose fusion for the surgical intervention.
