Brian Bone graft

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					                                   Brian C. Toolan MD
                            Orthopaedic Foot and Ankle Surgery
                                   The University of Chicago
                  Section of Orthopaedic Surgery and Rehabilitation Medicine
                  5841 S. Maryland Ave. MC 3079  Chicago  Illinois 60637
                               Phone 773.702.6984 Fax 773.702.0076

                                    Flat Foot Reconstruction

         A flat foot reconstruction is designed to give your foot an arch. A flat foot is a common
biomechanical problem that occurs when a person’s arch collapses. The arch is the main
supportive structure of your foot. If the arch loses its strength, the bony framework begins to
collapse causing your foot to flatten. Like a sagging bridge, the weakness in the middle strains
the joints at both ends of your foot. This can cause severe stress, inflammation, discomfort and
may lead to other foot problems.
         As the framework of the foot collapses, the foot flattens and may add additional stress to
other parts of the foot. These problems include hammertoes, bunions, heel spurs, arch strain,
corns, neuromas and sagging joints. Flat feet can also affect other parts of the body causing
fatigue, pain or stiffness in the ankles, knees, hips and lower back.

         Flat foot reconstruction involves fixing the bones and soft tissues to give your foot an
arch. It actually consists of a combination of procedures. Your physician will choose the
combination that will best help you. They are a lapidus procedure, lateral column lengthening,
calcaneal osteotomy, an FDL tendon transfer to the navicular, and a gastrocnemius recession.
         The lapidus procedure is part of the bony work of the reconstruction. It involves an
incision over the top of your foot on the same side as your big toe. The first metatarsal is fused
with the cuneiform bone in a position that restores the arch. It will be held together by two
screws. These screws will remain in place and will not be removed unless they cause you pain.
The joint that is fused does not have a lot of motion in the first place, so there will be no
significant change in the function related to the fusion.
         The lateral column lengthening is also part of the bony work of the reconstruction. This
involves taking a piece of bone (bone graft) from your pelvis. An incision can be expected above
your hip and is concealed by your under garments. The bone graft will be placed through an
incision on the outside of your foot between the cuboid and calcaneous. This is to help bring
your foot into good alignment (straight). The bone graft will be held in place by a plate and
screws that will not be removed.
         Sometimes, instead of using bone graft, your heel is cut and moved over to straighten
your foot. This procedure is called a calcaneal osteotomy. Your doctor will decide which
procedure works best for your particular case.
         The FDL tendon transfer is part of the soft tissue work of the reconstruction. The tendon
that usually supports the arch is no longer able to do all of the work by itself. So the FDL (flexor
digitorum longus) tendon is transferred to the navicular bone. The FDL is usually responsible for
curling the very end of your toes downward, and this motion is not missed. The FDL tendon
transfer helps to support the arch and is performed through an incision on the inside arch of the
         The gastrocnemius recession is part of the soft tissue work of the reconstruction. When
you have flat feet, this muscle tends to be contracted, or tight. When this muscle is contracted,
you are forced to put more weight on the front of the foot, straining the arch. When you release
the muscle, it allows you to distribute the weight on the hind foot, instead of being pushed to the
front of the foot. This is performed through a small incision on the back of your calf. After
surgery this often feels like a really bad “Charlie horse”. To get rid of this discomfort, you can
tense your calf muscle (just like when you have a cramp in the middle of the night).

         The surgery takes approximately 3 hours. It is a surgery that involves a lot of bone and
soft tissue work. Because of the involvement of the procedure, you will be admitted to the
hospital for an overnight stay following surgery. You will also go home in a short leg cast that
you will stay off of for 6 weeks.

Post operative management
         There are many factors that affect your healing time. The most important is to be patient
and do not put any weight on your foot for the first 6 weeks after surgery. This is the amount of
time it takes for the bone work to heal. This means you must use assistive devices, like crutches,
a walker or roll-a-bout to get around. We do not want you to use a wheel chair because your
entire body gets weak and it will lengthen your recovery time.
         Another factor is smoking. YOU MUST NOT SMOKE while you are recovering. It will
delay your healing. This includes second hand smoke. Smoking decreases the blood flow to your
surgical site. This means that oxygen and nutrients essential for healing are decreased and will
lengthen your recovery. It is also possible that the bones will not heal, or your wound will not
heal and the skin dies. In the event that the bones do not heal, you will require additional surgery
to get the bones to heal.
         Another factor is swelling. This is something that can be avoided by elevating your foot
above heart level. Swelling can also be controlled with ice therapy. Icing for 20-30 minutes in
intervals will significantly decrease your swelling. The best thing to use for ice therapy is
crushed ice or frozen vegetables because they can conform around your cast or splint. By
eliminating swelling, you can reduce or eliminate your pain.

Pain management
         The first 2-3 days after surgery will be the worst. You will have both swelling and pain.
During this time it is very important that you decrease your activity level, elevate the operated
foot above heart level, and use ice therapy. You will notice when you put your foot down, it will
begin to swell immediately and you will experience a throbbing pain. To treat this, elevate and
ice and it should go away. Over the next two weeks, you will be able to increase the amount of
time you can have your leg down. It is still important to keep your leg elevated as much as
         After surgery, you will be given a prescription for pain medication. You should not need
any refills. If you are out of pain medication, perhaps you are being too active and need to
decrease your activity level. Before taking a pain pill, we suggest that you elevate and ice your
foot 20-30 minutes for pain control first. If elevation and ice do not adequately control the pain,
you may then take your pain medication. It is important to only take your pain medication when
you need it. Just because the prescription says you may take it every 4-6 hours, does not mean
that you have to.

         After surgery you will be placed in a cast or splint. There is a handout on cast care. One
important thing is to wiggle your toes 10 times an hour while awake to prevent stiffness. You
will be in a cast for at least 6 weeks.
         Two weeks after surgery, you will return to the clinic. Your cast will be removed, and
your stitches will be taken out. We will inspect the incision and steri-strips (like band aids) will
be placed on the skin. You will be placed in a lighter weight fiberglass cast. You must still
remain non-weight-bearing.
         Six weeks after surgery you will return to the clinic for a cast removal and x-rays. If x-
rays demonstrate that the bone is healing, you will not need another cast, and will be placed in a
CAM Boot, which is like a big ski boot. A CAM Boot is a boot that can be removed for bathing
and physical therapy. It must still be treated like a cast and worn at all times, including at night.
If the x-rays demonstrate that the bone still needs time to heal, then you will be put in a cast for
another 4 weeks. Then x-rays will be taken again to assess the bone healing, and the decision for
casting or a CAM Boot will be made.

Physical Therapy
        When you are placed in a CAM Boot, you cannot walk on it right away. You will begin
at 30-50 pounds of weight bearing with crutches/walker. This is simply putting the leg down and
supporting the weight of the leg only. You will now start physical therapy 2-3 times a week for
6-12 weeks to progress to full-weight-bearing without crutches. After full weight bearing has
been achieved, you will be weaned out of your CAM Boot into your regular shoes.
        During therapy, you will work on strengthening, mobility and gait training. At three
months, after surgery you should be independent with activities of daily living, but should expect
continued swelling. You will continue to work on the therapy you have learned at home.

         At 10-12 weeks after surgery, you will return for a clinic appointment. X-rays will be
taken to see how well the bones have healed. You may be able to return to work without any
         It is important to remember that you may still have good and bad days after your
treatment is completed. It can take up to six months to return to your normal level of activity.
Although there will be some bad days, over time you will get progressively better. We will see
you back at the six month anniversary of your surgery. At six to nine months, the foot should
“feel normal”, range of motion is greatly improved, swelling is decreased and there are no
problems with the foot with normal activities.
         At any time during your treatment, you may call the office at (773) 702-6984 with any
questions or concerns.
Before Flat Foot Reconstruction

After Flat Foot Reconstruction

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