Flexor Digitorum Longus (FDL) Tendon Transfer to Posterior Tibial Tendon

What are the goals of an FDL tendon transfer?

The goals of the procedure are to relieve pain and to help restore the arch in patients who have acquired painful fallen arches. A fallen arch occurs when the foot loses its support and flattens out.  Generally this occurs due to weakening of tendons and ligaments in the foot.

What signs indicate surgery may be needed?

Tendon transfer surgery is indicated for people with an acquired flat foot that is flexible. A flexible flatfoot is one that can be “moved” into a more normal position. The posterior tibial tendon (PTT) is a main support for the arch of the foot. If it becomes “diseased,” it no longer functions properly and the arch begins to fall. The patient begins to walk on the inside of the foot as it flattens. The toes turn outward and a fairly obvious deformity develops. When nonsurgical treatment such as arch supports fail to provide relief, surgery may be necessary.

When should I avoid surgery?

If the deformity has become rigid (stiff) or arthritis has developed, more advanced surgery is needed. This typically includes re-making the arch by fusing bones of the foot together. Patients with other medical problems may be too sick to safely undergo surgery.

General Details of Procedure

The PTT normally connects to the navicular bone near the middle of the foot at the instep. The FDL is one of the tendons responsible for bending the toes down to the floor. In this surgery the FDL tendon is moved from its usual position and transferred to the navicular bone. This helps support or replace the diseased PTT in order to improve function. The diseased PTT is typically cleaned up or removed to eliminate it as a source of pain.

Specific Technique

The surgery is typically done through an incision on the inside of the ankle and foot. The initial step is to remove the scarred or inflamed tissue of the PTT. The tendon may be completely removed if it is severely damaged. Just below the PTT is the tendon of the FDL. The FDL is cut so that it is as long as possible. A hole is drilled in the navicular bone. The end of the FDL is placed through the bone. While the foot is held in the corrected position, the tendon is attached to the bone. It may be held in place with stitches and/or an anchor or screw. The incision is then closed. Other procedures are commonly performed along with the tendon transfer in order to improve the arch. These can include moving or shifting of bones and stretching of the calf muscles or Achilles tendon.

What happens after surgery?

Patients are usually placed in a well-padded dressing with a splint or split cast. No weight is allowed on the ankle and foot. Patients are typically given crutches or a walker. A knee walker/scooter may also be an option. This procedure may be done as an outpatient or may require an overnight stay.
At two weeks the sutures are typically removed and a new cast or removable brace is applied. At six weeks most patients transition into a walking cast or boot with a well molded arch.
At three months, patients return to a shoe with an arch support. Elastic hose may be prescribed for swelling and physical therapy may be prescribed to help with walking and to restore muscle strength and joint flexibility. It may take up to nine to 12 months for patients to fully recover.

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Standard wound complications can occur and may include delayed healing and infection. Irritation of an adjacent nerve can occur and may cause numbness or burning. These symptoms typically resolve with time. Rarely the repositioned tendon may pull out of the navicular bone and require re-placement. A more common problem is failure to restore the arch and a residual flat foot.

Frequently Asked Questions

Can I expect pain relief with this surgery?
Typically, pain relief is achieved with the procedure. The use of arch supports is typically recommended even after successful surgery. Ankle bracing may also be helpful. 
What alternatives do I have if my arch is not restored or falls again?
If the arch is not restored or falls further, and arch supports and/or bracing are not helpful, additional surgery may be considered.
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