When conservative treatment with physiotherapy or orthotics is insufficient, surgery may be required. Any treatment will naturally relate to the cause in question.
As injury to the posterior tibial tendon is an inherent part of this condition, it will be systematically explored during surgery. Surgery will excise the most inflamed areas (synovectomy), repair any tendon tears and, in the most advanced cases, reconstruct the tendon by transferring another tendon located nearby (generally the flexor digitorum).
The outcome of the surgery will depend on the severity of the injury.
In flexible flatfoot and in mild to moderate conditions, the exploration of the posterior tibial tendon will be associated with a section of the heel bone, also called an osteotomy. This allows us to move the area that touches the ground and used as an attachment for the Achilles tendon. It is worth restating that in cases of flatfoot the heel deviates laterally. During the osteotomy, the rear of the heel is moved inwards to correct the axis of the hindfoot (= calcaneal varus osteotomy). All is maintained in position by a screw or bone clips.
Calcaneal osteotomy: the heel is cut and moved to restore the normal alignment of the hindfoot.
In general, this surgery is performed using a 6-cm incision on the lateral edge of the heel. Very recently, new techniques have emerged and we now perform this technique using a percutaneous minimally invasive method. This reduces the scar to 2 mm and limits the risk of injury to the surrounding soft tissues.
Finally, shortening the Achilles tendon is standard practice in flatfeet (gastrocnemius equinus); the surgery is completed by stretching the tendon in the calf either via open surgery or by endoscopy.
In rigid flatfoot cases, tendon transfer surgery and osteotomy is not enough, as a dynamic correction is required, which is dependent on the various joints working properly. Cases of severe rigid flatfoot require the blocking of the joint, which implies major surgery. Several of the joints affected will then by sacrificed by merging them into the correct position in the foot, to straighten the arch, reduce the deviation of the heel and restore the correct support to the foot. The fusion of the joints, also called an arthrodesis, results in significant changes to the axes and the rotation of the various parts of the foot (double or triple arthrodesis of the foot).
Other procedures can also be carried out during the surgery, depending on the overall clinical picture.