Flatfoot Surgical Correction

What is adult flatfoot?

Adult flatfoot is a condition that causes flattening of the arch of the foot.

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X-ray views of a flatfoot before and after surgery. This patient had a first tarsal-metatarsal fusion, a medializing calcaneal osteotomy and a lateral column lengthening.


 
 

What are the goals of flatfoot surgical correction?

The goal of surgical correction is to improve alignment of the foot. This allows for more normal pressures during standing and walking. A combination of procedures is performed to repair the ligaments and tendons that support the arch. Bone cuts are often made to help restore the arch. Proper correction of flatfoot deformity can often help to improve pain and walking ability.
 

What signs indicate surgery may be needed?

Patients with flatfoot frequently describe ankle pain and difficulty with daily activities. Surgical reconstruction of the flatfoot is performed in patients with an arch collapse that is still flexible (not stiff). An orthopaedic foot and ankle surgeon should do a complete evaluation of the foot. This includes a medical history, physical exam and  X-rays. A trial of non-operative treatment should be completed prior to any decision to have surgery. Treatments can include rest, immobilization, shoe inserts, braces and physical therapy. If these are unsuccessful, surgery can be considered.
 

When should I avoid surgery?

Patients who have diabetes or take oral steroids should be evaluated by their primary care physician. These conditions may prevent you from being able to safely have surgery. Obese patients and smokers are at higher risk for blood clots and wound problems. Full recovery from flatfoot surgery can take up to a year. Patients who are unable or unwilling to complete this process should not have this surgery.
 

General Details of Procedure

A combination of surgical procedures can be used to reconstruct the flatfoot. Generally, these procedures can be separated into those that correct deformities of the bones and those that repair ligaments and tendons. Your orthopaedic surgeon will choose the proper combination of procedures for your foot.
 
Surgery of the foot can be performed under regional anesthesia, which is numbing the foot and ankle with a nerve or spinal block, or general anesthesia, which may require a breathing tube. A nerve block is often placed behind the knee to reduce pain after surgery.
 

Specific Techniques

Medializing Calcaneal Osteotomy
A medializing calcaneal osteotomy (heel slide) procedure is often used when the calcaneus (heel bone) has shifted out from underneath the leg. An incision is made on the outside of the heel, and the back half of the heel bone is cut and slid back underneath the leg. The heel is then fixed in place using metal screws or a plate.
 
Lateral Column Lengthening
Outward rotation of the foot may occur in patients with flatfoot. A lateral column lengthening procedure is sometimes performed for these patients. An incision is made on the outside of the foot, and the front half of the heel bone is cut. A bone wedge is then placed into the cut area of the heel bone. This wedge helps to “lengthen” the heel bone and rotate the foot back into its correct position. The wedge is usually kept in place using screws or a plate. The wedge can be taken from a cadaver or from a patient’s own hip.
 
Medial Cuneiform Dorsal Opening Wedge Osteotomy or First Tarsal-Metatarsal Fusion
Arch collapse can lead to the big toe side of the foot being raised above the ground. Your surgeon may perform a dorsal



X-ray views of a flatfoot before and after surgery. This patient had a first tarsal-metatarsal fusion, a medializing calcaneal osteotomy and a lateral column lengthening.

  opening wedge osteotomy of the medial cuneiform bone to treat this problem. An alternative is to perform a first tarsal-metatarsal joint fusion. Both procedures involve an incision over the top of the foot. In the case of the dorsal opening wedge osteotomy, a bone wedge is placed into the top portion of the bone to push it down toward the floor. In the case of the fusion, the bone is pushed down toward the floor at the level of a joint in the middle of the foot and the bones are fused into that position. Screws or a plate can be used to keep the wedge in place or to fuse the joint.
 
Tendon and Ligament Procedures
The posterior tibial tendon runs underneath the arch of the foot. It is often stretched and dysfunctional in patients with flatfoot. The tendon often requires removal if it is thickened or torn. Usually the tendon that bends the little toes can be transferred (rerouted) to help support the arch. The stresses placed on the flatfoot can lead to tearing of the ligaments that support the arch (spring ligament) and the inside of the ankle (deltoid ligament). Your surgeon may decide to repair these structures if significant damage has been done. Finally, the flatfoot condition is often associated with tightness of the Achilles tendon. This can be treated using a lengthening procedure to stretch the muscle fibers of the calf.
 
Double or Triple Arthrodesis
In the later stages of flatfoot, deformities are frequently inflexible (stiff). Arthritis of the foot may be present as well. Surgical correction of these severe cases requires fusion of one or more of the foot joints. This procedure is referred to as a double or triple arthrodesis depending on the number of joints fused. For more information, see the Triple Arthrodesis page.
 

What happens after surgery?

Patients may go home the day of surgery or they may require an overnight hospital stay. The leg will be placed in a splint or cast and should be kept elevated for the first two weeks. At that point, sutures are removed. A new cast or a removable boot is then placed. It is important that patients do not put any weight on the corrected foot for six to eight weeks following the operation. Patients may begin bearing weight at eight weeks and usually progress to full weightbearing by 10 to 12 weeks. For some patients, weightbearing requires additional time. After 12 weeks, patients commonly can transition to wearing a shoe. Inserts and ankle braces are often used. Physical therapy may be recommended.
 

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
 
Complications following flatfoot surgery may include wound breakdown or nonunion (incomplete healing of the bones). These complications often can be prevented with proper wound care and rehabilitation. Occasionally, patients may notice some discomfort due to prominent hardware. Removal of hardware can be done at a later time if this is an issue. The overall complication rates for flatfoot surgery are low.
 

Frequently Asked Questions

Will surgical correction of my flatfoot improve the cosmetic appearance of my foot?
Surgical correction of flatfoot is aimed primarily at reducing pain and restoring function. Although surgery will likely improve the cosmetic appearance of the foot, it is not one of the primary goals of treatment.
 
What activities will I be able to do following flatfoot surgery?
With proper correction and rehabilitation, many patients return to active lifestyles. Activities such as walking, biking, driving and even golfing are well tolerated. It is less likely, however, that patients will be able to participate in very strenuous activities requiring running, cutting or jumping.
 
The American Orthopaedic Foot & Ankle Society (AOFAS) offers information on this site as an educational service. The content of FootCareMD, including text, images and graphics, is for informational purposes only. The content is not intended to substitute for professional medical advice, diagnoses or treatments. If you need medical advice, use the "Find an Orthopaedic Foot & Ankle Surgeon" tool at the top of this page or contact your primary doctor.