Ankle > Posterior Tibial Tendon Disorder > Treatments

   Heel Bone Osteotomy and Tendon Transfer

Preparing for Surgery

When your posterior tibial tendon has been torn and caused a flatfoot deformity, surgeons may be able treat your disorder by transferring a portion of an adjacent tendon, called the flexor digitorum longus (FDL). However, the transferred FDL tendon may not be as strong over time as your original posterior tibial tendon. To take some of the tension off your reconstructed tendon, your heel bone (calcaneous) often needs to be cut to realign your foot. If you and your physician have decided on heel bone osteotomy and FDL tendon transfer to treat your posterior tibial tendon disorder, the decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring a healthy and successful recovery.

   Prior to your return home from the hospital, make sure that you have received any equipment you will need when you get home. This may include crutches or household items to make movement around the house easier. You should receive prescriptions for any of these from your doctor before you go home from the hospital.

   Any physical problems or changes in your overall health, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any new medications you are taking.

   Learn the potential risks and benefits of the surgery by asking your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   If possible, practice walking with your crutches so you are ready to use them after surgery.

   Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   To check if the orthopedist performing the surgery is board-certified or eligible, call the American Board of Orthopaedic Surgery at 919-929-7103.

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   What to ask the doctor

At most medical centers, you will go to "patient admissions" to check in for your operation. There may be separate check-in areas for ambulatory outpatient surgery (patients go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your doctor or one of his assistants about this. After you have checked in to the hospital, you will go to a holding area where the final preparations are made. The mandatory paperwork is completed, and your ankle may be shaved, though this is not always necessary. You will be asked to change into a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or one of his assistants and meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). An IV (intravenous) line may be inserted into your arm at this time. Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important things to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Since you will most likely be able to go home within a few hours of surgery, arrange for someone to drive you home when you are released.

   Wear a loose pair of shorts, sweatpants, or other clothing that will fit comfortably over your short leg cast or splint when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

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   ABC’s of anesthesia

A heel bone osteotomy and tendon transfer surgery usually takes two to three hours to perform. Spinal anesthesia typically is given to numb you from the waist down and you usually are sedated so you sleep through the procedure.

   An incision approximately 12 to 14 centimeters long is made down the back of your lower leg, along the length of your posterior tibial tendon.

   Torn and damaged tissue is cut out from your posterior tibial tendon.

   An appropriately-sized portion of your FDL tendon, located next to the torn posterior tibial tendon, is cut and transferred over to where the posterior tibial tendon used to insert in the navicular bone.

   The portion of your FDL tendon is sewn in to replace the function of your posterior tibial tendon.

   Another incision is made on the outside of your foot so surgeons can gain access to your heel bone.

   A portion of your heel bone is cut along an angle.

   Surgeons slide the heel bone piece medially, toward the inside (big toe side) of your foot.

   The heel bone piece is fixed in place with screws.

   This new heel bone alignment slightly inverts your ankle. Your reconstructed tendon has to pull less on your foot bones to maintain your arch height, and your Achilles tendon also becomes a partial ankle inverter.

   Both incisions usually are closed with stitches and your ankle is put into a splint to immobilize it. You are then taken to the recovery room.

After heel bone osteotomy and tendon transfer surgery for a posterior tibial tendon disorder, you will be transported to the recovery room where you will be closely observed for one to two hours while the immediate effects of anesthesia wear off. Your ankle will be immobilized in a splint when you wake up, and your ankle will be elevated. Tendon transfers and heel realignments cause a substantial amount of pain. Adequate pain medications will be prescribed for you. You ordinarily are hooked up to an IV patient-controlled analgesia (PCA) device, which delivers pain medications in safe amounts when you push a button. Some patients may be prescribed oral or intramuscular pain medications. Your temperature, blood pressure, and heartbeat will be monitored by a nurse who, with the help of the doctor, will determine when you are ready to leave the recovery room and be transported to the hospital ward for further post-operative care. In some cases, you may be transported to a ward for intensive care or heart monitoring if you have special post-operative medical needs. Most patients spend one to two days in the hospital before going home.

After a heel bone osteotomy and tendon transfer, most healthy patients remain in the hospital from one to two days. However, some patients may require a longer stay in the hospital due to pre-existing medical problems or medical issues that may arise after surgery. Patients are not released until they demonstrate that they are safe to go home. Each patient is different and may have different criteria for being able to go home, but in general, the length of your hospital stay is based on the amount of pain management you need. The dressing inside your post-surgery ankle splint usually does not need to be changed until the splint is removed about two weeks after surgery. You will receive fluids and medications, through an intravenous (IV) line. You will continue to receive fluids through the IV line until you can drink an adequate amount of fluids without nausea or vomiting. Most patients can drink something the night after surgery and eat something more substantial the following morning. Be sure to ask for pain medications as soon as you feel pain coming on, because medications are most effective on pain that is building rather than on pain that is already present. Your nurses will not give you more than your doctor has prescribed and what is considered to be safe. In general, you are asked to take it easy and keep your ankle elevated above heart level as much as possible for four to five days. Physicians prescribe crutches to help you move around without putting weight on your ankle. Your physician may obtain X-rays of your heel and ankle before you leave the hospital. You should arrange for someone to drive you home when you are discharged.

For four to five days after heel bone osteotomy and tendon transfer surgery, you should keep off your feet, elevate your ankle above heart level, and move around the house as little as possible. You should try to rest and avoid too much movement for at least a week. Crutches usually are prescribed for about six to eight weeks. Rest as much as possible with your ankle elevated above your heart level. This helps blood drain away from your ankle and controls swelling. The more weight you put on your ankle, the greater your chances of further damaging the tendon and disrupting the healing process in your heel bone. Household tasks that require you to be on your feet may be difficult for six to eight weeks. It can be helpful to have someone around the house to help with any physical chores. You will most likely return to your physician’s office in 10 to 14 days to have the sutures removed and the post-surgery ankle splint replaced by a short leg cast.

To keep the cast dry, either wrap a plastic garbage bag around the cast while showering or bathe with your leg out of the tub. You usually are told not to bear any weight while wearing the cast for about six to eight weeks. Typically, you will return to your physician for check-up visits every two weeks until your tendon and heel bone have healed. When you come out of the cast, your ankle may be put into a brace or removable splint, called a cam walker, for another four weeks. This routine varies from surgeon to surgeon. X-rays commonly are taken but are not necessary on each visit unless some new problem has arisen. In general, you should continue using your crutches and wearing your cam walker as instructed by your doctor. When the cast comes off at six to eight weeks, you typically begin partial weight bearing in a cam walker before going back to normal shoe wear. You usually can begin wearing normal shoes again about ten weeks after surgery. Physicians commonly prescribe orthotic inserts for your shoes that can help support your arch. You may need to wear orthotic inserts in your shoes for at least a year, sometimes longer. You usually can start more formal physical therapy after about 10 weeks.

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   When to call the doctor after surgery

After six to eight weeks in a cast, most patients perform daily range of motion exercises to stretch their ankles for about four weeks prior to using weights to strengthen their ankles. Most patients can recover strength in their ankle and return to sports and activities in six to nine months after surgery. Your physician ordinarily prescribes range of motion exercises for you to perform at home after your cast is removed. Patients generally are instructed to remove their brace or cam walker for a brief period and prop their lower leg on a stool or pillow so your ankle is off the floor. Physicians usually recommend moving your ankle up-and-down, and side-to-side. Start with slow movements and do not move your ankle too far in any direction. About 10-12 weeks after surgery, ankle strengthening exercises usually begin under the supervision of a physical therapist. The rehabilitation period after heel bone osteotomy and FDL tendon transfer surgery is highly variable. Your individual range of motion and strengthening exercise schedule progresses as you can tolerate. The goal is to strengthen your posterior tibial tendon enough to support your arch and control your foot and ankle motion during activities. Your ankle might very well feel stiff, so you should take it easy as you begin walking in normal shoes. Everyone heals at a different rate and you should begin exercises slowly until your pain has decreased. Your realigned heel bone should be stable before you put stress on your ankle with walking, running, and other exercise. Physical therapy usually involves learning ankle stretching exercises and performing ankle and lower leg strengthening exercises.

To prevent reinjury of your posterior tibial tendon, physicians generally recommend strengthening the leg muscles that help pull your arch up, including the peroneal muscles on the side of your leg and your anterior tibial tendons in the front. Orthotics that support your arch can help to protect your posterior tibial tendon and help relieve tension on the tendon as it transfers weight. You usually can go back to wearing normal shoes, even flat work shoes, but the orthotic insert should be worn at all times. In general, sports that put repetitive stress on your ankles, such as long distance running, increase your risk of reinjury. If possible, you may want to switch to a sport such as cycling that puts less strain on your ankle. Before engaging in sports and activities, remember to include ankle stretches in your warm-up routine. Most younger patients can recover fully from a posterior tendon disorder and return to a normal level of activity. Middle-aged patients typically can go back to tennis or golf, but physicians generally recommend avoiding high-repetition sports like running.