Flexor Digitorum Longus

The flexor digitorum longus (FDL) is one of the tendons responsible for bending the toes down to the floor. The goals of a FDL tendon transfer surgery are to relieve pain and to help restore the arch in patients with painful fallen arches. A fallen arch occurs when the foot loses its support and flattens out, generally due to weakening of tendons and ligaments in the foot.

Diagnosis

Tendon transfer surgery is indicated for people with a flexible flatfoot that can be moved into a more normal position. The posterior tibial tendon (PTT) is a main support for the arch of the foot. If it becomes diseased, it no longer functions properly and the arch begins to fall. The patient begins to walk on the inside of the foot as it flattens. The toes may begin to turn outward resulting in a flatfoot deformity. When non-surgical treatment such as arch supports fail to provide relief, surgery may be necessary.

If the deformity becomes stiff or arthritis develops, more advanced surgery is needed. This typically includes re-making the arch by fusing bones of the foot together. Patients with other medical problems may be too sick to safely undergo surgery.

Treatment

The PTT connects to the navicular bone near the middle of the foot at the instep. In this surgery, the FDL tendon is moved from its usual position and transferred to the navicular bone. This helps support or replace the diseased PTT to improve function. The diseased PTT is cleaned up or removed to eliminate it as a source of pain.

Specific Technique

The surgery is done through an incision on the inside of the ankle and foot. The initial step is to remove the scarred or inflamed tissue of the PTT. The tendon may be completely removed if it is severely damaged. Just below the PTT is the tendon of the FDL. The FDL is cut so that it is as long as possible. A hole is drilled in the navicular bone. The end of the FDL is placed through the bone. While the foot is held in the corrected position, the tendon is attached to the bone. It may be held in place with stitches and/or an anchor or screw. The incision is then closed. Other procedures may be performed with the tendon transfer to improve the arch. These can include moving or shifting of bones and stretching of the calf muscles or Achilles tendon.

Recovery

Patients usually are placed in a well-padded dressing with a splint or split cast. No weight is allowed on the ankle and foot. Patients are given crutches, a walker, or a knee walker/scooter. This procedure may be done as an outpatient or may require an overnight stay.

At two weeks the sutures are removed and a new cast or removable brace is applied. At six weeks most patients transition into a walking cast or boot with a well-molded arch. At three months, patients return to a shoe with an arch support. Elastic hose may be used for swelling and physical therapy may be prescribed to help with walking and to restore muscle strength and joint flexibility. It may take up to one year for patients to fully recover.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Standard wound complications can occur and may include delayed healing and infection. Irritation of an adjacent nerve can occur and may cause numbness or burning. These symptoms typically resolve with time. Rarely the repositioned tendon may pull out of the navicular bone and require re-placement. A more common problem is failure to restore the arch and a residual flat foot.

FAQs

Can I expect pain relief with this surgery?

Typically, improvement in pain control is achieved with the procedure. The use of arch supports often is recommended even after successful surgery. Ankle bracing may also be helpful.

What alternatives do I have if my arch is not restored or falls again?

If the arch is not restored or falls further, and arch supports and/or bracing are not helpful, additional surgery may be considered.

Ankle Cheilectomy

An ankle cheilectomy is a surgery that removes a bone spur from the talus or tibia, which are the lower and upper bones of the ankle joint.

The goal of an ankle cheilectomy is to relieve ankle pain caused by bone impingement or pinching at the front of the ankle. While this may be a sign of early ankle arthritis, an ankle cheilectomy is a joint preserving option that may help with pain and function and buy time before additional treatment is needed.

Diagnosis

If you have pain at the front of the ankle that does not improve with non-surgical treatment, your foot and ankle orthopedic surgeon may consider an ankle cheilectomy. The pain is usually worse with upward bending (dorsiflexion) of the ankle. The pain typically is caused by a bone spur.

An ankle cheilectomy is not recommended if you have severe ankle arthritis. Removal of bone spurs in arthritic ankles typically does not improve pain.

Treatment

An ankle cheilectomy can be performed arthroscopically (minimally invasive) or with an open procedure. The choice for open or arthroscopic procedure is made based on the size of the spur and the preference of the surgeon.

• Arthroscopic: When an ankle arthroscopy is performed, a camera is placed into the ankle joint through a small incision. The cartilage and soft tissues inside the ankle joint are examined and the bone spur is seen with the camera. It is removed with an instrument such as a burr or chisel placed into the ankle through a separate small incision.
• Open: An incision is made at the front of the ankle. The ankle joint is opened, and the bone spur is identified and removed.

Recovery

Activity after surgery may depend on the size of the bone spur and the degree of swelling or bleeding that occurs during surgery. There may be a period where you may not be allowed to put any weight, or only partial weight, on the ankle. This usually lasts for 1-3 weeks. Physical therapy is then typically started, and weight bearing and activity generally are increased as tolerated.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Patients may experience loss of feeling at the top of the foot after this procedure. Pain may not improve after an ankle cheilectomy, and an increase in ankle pain can occur. While many patients do experience a significant reduction of pain, there is a risk of recurrence of the pain after surgery as underlying arthritis progresses. However, the overall complication rate for this surgery is low.

FAQs

Will I regain range of motion in my ankle if the bone spur is removed?

Range of motion may increase after removal of bone spurs. This does not always occur as soft tissues such as tendons and ligaments around the ankle may still be tight, and these tissues also affect ankle motion. Often, even if motion is not improved, the pain from the bony impingement improves.

The Achilles tendon is a large tendon at the back of the lower leg and ankle that connects the calf muscles to the heel. It is the largest tendon in the body, and its strength allows us to push off with forces up to 10 times our body weight.

Achilles Tendon Tear

An Achilles tendon tear, or rupture, usually is a complete gap between the upper and lower portions of this tendon. It most often occurs 2-3 inches above the heel bone but can be directly at the attachment or higher in the leg.

Symptoms

A tear usually occurs during activities such as running and jumping, or trauma such as a slip and fall. Most patients report their first feeling was a “pop” or like they were struck in the back of the ankle, followed by some pain. There often is no pain in this area before the actual tear. After the tear, patients complain of weakness when pushing off of their foot during walking or when trying to stand on tiptoe.

Diagnosis

Your foot and ankle orthopedic surgeon often performs an examination to make a diagnosis. You will lie in a facedown position with your ankles off the edge of the exam table. When the Achilles tendon is not torn, it is taut and the ankle lies in a toe down position of approximately 20 degrees. Squeezing the upper calf will cause the toes to point down even further.

If the tendon is torn, it does not have this tension and the ankle usually will hang at about a 90-degree angle. Squeezing the upper calf will cause weak or no movement. Special tests such as ultrasound, X-rays, and MRI scans typically are not required but can be in some instances.

Treatments

At first, the leg is placed at rest in a splint or special boot. It is important to see a foot and ankle orthopedic surgeon soon after the injury so the best treatment can be started within a few days.

Both non-surgical and surgical treatments have been well studied but remain debated. In general, surgical treatment is thought to give greater strength and result in a lower risk of repeat tear. However, surgery has an increased risk of wound healing problems, nerve damage, and infection plus the usual risks associated with surgery. Blood clots are a concern with both types of treatment. Your foot and ankle orthopedic surgeon will be the best person to guide you through the pros and cons and help you to select the best option.

Non-surgical Treatment

Non-surgical treatment starts with a period of rest in a boot for the injured leg. You will need to use crutches, a walker, or wheelchair in order to not put weight on the leg. Within the first few weeks you will start doing active motion. Gradually, you will be allowed to put weight on the leg and start specific strengthening exercises. The length of treatment may be different for each patient but usually takes about three months. It is often guided by a physical therapist along with the orthopedic surgeon.

Surgical Treatment

In this surgery, your foot and ankle orthopedic surgeon will place stitches into the tendon above and below the area of the tear and then pull the ends together. The surgery often is performed through a very small incision to minimize the risk of wound complications. The recovery after surgery is similar to the non-surgical treatment but can be slightly shorter.

Recovery

Since tendons do not have a great blood supply, healing is a slow process. Patients usually can start light jogging in 3-6 months with return to sports involving cutting and jumping in 6-9 months. Full return of strength and the feeling of being normal may take more than a year.

FAQs

After an Achilles tendon tear, how likely am I to tear the other side?

About 6% of patients with an Achilles tendon tear will have the same injury in the other foot.

Is there anything I can do to make the tendon heal faster?

Starting range-of-motion exercises and putting weight on the injured leg early have shown better results than long periods of immobilization on crutches. However, it has to be balanced by the risk of pulling apart the ends of the tendon if you stretch too much too early. Stopping smoking for at least a few months while the tendon heals also is likely to be of benefit.

Adult Acquired Flatfoot Deformity (AAFD)

Adult acquired flatfoot deformity (AAFD) is a progressive flattening of the arch of the foot that occurs as the posterior tibial tendon wears down. It has many other names such as posterior tibial tendon dysfunction, posterior tibial tendon insufficiency, and dorsolateral peritalar subluxation. This problem may progress from early stages with pain and swelling along the posterior tibial tendon to complete arch collapse and arthritis throughout the hindfoot (back of the foot) and ankle.

Anatomy

The posterior tibial muscle originates on the bones of the lower leg (tibia and fibula). This muscle then turns into the posterior tibial tendon, which passes behind the inside of the ankle and attaches to the navicular bone along the instep of the foot. The posterior tibial tendon plays a central role in maintaining the arch of the foot when you stand and walk.

In addition to tendons running across the ankle and foot joints, a number of ligaments span and stabilize these joints. The ligaments at the inside of the ankle also can become stretched and contribute to the progressive flattening of the arch.

Several muscles and tendons around the ankle and foot act to counter-balance the action of the posterior tibial tendon. Under normal circumstances, the result is a balanced ankle and foot with normal motion. When the posterior tibial tendon fails, the other muscles and tendons become relatively overpowering. These muscles then contribute to the progressive deformity seen with this disorder.

Symptoms

Patients with AAFD often experience pain, deformity, and/or swelling at the ankle or hindfoot. When the posterior tibial tendon does not work properly, a number of changes can occur to the foot and ankle. In early stages, symptoms often include pain and swelling along the posterior tibial tendon behind the inside of the ankle.

As the tendon fails over time, deformity of the foot and ankle may occur. This deformity can include:

• progressive flattening of the arch
• outward shifting of the heel so that it no longer is aligned underneath the rest of the leg
• rotational deformity of the forefoot
• tightening of the heel cord
• development of arthritis
• deformity of the ankle joint

At certain stages of this disorder, pain may shift from the inside to the outside of the ankle as the heel shifts outward and structures are pinched on the outside of the ankle.

A patient with AAFD of the left foot. You can see that the heel has shifted outward and is no longer aligned under the leg.

Causes

Posterior tibial tendon dysfunction is the most common cause of AAFD. Often there is no specific event or injury that starts the problem. More commonly, the tendon is injured from “wear and tear” over time. Posterior tibial tendon dysfunction occurs more commonly in patients who are born with a flat foot or who develop the condition for other reasons. With a relatively flat arch, more stress is placed on the posterior tibial tendon and also on the ligaments on the inside of the foot and ankle. The result is a progressive disorder. Weight also plays a role in the progression of this disorder. For overweight patients, significant weight loss may lead to some improvement of symptoms.

Diagnosis

The diagnosis of posterior tibial tendon dysfunction and AAFD usually is made from a combination of symptoms, physical exam and X-rays. Your foot and ankle orthopedic surgeon will look at the location of the pain, shape of your foot, flexibility of the hindfoot joints, and how you walk to make the diagnosis and assess how advanced the problem is.

Achilles Tendon Rupture Surgery

The goal of Achilles tendon rupture surgery is to reconnect the calf muscles with the heel bone to restore push-off strength. Regaining Achilles tendon function after an injury is critical for walking.

Diagnosis

Those best suited for surgical repair of an acute or chronic Achilles tendon rupture (tear) include healthy, active people who want to return to activities such as jogging, biking, or other sports. Even those who are less active may be candidates for surgical repair. Non-surgical treatment may also be an option. You should discuss the decision to have surgery with your foot and ankle orthopedic surgeon.

You should not have this surgery if you have an active infection or unhealthy skin at or around the site of the Achilles tendon rupture, or if you are not healthy enough to undergo surgery. Other concerns include diabetes, smoking, sedentary lifestyle, steroid use, and inability to follow postoperative instructions. Any health concerns should be discussed with your foot and ankle orthopedic surgeon.

Treatment

Surgery for an acute or chronic rupture of the Achilles tendon typically occurs in an outpatient setting. This means you will have surgery and go home the same day. Numbing medicine is placed into the leg around the nerves to help decrease pain after surgery. This is called a nerve block. You will then be put to sleep and placed in a position that gives the surgeon access to the ruptured tendon. Repair of an acute rupture usually takes between 30 minutes and one hour. Repair of a chronic rupture can take longer depending on the steps needed to fix the tendon.

There are a variety of ways to repair an Achilles tendon rupture. The most common method is an open repair. This starts with your surgeon making an incision on the back of the lower leg starting just above the heel bone. After the surgeon finds the two ends of the ruptured tendon, they sew these ends together with sutures and close the incision.

In most cases, Dr. Reed can repair your rupture through a percutaneous approach. He makes a small incision on the back of the lower leg at the site of the rupture. Then he will pass a series of needles with sutures attached through the skin and Achilles tendon and then bring them out through the small incision. He will then tie the sutures together. Talk to your foot and ankle orthopedic surgeon to determine the best surgical technique for your Achilles rupture.

Recovery

After surgery, you will be placed in a splint or cast from the toes to just below the knee. Typically you will not be allowed to walk or put weight on the involved leg. You can use crutches, a walker, knee scooter, or wheelchair to move around. Keeping the operated leg elevated above heart level will help decrease swelling and pain. If a nerve block has been given, you can expect the numbing sensation to last from 8-24 hours.

Patients typically are seen in the office two weeks after surgery. The splint or cast is removed and the surgical incision is evaluated. Stitches usually are removed at this time if they need to be removed at all. From 2-6 weeks, the postoperative protocol varies based on the surgeon’s preference. You may be allowed to begin weightbearing in a walking boot. Ankle motion is often allowed and encouraged. A cast is sometimes used instead of a boot.

At six weeks patients usually are allowed full weightbearing out of the cast or boot. You may start physical therapy to restore ankle range of motion. Your surgeon will gradually allow strengthening exercise for the calf muscles and Achilles as the tendon heals. Patients usually are able to return to full activity by six months, but it may be more than a year before they achieve full recovery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Potential complications specific to Achilles tendon surgery include wound infection and delayed wound healing. Re-rupture can also occur. There may be scarring of the tendon or thickening of the surgical scar. A nerve that gives sensation to the outside part of the foot can be stretched or injured during surgery, which can result in numbness or burning.

FAQs

What is the likelihood of success with Achilles tendon rupture surgery?

Surgical repair of an acute rupture usually does well. It is important to understand that even after a successful surgical repair the ultimate strength of the leg will likely be less than it was before the injury.

What is the risk of tendon re-rupture?

The risk of re-rupture after surgical repair is less than 5%. If re-rupture occurs, the tendon can be repaired again either directly or with other techniques that utilize other tissues and materials to reinforce the repair. Revision surgery is always more complex than the original surgery.