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Flat Foot Surgery

General

A flat or low arched foot is not considered abnormal, the height of the arch does not have any bearing on how well a foot can function.  A foot that rolls in excessively with most of the weight passing over the inside border is a cause for concern.  Treatment is required in the severe cases were the degree of mal alignment is such that the patient experiences pain or fatigue or is likely to do so.  These patients are considered to have a pathological flat foot.  The majority of these cases respond to stretching exercises, orthoses (shoe inserts) and supportive footwear.  If the patient doesn’t respond to conservative treatment or only in a limited fashion, then surgery might be considered.

Causes of a pathological flat foot

Congenital mal alignment
Tendon injuries, typically Tibialis posterior
Neurological and muscular diseases
Joint hypermobility
Abnormal joining of two bones (coalition) resulting in a rigid flat foot
Arthritis

Types of flat foot

Flexible
Here the foot is poorly aligned when standing but when sitting with the weight off the foot the deformity corrects itself. 

Rigid
Here the foot remains in a poor position irrespective of whether it is weight bearing or not.

Diagnosis

The diagnosis is made by the examining the foot in combination with investigations such as X-ray, Ultra sound scanning and MRI.

Treatment options

Conservative care

• Stretching exercises for the calf and hamstring muscles
• Physiotherapy to strengthen muscles and improve coordination
• Orthoses (Insoles), ankle braces
• Anti inflammatories and analgesics
• Local steroid injections
• Supportive shoes

Surgical Management

This involves a combination of techniques to restore alignment of the foot to the lower leg and includes osteotomies (cutting bones to re-align them), fusing joints, tendon lengthening and transfers as well as implanted devices to help maintain correction. The combinations required for you will be determined by Professor Tagoe and will be discussed with you prior to your operation.

Day surgery

These operations are normally carried out on a day care basis.  You would be admitted to the hospital on the day of your operation.  Professor Tagoe will confirm your consent form and mark the surgical site. Dr Nathwani (Anaesthetist) will also see you to discuss your anaesthesia.

Anaesthesia

Most patients have their operation carried out under local anaesthetic with sedation, under the care of Dr Nathwani Consultant Anaesthetist.

Anaesthesia is a gradation from sedation through to general anaesthesia. Sedation provides reduced consciousness with most of your reflexes left intact and spontaneous breathing. This means that your airway is secure and there is no need to place a tube into your throat to maintain it. The level of anaesthesia though is not sufficient to perform the operation and so a local anaesthetic block at the level of the knee (Popliteal block) is performed to render the lower leg anaesthetised. This allows us to keep the amount of drugs used to a minimum.  As a consequence when the sedation wears off, normally within a few minutes of the end of the operation, there is not the accompanying drowsiness and nausea that is sometimes associated with general anaesthesia. The operation is pain free and you will remember nothing of the operation at all.

Professor Tagoe will perform the Popliteal block and  this will be carried out either prior to being sedated or afterwards depending on the logistics of your operation.  As the anatomy behind the knee varies a little from person to person  a nerve stimulator is used to accurately identify the nerves. This sends a small electric current down the needle so that when the nerve is approached it is stimulated. This means that the muscles controlled by that nerve begin to contract and relax causing the foot to ‘flick’. If you are conscious it is a strange sensation, but it is not uncomfortable and helps us to deliver the anaesthetic around the nerve with precision.

Local anaesthetic at the level of the knee not only blocks sensation but also the nerves that enable you to move your foot.  This is temporary lasting for 24 to 36 hours and has the advantage of providing long lasting analgesia. 

The operation

The operation will probably incorporate several different procedures in order to get a well positioned and functional foot.  Listed below are the common ones. Professor Tagoe will indicate which ones are applicable to you.  The operation normally lasts for about 90 minutes with a cast put on the leg in theatre whilst you are asleep  The cast will run from just below your knee to your toes allowing us to maintain correction whilst the your body is healing reducing the likelihood of damage.  Dissolving sutures will be used to close the skin. 

Lengthening of the calf tendon

A tight calf muscle will cause your foot to roll in. This can be rectified by lengthening the tendon just below the calf muscle (gastrocnemius).  An incision of approximately 7cm is made in centre of the back of your leg and the tendon lengthened.  Lengthening of the tendon allows normal foot function but the calf is often weaker than the other side.  Rarely the sural nerve is irritated leaving numbness or hypersensitivity to the lower leg.

 

Here an incision is made on the back of the calf and the tendon lengthened in a tongue and groove fashion

 

 

 

Tibialis Posterior tendon shortening

The Tibialis posterior muscle is a powerful antagonist to the foot rolling in.  In some cases either the attachment of the tendon is affected by an extra bone or the tendon s too long both effecting its function.  The surgery here shortens the tendon and if present removes the accessory bone.  The incision runs from around the ankle to the midfoot.

Tendon transfer

In cases where the tibialis posterior tendon has torn the foot will collapse inwards.  In most cases the tendon is beyond repair.  The torn tendon would consequently be replaced by a nearby tendon (flexor digitorum longus tendon). This tendon can be used without greatly affecting lesser toe function as there is another tendon which performs almost the same job within the foot.  Flexor digitorum longus tendon would be cut and attached under tension onto the navicular.

 

Young’s tenosuspension

Here half of the tibialis anterior tendon is re-routed through the navicular to pull the arch of the foot up in cases where it has collapsed.  This can only be performed when there are no significant arthritic changes to the local joints and the patient is not over weight.

Calcaneal (heel bone) osteotomy

This procedure is used to place the heel back in line with the lower leg.  In cases where the foot excessively rolls in, the heel bone can also tilt out of alignment.  If this is the case then the heel bone is cut and the alignment restored.  This helps provide greater stability and improve the leverage of muscles tasked in controlling the position of the foot.

Sinus tarsi implants

Here the excessive rolling in of the foot is controlled  by placing a titanium implant into the gap between the calcaneus and the talus called the sinus tarsi.  When the foot rolls in this gap reduces in size and expands when the foot rolls out.  By placing the right size implant in the sinus tarsi we can limit the amount of rolling in (pronation) of the foot.  This implant is normally well tolerated by the patient, but in certain cases it can cause irritation and as a consequence would have to be removed.  Whilst this is not common, we have noticed that when the implant is removed not all the correction is lost.

 

Evans Calcaneal osteotomies

This procedure lengthens the outside of the foot in cases where the foot has become severely mal-aligned.  The procedure is nornmally reserved for the younger patient who has a mobile flat foot.  The heel bone is cut and a bone graft is inserted lengthening the lateral border and increasing the arch height and stabilising the foot.

 

The diagram shows the forefoot rotated outwards on the hind foot.  The X-ray below shows a bone graft placed in the heel to lengthen the outside of the foot.  The position of the graft and heel bone is maintained with a plate.

 

 

Fusion of the foot

In cases where the foot is rigid either as a result of arthritis or the abnormal formation of bones (coalition) then a fusion of part or all of the major (large) joints in the foot might be considered.  The ankle is not included allowing the foot to move up and down, but the rolling in and of the foot would be restricted.  The foot would be repositioned to restore alignment and stability. 

The fusion might be of an individual joint as seen below with a talo navicular arthrodesis.  

Or of multiple joints with a triple fusion of three joints of the hindfoot

 

 

Discharge

Before you leave the hospital the physiotherapists will show you how to manoeuvre around on crutches non weight bearing as the operated leg will be in a cast and you will not be able to put the foot to the ground.  Post operative painkillers will be dispensed by the nurses. 

You should arrange to go home via car or taxi with an escort.  You are advised to have someone with you for the first twenty four hours in case you feel unwell.

Recovery

You must rest with the leg elevated for the first 48hrs (essential ambulation only). It is important that you keep the cast clean and dry.  Professor Tagoe will you for a dressing change 3-4 days post surgery, here the cast will be removed and the wound inspected.  An X-ray will be taken to ensure good position and stable internal fixation. 

Typical post operative regimes:

• 6 weeks in a below knee cast non weight bearing with an additional 2 weeks in a cast partial weight bearing
• 8 weeks in a below knee cast non weight bearing with the use of an ankle brace for 2 weeks in a trainer shoe.
• 8 weeks in a below knee cast with a further 4 weeks partial weight bearing.

The length of time you are in a cast for depends on the procedure and how well you are healing.

Once the cast has been removed exercises will be prescribed along with physiotherapy.  Returning back to activity and regular footwear is gradual and very much depends on the type of operation, your body’s healing response and the individual’s level of motivation. Once the cast is removed and you are advised to return to a supportive shoe e.g. trainers with driving as soon as you feel you feel safe.

Possible complications

Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital.  Most patients have an uneventful recovery.  Outlined below are the common problems or those rare complications with serious outcomes.  In cases where we don’t have accurate audit, we have used published results from the podiatric literature.  These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Haematoma – a painful accumulation of blood within the operation site. No recorded incidents.
• Thick and or sensitive scar – no audit data is available.
• Screws and plates were removed from 118 patients during a twelve month period.  This is often planned but can occur as a result of irritation.  
• Adverse reaction to the post operative pain killers.  1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue.  The incidence is 1 in every 83 operations*
• Infection of bone occurred in 3 out of 916 patients.
• Delayed healing of soft tissue or bone.  No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
• Loss of sensation can occur although this is usually transient but can take up to a year to resolve.
• Deep vein thrombosis which can result in a clot in the lung is potentially a life threatening condition.  Deep vein thrombosis incidence is 1 in every 900 cases.
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident.  This normally requires management by specialists in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.
• Reoccurrence of the deformity or failure of the operation: incidence is 1 in every 500 operations.*
• Development of secondary problems including overloading of joints adjacent to the ones operated on occurs in 1 in every 700 operations.*

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.

Pre operative screening of your health allows us to determine whether you are fit for surgery.  It is important that you disclose your full medical history.  If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. The surgeon and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post operative instructions which include resting and elevating the operated leg.  Keeping the wound clean and dry until advised otherwise is essential.  Please ask the nurse or Professor Tagoe if you are not sure what to do.
• Having a healthy diet is important. This provides the nutrition required for healing.
• Smoking is associated with a 20% increased risk of delayed or non healing of bones.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.

Post-operative exercises and in certain cases physiotherapy will be advised.  This helps improve the flexibility, strength and stability of your foot.

Podiatric surgeons evaluate, diagnose, prevent and treat diseases, disorders and conditions affecting the foot and all associated structures.  This is carried out in keeping with the individuals, education, training and experience, in accordance with the ethics of the profession and applicable law.  

Podiatric Surgical Training
3 year:	Degree in Podiatry
2 year:	General Podiatric Practice
2 year:	Diploma in the theory of podiatric surgery
2 Year	Surgical training programme (Podiatric Surgical Trainee)
	Final fellowship examinations
3 year:	Specialist training (Podiatric Registrar)
Accreditation with the Faculty of Podiatric Surgery Consultant Podiatric Surgeon

Consultant:

Professor Mark Tagoe

Secretaries:

Marina Nichols:
08700 410 448
Email: marina@thetagoeclinic.co.uk