Surgical Procedures for Flexible Flatfoot
Surgical intervention for flexible flatfoot should be considered only after failure of conservative management, with procedures selected based on the specific anatomical abnormalities and severity of deformity.
Initial Assessment and Conservative Management
Before considering surgical options, conservative treatment should be attempted:
- Activity modification and proper footwear selection
- Orthotic devices including heel lifts, arch supports, and custom orthotics
- Weight loss for obese patients (78% of adult-acquired flatfoot patients are obese) 1
- Physical therapy focusing on calf muscle and Achilles tendon stretching
- NSAIDs for pain and inflammation management
Surgical Procedures for Flexible Flatfoot
Soft Tissue Procedures
- Digital flexor tenotomy: Strongly recommended for patients with neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity 2
- Tibialis posterior tendon procedures:
- Synovectomy
- Tendon augmentation
- Tendon transfers (using tibialis anterior, flexor hallucis longus, or flexor digitorum longus) 3
- Achilles tendon lengthening: For cases with equinus contracture contributing to flatfoot deformity 4
Bony Procedures
- Calcaneal osteotomy: Medializing or lateral column lengthening procedures to correct hindfoot valgus 3
- Medial column stabilization: For navicular-cuneiform or first tarsometatarsal instability
- Modified Evans procedure: Lateral column lengthening, particularly effective when combined with procedures addressing forefoot supination 5
- Metatarsal osteotomy: For patients with neuropathic plantar ulcers on metatarsal heads 2-5 that fail non-surgical treatment 2
Joint Fusion Procedures (for more severe cases)
- Subtalar arthrodesis: For stage 3 deformities with fixed hindfoot valgus 3
- Double or triple arthrodesis: For rigid deformities or advanced stage flatfoot 3
- Joint arthroplasty: For neuropathic hallux ulcers that fail non-surgical treatment 2
Surgical Decision Algorithm
Mild flexible flatfoot (early stage):
- Begin with soft tissue procedures if specific tendon pathology is identified
- Consider digital flexor tenotomy for toe deformities causing ulceration
Moderate flexible flatfoot (stage 2):
- Combine calcaneal osteotomy with lateral column lengthening
- Add tendon transfers to restore dynamic support
Severe or rigid flatfoot (stage 3):
- Subtalar, double, or triple arthrodesis based on joint involvement
- Address both hindfoot and midfoot components of deformity
End-stage deformity (stage 4):
- Pantalar fusion may be necessary 3
Special Considerations
Pediatric patients: Surgical intervention is rarely indicated in asymptomatic children as most flexible flatfeet are physiologic and resolve with age 6, 4
Diabetic patients:
Neuromuscular conditions:
- Treatment principles differ based on severity, tibialis posterior spasticity, and ambulatory status
- Osteotomies for mild to moderate deformity in ambulatory patients
- Arthrodesis for severe deformity in non-ambulatory patients 5
Outcomes and Complications
- Success rates of 87.5% have been reported with appropriate non-surgical management 1
- Surgical complications may include:
- Overcorrection leading to cavus foot
- Undercorrection with persistent symptoms
- Transfer lesions or pressure points (particularly in diabetic patients) 2
- Non-healing surgical wounds in patients with poor vascular supply
Follow-up Care
- Regular monitoring for recurrence of deformity
- Custom footwear or orthotics may be needed post-surgery
- Continued calf stretching and strengthening exercises
Surgical treatment of flexible flatfoot should be tailored to address the specific anatomical abnormalities present, with the goal of creating a plantigrade, pain-free foot with good function.