What is it?

An operation to realign and stiffen (fuse) part of the hindfoot due to severe deformity. It may be done alongside other orthopaedic foot surgeries.

Why would it be performed?

To improve the position of a severe equinovarus (foot points down and inwards in a fixed position) deformity usually secondary to neuromuscular conditions such as polio or clubfoot. The operation will result in a repositioned stiff hindfoot which will be easier for footwear fitting, reduce any pressure points on the foot and ankle and make walking short distances easier.

What does it involve?

Cuts in the skin are made and a wedge-shaped area of bone is removed to remodel the hindfoot. The aim is to bring the foot up so that it is at a right angle to the lower leg or as close as possible. The remodelled bones in the hindfoot are then surgically fused together to maintain this corrected position. Sometimes a bone graft is needed to help with the remodelling. This can be taken from your shin or hip bone. Alternatively, sterile bone chips are sometimes used.

How long will I be in hospital?

Most people come in on the day of surgery after having a preoperative assessment a few weeks before. Most people will be in hospital for a few days after this operation. You will be given pain killers after the operation and you will be in a plaster which will be changed before you go home. The physiotherapists will show you how to walk without putting your foot to the floor using crutches.

Will I have to go to sleep for the operation?

Most people will go to sleep (have a general anaesthetic) for this operation. In some cases, you may have a spinal anaesthetic instead and remain awake during the operation. Your anaesthetist will advise you regarding the most suitable anaesthetic for you. In addition, you will have a local anaesthetic injection in your foot and ankle to help reduce the pain after the operation even if you are asleep for the surgery.

Will I have a plaster cast on after the operation?

You will need to wear a plaster cast from just below your knee to your toes until the bones have fused together. This is likely to take approximately 12 weeks.

What will happen afterwards?

You will be seen in clinic approximately 2 weeks after your surgery when your stitches will be removed/trimmed, the wounds checked and the plaster cast changed. You must continue to regularly elevate your foot above the level of your heart, do not weight bear on your operated foot and keep it dry. These measures will help to reduce swelling and to reduce the chances of wound complications.

You will be seen again approximately 6-8 weeks after your surgery for another wound check and to have some x-rays. You will likely be able to start weight bearing on the foot and will be given more details about this by your clinician.

Approximately 12 weeks after your operation, you will be seen again in clinic. Further x-rays will be arranged and if all is well, you can come out of the cast/boot and into supportive footwear. Your clinician will advise you regarding returning to work and other activities.

What are the risks?

• Infection of the bones is the most serious complication. If this happens, further surgery to drain the area and remove the infected bone and any hardware (screws and plates) will be needed. You may then need further surgery to get the foot to fuse in a satisfactory position. The results are then not as good had this complication not occurred.
• Minor infections of the wounds are slightly more common and usually settle after a short course of antibiotics.
• Sometimes surgical cuts are rather slow to heal. This usually just requires extra checks to redress the wounds and careful watching for infection.
• Swelling of the foot may take many months to decrease and some swelling will always be present. Swelling is part of your body’s response to the surgery rather than the operation going wrong but if you have any concerns and are worried about the swelling of your foot you should seek the advice of the foot and ankle team.
• Failure of the bones to heal properly. This may require another surgery.
• Loosening of the hardware (screws and plates) as the bones heal. This may cause pain and can be removed if needed.
• Nerve damage. Sometimes the small nerves in the surgical area may be stretched or damaged during the operation leading to some altered sensation in the foot. Occasionally there is pain associated with this damage that does not settle with time.
• Clot in the leg known as deep vein thrombosis (DVT) or the lungs known as pulmonary embolism (PE).
• Chronic regional pain syndrome (CRPS) is a broad term used to describe excess prolonged pain following injury to the foot. It can last for many months or even years.

There are general risks with any operation that include blood clots, anaesthetic and tourniquet complications.

What can I do to help?

Most patients find that simple measures can make a big difference to the outcome of surgery. The evidence from studies and our own experience supports this:

• Take simple Vitamin C and Vitamin D tablets or multivitamins helpful for tissue healing.
• Stop smoking – smoking slows down healing and is linked to increased complications.
• Keep fit and healthy- many problems are improved by losing weight.