Ms Julie Kohls
Consultant Orthopaedic Surgeon
Part of the group
information to guide your decision making about treatment & to help you plan your recovery
Fusion Surgery for Arthritic Painful Flatfeet
What are the treatment options?
When an elderly (usually) patient has arthritis due to longstanding flatfoot deformity there are only a few options:
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Try a steroid injection because for some patients a guided injection can bring 6 -12 months of pain relief
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Try custom shoes and insoles or even calipers, custom shoes and insoles
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Fuse the arthritic joints
Why does fusing the arthritic joints work?
A subtalar and talonavicular joint fusion work because the arthritic bones fuse or "grow" together in a better position that gives the patient an arch again. There are two sources of pain leading to the decision to proceed to fusion surgery -one is arthritis in the joints producing pain and the other is the unnatural areas that rub together because the foot has been so flat for so long (usually on the outside of the foot between the calceneus and fibula)
What about ankle replacements?
Ankle replacements have a role for patients with rheumatoid arthritis but actually the ankle joint is quite normal for many patients who have an arthritic flatfoot deformity. If there is ankle OA and subtalar joint OA there can be a role for the option of fusing the subtalar joint and or ankle joint and replacing the ankle joint with an ankle replacement
What movement stops after fusion?
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The ankle still moves normally so what patients usually think of us up and down movement (and what surgeons call plantarflexion and dorsiflexion) still occur
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The side to side motion necessary for walking on cobblestones is lessened.
What can I expect on the day of surgery?
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The surgery will normally be under a general anaesthetic.
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Normally this is an overnight stay surgery.
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I will numb the ankle with local anaesthetic so that you will be comfortable when you wake.
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There will be a bulky half plaster cast on your lower leg which you will keep clean and dry.
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You will be given crutches or a frame and told not to weight bear.
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This is a major surgery and some patients may chose to pay to stay in a rehabilitation centre for a few days rather than going home.
What are the risks and complications?
The vast majority of patients do extremely well. A small group of patients need extra physio due to swelling or stiffness. Some patients require longer periods in plaster to assist healing. Complications include infection, blood clots (DVT), nerve damage, tendon injury, non-union, painful screws requiring removal, and long term there is risk of arthritis occurring in other joints.
Non union is a serious complication which occurs in one patient in twenty. If a non union is painful the entire surgery must be repeated.
When can I drive?
The best guide that you are safe to return to driving is that you are able to walk well without crutches and without a plaster or a boot. The usual time scale also depends on whether you had surgery on your right or left foot and whether you drive a manual or an automatic
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Right side and all car types: 3 months
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Left side and manual car: 3 months
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Left side &automatic car: 2 weeks
How long should I take off work?
The time you require off from work if you are still working depends on what type of job you do. The first two weeks of healing are critical and so you must have this time off work. Many people are able to work from home and so if you can avoid commuting in the first six - twelve weeks, you will find that your ankle does better. If your employer can be flexible with your activity at work you may be able to do some lighter duties or reduced hours from 3 weeks onward. If you work on your feet all day, do a manual job, or are required to wear dress shoes you may need 12 weeks before you are back at work.
Clear Advice About DVT
A DVT is a Deep Vein Thrombosis or a blood clot in the leg. A blood clot occurs after surgery where patients are placed into plaster or a splint for about 2 in every 100 patients. You can help prevent a blood clot by keeping your knee moving. Keeping yourself hydrated is also helpful to prevent a DVT. Finally elevating your leg to the level of your heart will minimise the amount of swelling you have which will also help to prevent a DVT. You will be given blood thinners for the first two weeks when you at your least active.
We will discuss how best to prevent a DVT and for most patients we opt to use injections of blood thinners for the first two weeks after surgery. After two weeks the risk is not completely gone however, you will be able to be more active. Most patients would rather stop blood thinners at that stage and monitor their leg for symptoms.
If you were to develop a DVT you would likely have some symptoms and so it is very helpful if know what to look for:
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The leg (above the dressing/foot) would become hard, heavy, swollen, painful and/or red
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If you were to have any of the above symptoms you would have to have a scan to look for a blood clot and then be treated with blood thinners
If the blood clot were to move to the lungs you would have a pulmonary embolism which is a medical emergency
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The symptoms of a pulmonary embolism are breathless & chest pain- Call 911
The Recovery after subtalar and talonavicular fusion surgery
Instructions 0-2 weeks
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Elevate Leg Above Heart most of the time
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Keep dry for two weeks
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Low-Molecular-Weight Heparin Injection daily for two weeks
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Non weight bearing in plaster back slab
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Move toes and knee
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Take Vitamin D (25ug) and ensure good sources of Calcium in Diet (yoghurt, cheese, milk, oily fish, dark green vegetables and fortified cereals) and do so for the first 3 months after surgery
2 weeks in clinic
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I will arrange to have your plaster & sutures removed
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You will then be placed in a full plaster and instructed to be non weight bearing for the next four weeks
6 weeks in clinic
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I will remove your plaster and send you for a X-rays of the ankle
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Provided the X-rays show some early healing you will be placed in a weight bearing plaster
6 weeks- 3 months
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Initially you will only place some weight through the plaster and some through crutches
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Week on week you should find that you can put more weight through the plaster
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Eventually you will take your weight fully through the plaster
3 months in clinic
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I will remove your plaster & send you for new X-rays
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If there is any doubt about whether there is solid bony union a CT scan will be arranged
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You will go into an Aircast boot
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You will then be able to wash the ankle
Physiotherapy instructions once able to weightbear and remove the Aircast boot
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Use the Boot for comfort but start to take small steps at home without the boot
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Gradually use the boot less and less as comfort allows
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Use Contrast bathing with bowls of hot and cold water. Place foot for 20 sec in cold and then alternate for 30 sec in hot. Do for 5 min.
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Your physiotherapist can use other local modalities to reduce swelling
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You may ice the ankle if this helps
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Use a compression stocking and elevate the ankle above the heart to help swelling
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Start to work on strengthening
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Theraband Resistance
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Cycling on stationary cycle
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Swimming and Hydrotherapy
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Work on developing an even gait
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Progressing to double heel rises
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THE ‘SURREY STAGES’ PHYSIOTHERAPY STRENGTHENING PROGRAM
BRONZE AWARD
DOUBLE HEEL RISES (DHR)
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You can go up and down on tiptoes in sets of 3, slowly and 15 reps in each
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You can stand on a skipping rope and adjust your foot position
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You can hold a DHR for 15 seconds
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It can be difficult to progress to the next award level because the ankle will take double the weight when you move to lifting the good leg to lower only on the operated leg.
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You are better to stay at the bronze award level but to add in a back pack with increasing weight as you feel ready for more
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When you have done this for some time you will be ready to progress to the silver award level
SILVER AWARD
DOUBLE HEEL RISES WITH A LIFT
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May need to add weight in backpack on DHR to reach silver level
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You go up on both feet but lift unoperated leg and lower slowly only on operated leg
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3 sets, working up to 15 reps in each
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You can stand both feet on a wobble board
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You can hold a solid DHR for 20 seconds
GOLD AWARD
SINGLE HEEL RISES
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3 sets, working up to 15 reps in each
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You can stand on one foot on wobble board
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You can hold a solid DHR for 40+ seconds
PLATINUM AWARD
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Progress to hopping in all directions
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Double Hops
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Gentle jogging to reintroduce running
All Ankle Fusions are entered into the UK data base held by the British Orthopaedic Foot and Ankle Society. Although the subtalar joint fusion is not yet part of the registry we can discuss consent on the day of surgery
The consent form is below