Flat Feet Explained Final Part: Surgical Treatment

flat foot

This week, I will conclude my discussion on the treatment of flat fee by discussing surgical correction.  Surgery is usually reserved for people who have failed orthotic therapy, or those who have rigidly flat feet that generally will not benefit from orthotic inserts.  Each surgeon has their own criteria regarding how early they consider surgically correcting flat feet.  Some surgeons wait until all other options are exhausted, and others consider surgery much sooner in the treatment process.

Surgery must correct all components of a deformity that can be quite complex.  There are three different lines of motion that are involved in the flat foot deformity.  Each individual case has a different arrangement, where some feet are more deformed in one or two lines of motion compared with others.  The abnormal motions that dominate the deformity are the ones the surgeon needs to concentrate on, as this will affect their choice of surgical procedure.  Different surgical procedures have been developed to deal with the many nuances of the flat foot deformity.  A typical flat foot reconstructive surgery involves several different individual procedures to correct each component of the deformity.  The flat foot deformity can involve a shifting of the foot outward, a bending of the foot upward, and/or a rolling of the foot inward toward the big toe side.  By addressing the components that dominate the deformity, a surgeon can effectively reconstruct the foot to obtain better foot structure.  These procedures involve various combinations of bone cuts and soft tissue procedures that rotate, flex downward, or lengthen the foot.  More flexible deformities can tolerate the use of a blocking cone-like implant that keeps the foot from flattening, especially in younger patients.  Given the nature of the bone cuts, the foot and leg is usually immobilized during the recovery period, which can take two to three months before regular shoes can be worn.  Patients with the implant recover much faster.

Many people who have flat foot reconstructive surgery do quite well.  Such surgery does carry with it potential complications, including over or under correction, non-fusing bones, infection, and scar tissue formation.  Depending on general health, some people may not be good candidates for what amounts to be a mildly extensive foot procedure.  Proper following of all postoperative instructions is very important, as that alone can sometimes be the difference between a successful surgical outcome and a poor result.  These procedures are generally performed in an outpatient, same-day setting.

As you can see, the flat foot deformity is a very complicated condition that requires very careful consideration of all it’s components for treatment to be successful.  While most people do well in orthotics, surgery is needed in more advanced cases.

Flat Feet Explained: Part One

flat foot

Over the next couple of weeks I would like to discuss the nature of painful flat feet in the older child/teen and adult, and share some of my thoughts on treatment of this foot deformity.  Since this is a fairly involved topic, splitting the discussion up will help keep the post from getting too ‘wordy‘.

To start with, I would like to explain why we use the word ‘deformity’ to describe flat feet.  Flat feet are simply a normal anatomic variation of the human foot, as much as ‘normal’ or ‘high’ arches are.  It is likely mostly genetic, and passed to our children.  This variation is quite common, but does pose a unique challenge to modern humans, who tend to wear shoes most of their lives to protect the foot skin from the dangers of civilized living.  In populations where shoes are not worn, the foot’s muscle and support system is usually able to adapt to this flat structure from an early age.  By wearing shoes, we take away some of this adaptation.  However, the danger to the foot by walking barefoot in public or on concrete, gravel, and other hard surfaces far outweighs the lack of structural adaptation, and the notion that one should walk barefoot to keep this ‘natural’ process active is potentially harmful.  Unfortunately, because of the infrastructure we have paved our ground with for thousands of years, we are far better off in shoes.  However, those of us with flat feet must now deal with the issues that come with an unadjusted foot structure.  Even though flat feet are not a deformity in the same vein as an extra toe or clubfoot, we still refer to it as a deformity because in essence it functions as a foot deformity by being the source of numerous foot problems over time.

The foot problems that develop due to flat feet are generally due to instability that is present in the foot when it is allowed to over flatten.  This instability will gradually cause numerous other actual foot deformities by forcing the foot’s muscle and support system to change the way it anatomically is supposed to function.  The change in the way certain muscles and tendons pull on the foot, and the change in how ligaments and joints are positioned, will often lead to foot deformities like bunions and hammertoes.  These deformities in and of themselves can become painful over time in certain people.  However, of more importance to this discussion is the role flat feet play in causing tissue injury, which leads to chronic pain.  When flat feet are subjected to lengthy or strenuous activity, the overly flexible nature of this foot type can allow other parts of the foot to become overly stretched and strained.  This includes the plantar fascia, a thick cord on the bottom of the foot that is the source of the common heel pain when it is injured, as well as a large tendon under the inner side of the ankle called the posterior tibial tendon.  When this tendon is injured and not treated properly, it can lead to a debilitating degenerative process that can actually allow the foot to flatten further.  Other injuries directly related to flat feet include nerve inflammation in between the long bones of the foot known as a neuronal, as well as various arthritic conditions.

Since we now understand how and why feet are flat in some people, as well as what problems they can cause, we should move on to what is typically done to treat this condition so that it does not lead to pain and suffering.  This can be done by modifying the foot structure externally (better shoes and orthotics inserts), or by physically changing the internal structure of the foot (reconstructive surgery).  On the next couple of posts, I will discuss the reasoning behind each approach, and what I feel is the appropriate situation for either external or surgical treatment.

Can diabetics have bunion surgery?

bunion

Bunions can present a problem for diabetics in several different ways.  These problems sometimes make the option of surgically correcting the bunion more attractive than simply leaving it alone.

A bunion is a complicated deformity in which the 1st metatarsal bone at the base of the big toe joint is gradually moved outward towards the skin, making a large prominence on the side of the foot and pushing the big toe towards the second toe.  A comprehensive guide to bunions can be found by following the highlighted link.

The simple issue with bunions for a diabetic is the prominence of the bone against the skin, which can lead to abnormal shoe pressure and a skin wound.  Because the skin is generally stretched thin over this prominence, wounds can quickly deepen to bone, exposing it to bacteria and infection.  A somewhat less obvious issue with bunions for diabetics is the second part of the bunion deformity, namely a subtle inward rotation of the big toe that exposes more of the side of the toe to the ground pressure.  Since the skin on the side is not as thick as the skin on the bottom, a thick callus will result from this pressure.  This callus on the side of the big toe often becomes ulcerated after persistent pressure, leading to chronic wound problems that are difficult to treat due to the rotation acting on the toe.

By correcting the bunion deformity somewhat earlier in this process, these wounds can be avoided, and the risk of amputation is lowered.  Not all diabetics can or should have this elective intervention, as bone and skin must heal after the surgery.  For those in relatively good general healthy and stable blood sugars, this option can be attractive as a means to prevent future problems.