Surgical Overview
The posterior tibialis muscle originates off the posterior aspect of the lower leg bones and the tendon then courses behind the medial malleolus (inner ankle bone) and attaches to several bones of the foot. The arch of the foot is maintained by the constant work of the posterior tibial tendon as well as other supportive ligaments.
PTTD is an inflammation and/or overstretching of the posterior tibial tendon in the foot. Posterior tibial tendon injuries fall into 2 categories: traumatic and degenerative. Traumatic injuries are usually a result of a blow or force to the inner ankle causing a complete or partial tear. Degenerative tears, the most common cause of PTTD, is a chronic dysfunction that develops over a period of time. The damaged tendon may result in a complete tear, a partial tear or a stretching type of injury that allows the tendon to remain in one piece but becomes functionally too long and ineffective. As the tendon tears it can no longer support the arch of the foot and the foot begins to roll inward and flatten, causing pain. Once the foot begins to flatten other structures will be stretched and tear and the foot will flatten even more. PTTD is a progressive problem and if left untreated can cause significant foot deformities that can make daily walking very painful and difficult. The longer the dysfunction goes untreated, the more difficult and extensive the treatment becomes.
Because of the progressive nature of PTTD its best to seek treatment as soon as possible. Treatment for PTTD is dependant upon the clinical stage of the dysfunction and the patient’s health status. Conservative treatment focuses on supporting the arch of the foot to maintain it in a reasonably straight position. This is done with shoe modifications, orthotic arch supports and custom molded bracing.
Surgical treatment for the adult acquired flat foot deformity (PTTD) is divided into 3 different types depending on the stage of the dysfunction:
This surgical technique can be used for a flat foot caused by a rupture of the posterior tibial tendon with no significant foot deformity. The PTT is cleaned up and reattached if possible and then the flexor digitorum longus tendon, which is found right near the PTT, is transferred over and attached to the main attachment site of the PTT, the navicular bone.
This surgical technique is often used for a flat foot caused by a rupture of the posterior tibial tendon with a flexible foot deformity. The heel bone is shifted to add support to the tendon transfer on the inside of the ankle. This is the most common operation performed for this condition.
This surgical technique is often used for severe, fixed flat foot deformities. Joints are fused together (arthrodesis) to re-position the foot and stabilize it. In some severe cases bone grafts need to be used to help reshape the foot. The most common fusion technique used is called a triple arthrodesis, meaning the 3 main joints making up the hindfoot (back of the foot) are fused.
Flat foot deformity
Your surgery generally takes place at the New England Baptist Outpatient Center and is an outpatient surgical procedure.
The procedure generally takes about 1.5 hours.
General anesthesia is usually used, but occasionally spinal anesthesia will be recommended by the anesthesia team. Most patients will have a preoperative anesthetic popliteal block performed to the back of the knee immediately before the surgery. This will decrease intra-operative anesthesia requirements as well as post-operative pain medication requirements. It is very effective in greatly reducing pain.
This procedure can improve function with daily activities/walking, decrease pain and avoid long-term bracing.
Wearing a custom-molded brace for life.
Walking, biking, swimming, golfing, occasional tennis, general working out at the gym.
Like any surgery, complications can develop. Fortunately, they are rare for most patients, but not zero. These include infection, bleeding, numbness, blood clots, tendon injury, delayed union, non-union, or chronic pain and swelling. Appropriate recognition and medical treatment of these complications generally will allow for a satisfactory outcome.
Once the rehabilitation process is complete, it is recommended to wear supportive shoes with custom made, full length semi-rigid orthotics to assist in supporting the arch and surgical site. Wearing orthotics is recommended as a life-long activity, however, after 6 months to 1 year, more dressy shoes can be worn on special occasions.
You will get a dose of antibiotics before surgery. Also, due to a length of time being immobilized, patients are started on one 325 mg aspirin once a day for 4 weeks.
Read carefully the handouts in the surgical folder.
No. Bleeding is minimal with use of a tourniquet during the surgery.
Discuss the surgery with your rheumatologist, but it is generally recommended that immunosuppressive modulator medications (eg. Methotrexate, Enbrel, Humira) are stopped for 2 weeks before and 2 weeks after surgery.
The foot is placed in a bulky cotton and plaster splint immediately after surgery. Recovery occurs in the Post Anesthesia Care Unit or PACU, and then you are discharged home. Physical therapy will assist in proper use of crutches, walker or medical scooter.
Focus for the first 2 weeks post surgery is to rest, get plenty of sleep, eat well and drink plenty of water. Your body will have greater metabolic demands on it to heal. If you are a poor eater, I strongly recommend drinking one or two medical protein shakes per day for the week before surgery and for two weeks after. Keep your surgical foot elevated at the level of your heart when you are not getting up to eat or use the bathroom. You should take the pain medication as directed as necessary. If prescribed, you should take the medication for reducing the chance of blood clots as well. Keep the splint dry.
Small spots may appear on the bandage. You may reinforce the dressing with an ace wrap obtained from a pharmacy. While highly unlikely, excessive bleeding through the bandage is of concern and you should call the office to be seen.
If the surgery was on the LEFT side, many patients drive by two weeks when they are off the pain medication. If surgery was on the RIGHT side, driving can resume at the eight week mark, at which time the walker boot can be removed to drive and then place back on when getting out of the car. You may also want to apply for a handicap parking placard.
That depends on what you do. Sedentary desk workers may return as soon as two weeks. On the other end of the spectrum, construction laborers are typically out of work for three to six months. You will be provided out of work notes, or restricted duty notes, as necessary during the recovery phase. Family leave paperwork can also be submitted.
Download the Flat Foot Deformity Post-Operative Guidelines for full details.
Get ready for it! Optimize your physical and mental state and make sure you have allowed yourself the time necessary for recovery. Certainly, call us if you have any questions. More information can be obtained from the American Orthopedic Foot andAnkle Society website .
