Ankle fusion for posterior tibial tendon dysfunction

Hi @1956 and welcome to Mayo Clinic Connect. I'm bringing in @jenniferhunter @plantbased2 @user_ch3aef5aa @melcpa86 and @bijouxb into this discussion in the hopes that they might have some insights to share.

1956, I found this information from the American Academy of Orthopaedic Surgeons about different surgical options
https://orthoinfo.aaos.org/en/diseases--conditions/posterior-tibial-tendon-dysfunction/
Is fusion the only surgical option for your situation or were others discussed too?

@1956 Right now, I am recovering from an ankle fracture that is called a bimalleolar fracture, and basically that means that the "knobs on both sides of my ankle were broken. The inside one is the tibia which was also shattered on the front, and the outer knob is the fibula which was a compound fracture. I am just now working on rehabbing my ankle with a physical therapist and have been out of my cast 5 weeks and trying to learn to walk normally again. I understand how hard this is to try to get an ankle functioning and to get muscles to work that don't want to respond correctly and the weakness that goes with that. I also assisted my elderly mom who had fallen and broken her pelvis and foot a few years ago. She went through rehab, but her foot always hurt and she didn't want to walk, and what happened is her Achilles tendon became tight and short. Her foot was a bit deformed before this happened because of bunions and when it tightened, her foot twisted into a position of pointing her toe and twisting her ankle at the same time and she could not put her foot flat on the floor. We got 3 opinions about surgery, one of which was an ankle fusion. The surgeon she selected did a procedure to lengthen and splice her Achilles tendon and he also changed some of the tendon muscle attachments on her foot itself. He lengthened the Achilles by cutting the tendon in a kind of "zig zag" so he could slide that apart to lengthen it, and sutured it back together. That surgeon was a foot deformity specialist, not a general surgeon, and it was successful. Because of her age (she was 86 at the time) her surgeon wanted her to also wear a custom brace on that foot. She can walk, but will never walk well, but her foot was a lot more functional than it would be if it had been fused. She does not like the brace, so she uses her wheelchair instead of walking which is a safer choice for her. My recommendation would be to find an orthopedic foot deformity surgeon who only does foot and ankle types of surgery for an opinion. Get several opinions. I was surprised at the variety of procedure opinions my mom got with her ankle. I think the tendon lengthening was the best choice for a more normal function.

I also do have somewhat flat feet, and getting custom orthotics from a podiatrist helped me a lot. Orthotics would support your foot in a normal position. I was having a lot of pain and straining my ankle because of horseback riding with the pressure of my foot in the stirrup. Getting orthotics and getting 4 inch wide padded stirrups resolved that problem and I could ride pain free again. Since breaking my ankle, I have needed the orthotics for weight bearing because otherwise it is too painful for me to stand or walk with pain not just in my foot , but my entire leg. If the alignment isn't right, it stresses the knee joint and I also have to make sure my pelvis stays aligned. A physical therapist needs to check and correct foot/knee/pelvis alignments or it will throw everything off. I had corrective shoes as a kid, but it was discovered when I was about 6 which was too late to get complete correction as I grew. Since having my foot immobilized for 6 weeks due to the fractures, my arch now seems to be higher and my ankle is stiffer. I don't know if that will be permanent but it seems to be a positive outcome.

With the link Colleen posted, there is a discussion about tendon transfers. Ask questions about what function you would loose with a tendon transfer as well as what you would gain. My husband discussed this with a doctor because he has a partial Achilles tendon tear, and a tendon transfer for that would cause him not to be able to curl his toes downward. A tendon transfer isn't always necessary, and they also talked about removing the damaged tendon tissue and letting it fibrose back together. A tendon transfer could affect walking and there may always be some compensation. A physical therapist might also be a good source for questions about walking function if one of the tendons was removed and moved somewhere else.

I am a 68 year old retired male and have a progressively deteriorating left foot and ankle. I was diagnosed about 10 years ago with PTTD. I have been trying to ignore this disability and profound discomfort for as long as I can. I am way past conservative treatment and probably need surgery. I’ve been in denial too long and I’m not getting any younger.

Welcome @kidddrocks, I know the feeling about ignoring health issues until fix or else time. I'm assuming you've tried orthotics and other conservative treatments already if you are way past that. Maybe you've already seen this but I thought it might be helpful to know what the options are for treatment.

"How do you fix PTTD?
Most patients can be treated without surgery, using orthotics and braces. If orthotics and braces do not provide relief, surgery can be an effective way to help with the pain. Surgery might be as simple as removing the inflamed tissue or repairing a simple tear."
-- Posterior Tibial Tendon Dysfunction - OrthoInfo - AAOS: https://orthoinfo.aaos.org/en/diseases--conditions/posterior-tibial-tendon-dysfunction/

Have you discussed surgery or other treatment with your doctor or orthopedic surgeon?

When I very first started having unrelenting pain, I went to a local podiatrist. I was injected and put in a boot then a brace. Since then, fast forward I’ve had a knee replacement and my orthopedic doctor suggested seeing a surgeon in Orlando which I haven’t done. But I just had prostate surgery at Mayo in Jacksonville and this experience has spoiled me for any other hospital. I believe my bad foot is deteriorating because I develop blisters on my great toe every few months as my arch deteriorates.

Have you tried sending using your Mayo Clinic Patient Portal to send a message to your previous surgeon to see if they can hook you up with a foot surgeon? Might be worth a try.

The surgeon who did my TKR is not a Mayo guy (not that he is necessarily against Mayo). He suggested a doctor in Orlando who is, according to him, very familiar with this type of repair surgery. Do you know if I request an appointment at Mayo can it be quickly streamlined to the best guy for the job? My local urologist facilitated the referral for my prostate surgery. Do I necessarily need a doctor to doctor referral for the orthopedic issue?

I think you can message your care team through your Mayo Clinic patient portal. I was thinking you could explain your situation in the message and see if they can hook you up with the best surgeon. I know Mayo Clinic surgeons are highly rated. I had my right knee replaced and cataract surgery in both eyes at Mayo Rochester and have been super happy. I don't think you need a doctor referral but it sometimes can help depending on the situation.

You can also request an appointment here - http://mayocl.in/1mtmR63

Jacksonville is about 90 miles from us. It was well worth having my HoLEP laser prostate done there. I’ve been in health care all my life and it was an amazing experience and I have a big frame of reference.

My health care team is focused on urology. I would not ask them an ortho question.