Tibial Tendon Disorder >
Bone Osteotomy and Tendon Transfer
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.
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.
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.
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.
possible, practice walking with your crutches so you
are ready to use them after surgery.
a second opinion from another qualified surgeon is often
advisable, particularly in rare or unique cases.
check if the orthopedist performing the surgery is board-certified
or eligible, call the American Board of Orthopaedic
Surgery at 919-929-7103.
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:
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
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.
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.
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.
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
incision approximately 12 to 14 centimeters long is
made down the back of your lower leg, along the length
of your posterior tibial tendon.
and damaged tissue is cut out from your posterior tibial
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.
portion of your FDL tendon is sewn in to replace the
function of your posterior tibial tendon.
incision is made on the outside of your foot so surgeons
can gain access to your heel bone.
portion of your heel bone is cut along an angle.
slide the heel bone piece medially, toward the inside
(big toe side) of your foot.
heel bone piece is fixed in place with screws.
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.
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.
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,
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.