Medial column procedures in the correction of adult acquired flatfoot deformity

AAFD is a complex problem with a wide variety of treatment options. No single procedure or group of procedures can be applied to all patients with AAFD because of the variety of underlying etiology and grades of deformity. As the posture of the foot progresses into hindfoot valgus and forefoot abduction through attenuation of the medial structures of the foot, the medial column begins to change shape. The first ray elevates and the joints of the medial column may begin to collapse. Careful physical examination and review of weight-bearing radiographs determines which patients have an associated forefoot varus deformity that may require correction at the time of flatfoot reconstruction. Correction of an AAFD requires a combination of soft-tissue procedures to restore dynamic inversion power and bony procedures to correct the hindfoot and midfoot malalignments. If after these corrections forefoot varus deformity remains, the surgeon should consider use of a medial column procedure to recreate the “triangle of support” of the foot that Cotton described.5 If the elevation of the medial column is identified to be at the first NC or the first TMT joint, then the joint should be carefully examined for evidence of instability, hypermobility, or arthritic change. If none of these problems exist, then the surgeon can consider use of the joint-sparing Cotton medial cuneiform osteotomy to correct residual forefoot varus. However, if instability, hypermobility, or arthritic change is present, then the surgeon should consider use of an arthrodesis of the involved joint to correct residual forefoot varus. Either procedure provides a safe and predictable correction to the medial column as part of a comprehensive surgical correction of AAFD.     

Plantarflexion opening wedge medial cuneiform osteotomy for correction of fixed forefoot varus associated with flatfoot deformity

BACKGROUND: Flatfoot presents as a wide spectrum of foot deformities that include varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Medial displacement calcaneal osteotomy, lateral column lengthening, and subtalar fusion can correct heel valgus, but may not adequately correct the fixed forefoot varus component. The purpose of this study was to determine the effectiveness of plantarflexion opening wedge medial cuneiform (Cotton) osteotomy in the correction of forefoot varus. METHODS: Sixteen feet (15 patients) had plantarflexion opening wedge medial cuneiform osteotomies to correct forefoot varus associated with flatfoot deformities from several etiologies, including congenital flatfoot (six feet, average age 37 years), tarsal coalition (five feet, average age 15 years), overcorrected clubfoot deformity (two feet, ages 17 years and 18 years), skewfoot (one foot, age 15 years), chronic posterior tibial tendon insufficiency (one foot, 41 years), and rheumatoid arthritis (one foot, age 56 years). RESULTS: Standing radiographs showed an average improvement in the anterior-posterior talo-first metatarsal angle of 7 degrees (9 degrees preoperative, 2 degrees postoperative). The talonavicular coverage angle improved an average of 15 degrees (20 degrees preoperative, 5 degrees postoperative). The lateral talo-first metatarsal angle improved an average of 14 degrees (-13 degrees preoperative, 1 degree postoperative). Correcting for radiographic magnification, the distance from the mid-medial cuneiform to the floor on the lateral radiograph averaged 40 mm preoperatively and 47 mm postoperatively (average improvement 7 mm). All patients at followup described mild to no pain with ambulation. There were no nonunions or malunions. CONCLUSIONS: Opening wedge medial cuneiform osteotomy is an important adjunctive procedure to correct the forefoot varus component of a flatfoot deformity. Advantages of this technique in comparison to first tarsometatarsal arthrodesis include predictable union, preservation of first ray mobility, and the ability to easily vary the amount of correction. Because of the variety of hindfoot procedures done in these patients, the degree of hindfoot correction contributed by the cuneiform osteotomy alone could not be determined. We have had excellent results without major complications using this technique.     

Cotton Osteotomy in Flatfoot Reconstruction: A Case Report Highlighting Surgical Technique and Modified Incision to Protect the Medial Dorsal Cutaneous Nerve

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is rarely performed in isolation. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical, because preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated with arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus, or iatrogenic deformity after base wedge osteotomy in hallux valgus. We present the case of an adolescent patient who underwent flatfoot reconstruction, including Cotton osteotomy for correction of forefoot varus that was accentuated after double heel osteotomy. This case highlights our preferred procedure technique, including the use of a nerve-centric incision design. The use of an oblique dorsal medial incision is primarily intended to minimize the risk of trauma to the medial dorsal cutaneous nerve. At 20 months postoperatively for the right extremity and 12 months postoperatively for the left extremity, sensation remained intact, and the patient had not experienced any postoperative nerve symptoms. The patient had returned to playing sports without pain or restrictions.     

Adult cavovarus foot

Cavovarus foot deformity, which often results from an imbalance of muscle forces, is commonly caused by hereditary motor sensory neuropathies. Other causes are cerebral palsy, cerebral injury (stroke), anterior horn cell disease (spinal root injury), talar neck injury, and residual clubfoot. In cavovarus foot deformity, the relatively strong peroneus longus and tibialis posterior muscles cause a hindfoot varus and forefoot valgus (pronated) position. Hindfoot varus causes overload of the lateral border of the foot, resulting in ankle instability, peroneal tendinitis, and stress fracture. Degenerative arthritic changes can develop in overloaded joints. Gait examination allows appropriate planning of tendon transfers to correct stance and swing-phase deficits. Inspection of the forefoot and hindfoot positions determines the need for soft-tissue release and osteotomy. The Coleman block test is invaluable for assessing the cause of hindfoot varus. Prolonged use of orthoses or supportive footwear can result in muscle imbalance, causing increasing deformity and irreversible damage to tendons and joints. Rebalancing tendons is an early priority to prevent unsalvageable deterioration of the foot. Muscle imbalance can be corrected by tendon transfer, corrective osteotomy, and fusion. Fixed bony deformity can be addressed by fusion and osteotomy.     

Radiographic Outcomes of Isolated Subtalar Joint Arthrodesis With Varying Fixation Technique

Subtalar joint (STJ) arthrodesis is a well-established and accepted surgical procedure utilized for the treatment of various hindfoot conditions including primary or posttraumatic subtalar osteoarthritis, hindfoot valgus deformity, hindfoot varus deformity, complex acute calcaneal fracture, symptomatic residual congenital deformity, tarsal coalition, and other conditions causing pain and deformity about the hindfoot. Union rates associated with isolated subtalar joint arthrodesis are generally thought to be favorable, though reports have varied significantly, with non-union rates ranging from 0 to 46%. Various fixation constructs have been recommended for STJ arthrodesis. The purpose of this study was to compare radiographic union in a 2-screw fixation technique to a 3-screw fixation technique for patients undergoing primary isolated STJ arthrodesis. To this end, we retrospectively reviewed 54 patients; 26 in the 2-screw group and 28 in the 3-screw group. We found the median time to radiographic union to be 9 weeks for the 2-screw cohort and 7 weeks for the 3-screw cohort. Additionally, we found that the 2-screw fixation cohort had a radiographic non-union rate of 26.9% while the 3-screw cohort had no non-unions. We conclude that the use of a 3-screw construct for isolated STJ arthrodesis has a lower non-union rate and time to union when compared to the traditional 2-screw construct and should be considered as a fixation option for STJ arthrodesis.     

Modified Dwyer Osteotomy with Rotation and Reinsertion of Autograft Bone Wedge for Residual Heel Deformity Despite Previous Delayed Subtalar Joint Arthrodesis After Calcaneal Fracture

Calcaneal fracture patterns vary widely, and many factors determine the type and timing of the treatment rendered. Severe calcaneus fractures involving joint damage, loss of heel height, and varus deformity of the tuberosity are ideally treated with open reduction and internal fixation to repair the joint surface and re-establish anatomic structure. This is not always possible owing to delayed presentation, soft tissue compromise, unrelated injuries, unstable medical condition, or lack of expertise by the treating physician. We present the case of a patient who had residual forefoot and rearfoot deformity despite undergoing delayed subtalar joint arthrodesis at an outside hospital 10 years before for a calcaneal fracture that was initially treated nonoperatively. At 4 years of follow-up after modified Dwyer calcaneal osteotomy with rotation and reinsertion of the autograft bone wedge and Cotton midfoot osteotomy, the postoperative gait was relatively normal, other than the expected lack of hindfoot mobility. The lateral column pain was resolved. The patient remained highly satisfied with the outcome at long-term follow-up of 48 months, with improved heel alignment, lack of a wide stance gait, a functional medial column, and a relatively normal gait. This case demonstrates the value of periarticular calcaneal osteotomies without the need to revise the subtalar joint arthrodesis for this challenging clinical situation.     

Cotton Osteotomy in Flatfoot Reconstruction: A Review of Consecutive Cases

The Cotton osteotomy or opening wedge medial cuneiform osteotomy is a useful adjunctive flatfoot reconstructive procedure that is commonly performed; however, the outcomes are rarely reported owing to the adjunctive nature of the procedure. The Cotton procedure is relatively quick to perform and effectively corrects forefoot varus deformity after rearfoot fusion or osteotomy to achieve a rectus forefoot to rearfoot relationship. Proper patient selection is critical because the preoperative findings of medial column joint instability, concomitant hallux valgus deformity, or degenerative joint disease of the medial column might be better treated by arthrodesis of the naviculocuneiform or first tarsometatarsal joints. Procedure indications also include elevatus of the first ray, which can be a primary deformity in hallux limitus or an iatrogenic deformity after base wedge osteotomy for hallux valgus. We undertook an institutional review board-approved retrospective review of 32 consecutive patients (37 feet) who had undergone Cotton osteotomy as a part of flatfoot reconstruction. All but 1 case (2.7%) had radiographic evidence of graft incorporation at 10 weeks. No patient experienced graft shifting. Three complications (8.1%) were identified, including 2 cases with neuritis (5.4%) and 1 case of delayed union (2.7%) that healed with a bone stimulator at 6 months postoperatively. Meary's angle improved an average of 17.75°, from ?17.24°± 8.00° to 0.51°± 3.81°, and this change was statistically significant (p < .01). The present retrospective series highlights our experience with the use of the Cotton osteotomy as an adjunctive procedure in flatfoot reconstructive surgery.     

Radiographic Analysis of the Lateral Column Lengthening Procedure in Stage II Adult Acquired Flatfoot Deformity

Adult acquired flat foot deformity (AAFD) is a progressive, tri-planar deformity involving collapse of the medial longitudinal arch, valgus deformity of the rear foot, and abduction of the mid-foot on the rear foot. There are a wide variety of surgical treatment options for this deformity, including lateral column lengthening (LCL) which results in tri-planar correction of AAFD. We retrospectively reviewed weightbearing preoperative radiographs and weight-bearing 6-week postoperative radiographs of 34 patients with stage II AAFD who underwent LCL (with and without concurrent procedures) with a minimum of 1-year of follow up. Outcomes, including complications and postoperative differences in 6 types of angle measurements were evaluated. Radiographic evaluation showed statistically significant differences in preoperative and postoperative measures in the following angles: calcaneal inclination, Meary's, Simmons, talocalcaneal, and metatarsus adductus (each p ≤ .05). Postoperative Engel's angle difference did not reach statistical significance (p = .07). Paired t tests showed TN coverage angles increased greater with LCL plus a Cotton osteotomy as compared to isolated LCL. Additionally, there was no significant difference in TN coverage angle based on LCL graft size (p = .20). Furthermore, the distance of the osteotomy from the calcaneocuboid joint on anteroposterior and lateral radiographs did not significantly predict TN coverage angle change.Our study suggests that LCL corrects AAFD in three planes while decreasing the metatarsus adductus angle. LCL appears to be more effective when performed with a Cotton osteotomy. Wedge size (6 mm, 8 mm, 10 mm) and osteotomy location did not demonstrate a relationship with postoperative TN coverage angle or incidence of lateral column overload.     

Evans Calcaneal Osteotomy: Assessment of Multiplanar Correction

Flatfoot deformity consists of collapse of the medial arch, forefoot abduction, increased talonavicular uncoverage, and hindfoot valgus. Although numerous soft tissue and bony procedures have been proposed to correct each plane of deformity, there is a lack of objective data in the literature quantifying the amount of structural correction. The purpose of this study was to quantify the multiplanar deformity correction of the lateral column lengthening osteotomy (Evans) on hindfoot alignment through objective, reproducible, radiographic measurements. We retrospectively reviewed 45 Evans calcaneal osteotomy procedures in 24 female (53%) and 21 male (47%) feet performed on 40 patients (5 bilateral). The mean follow-up was 53 weeks (range, 32-116). The mean age at the time of surgery was 35 years (range, 11-73). Statistically significant improvement in radiographic alignment was found in the calcaneal inclination angle, tibial-calcaneal angle, tibial-calcaneal position, and the anteroposterior talo-first metatarsal angle (p < .0001 for all). Although a direct correlation between graft size and degree of angular correction was not observed, it should be noted the calcaneal graft size (mean, 11.8 mm) and the amount of hindfoot valgus correction (mean, 12.6°) appear to be clinically related. The results of this study support that the Evans calcaneal osteotomy corrects the hindfoot alignment in 3 planes as evidenced by our multiplanar radiographic measurements.     

Calcaneal osteotomy in the treatment of adult acquired flatfoot deformity

Calcaneal osteotomies are an essential part of our current armamentarium in the treatment of AAFD. Soft tissue correction or bony realignment alone have failed to adequately correct the deformity; therefore, both procedures are used simultaneously to achieve long-term correction. Medial displacement and lateral column lengthening osteotomies in isolation or in combination and the Malerba osteotomy have been employed along with soft tissue balancing to good effect by various authors. The goal is to create a stable bony configuration with adequate soft tissue balance to maintain dynamic equilibrium in the hindfoot. In “pronatory syndromes,” the relation of the osteotomy to the posterior subtalar facet modifies the biomechanics of the hindfoot in different ways. Anterior calcaneal osteotomies correct deformities in the transverse plane (forefoot abduction), whereas posterior tuberosity osteotomies result in “varization” of the calcaneus and correct the frontal plane deformity. The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, transverse plane movement is cancelled out and the frontal plane eversion–inversion is predominant. The patient presents with marked hindfoot valgus without significant forefoot abduction. Conversely, if the subtalar axis is more vertical than normal, transverse plane movement is predominant and the patient presents with forefoot abduction and instability of the medial midtarsal joints, although without significant hindfoot valgus. In this situation, a lateral column lengthening procedure is recommended to decrease the uncovering of the talar head and improve the height of the arch while correcting the forefoot abduction. With a predominant frontal plane deformity, medialization of the calcaneal tuberosity is used to displace the calcaneal weight bearing axis medially, aligning it with the tibial axis and restoring the function of the gastrosoleus as a heel invertor. An essential prerequisite for this is the absence of arthritis affecting the subtalar joint. The Achilles tendon may need to be lengthened at the same time.     

The cavovarus foot deformity. Etiology and management

The cavovarus foot is a complex deformity of the forefoot and hindfoot, frequently of neuropathologic etiology. A progressive spinal or peripheral neuromuscular disorder must be excluded by a thorough clinical evaluation. With the failure of nonoperative modalities, surgical options depend on patient age, etiology of the deformity, and the constellation and flexibility of the defects observed. If the hindfoot varus is flexible, correction of the cavus and forefoot pronation through extensive plantar release and metatarsal osteotomies is reliable. The underlying muscle imbalance must be addressed through tendon transfers to prevent further progression. In the young child, a rigid hindfoot varus will often be corrected by a radical plantar-medial release, but the more mature foot may require midtarsal osteotomy and calcaneal osteotomy or triple arthrodesis. The surgery is usually staged to provide correction of deformity and stabilization of the hindfoot prior to tendo Achilles lengthening or tendon transfer. Arthrodesis of a previously well-corrected foot is common due to progression of the neurologic deficit or failure to achieve muscular balance. The claw toe deformity also must be corrected by tendon transfer, osteotomy, and arthrodesis for reasons of both comfort and function.     

Different faces of the triple arthrodesis

Patients with severe pes planovalgus or cavovarus foot deformities who fail conservative treatment may require a triple arthrodesis. Modifying the triple arthrodesis to include extended bone wedge resections allows for improved correction. The goal of each procedure is to obtain a less painful, plantigrade foot, and to improve function. Additional hindfoot or midfoot osteotomies may be needed in the modified triple arthrodesis. Midfoot or forefoot cavus can be addressed with either the Japas, Cole, or Jahss osteotomies, as described above. Residual hindfoot valgus can be adequately corrected with a medial displacement osteotomy of the calcaneus. Residual hindfoot varus is preferably corrected through a lateral closing wedge calcaneal osteotomy. This allows for adequate correction without the need for bone graft or an extended medial incision in the area of the tibial neurovascular bundle. Good results have been obtained with these types of complicated reconstructive procedures.     

Medial-sided bony procedures: why, what, and how?

The adult acquired flat foot deformity is a common clinical entity; rupture or incompetence of the posterior tibial tendon is a frequent cause. The natural history is characterized by progressively worsening deformity and early recognition is important. Nonoperative treatment can alleviate symptoms and control progression in nearly all stages of the disease. Should this fail to control symptoms or prevent progression of deformity, operative intervention should be considered. In stage I disease, exploration and debridement, with or without FDL tendon transfer, is a viable option. In stage II disease, the PTT becomes elongated and the medial soft tissues become attenuated. Exploration and debridement of the PTT is performed, but frequently a FDL tendon transfer or side-to-side anastomosis is required. It has been shown that soft tissue procedures alone may fail to correct deformity and this can lead to deterioration of results over time. Combined procedures, including soft tissue reconstructions to restore PTT function and bony procedures to correct deformity, have become popular. When the PTT is intact and degeneration or elongation is minimal, as in stage I or early stage II disease, reconstruction of the medial column with advancement of an osteoperiosteal flap based on the PTT insertion, combined with selective arthrodeses of the medial column, may be considered. These procedures have been well described for the treatment of symptomatic flexible flat foot in children and adolescents but experience in adults is lacking. Although it may be theoretically possible to passively correct hindfoot valgus with these procedures, it seems prudent to limit the indications to patients who have early disease accompanied by an isolated midfoot sag. In more advanced stage II disease, correction of deformity with a tendon transfer combined with a medial displacement calcaneal osteotomy or a lateral column lengthening is currently recommended. This allows for correction of deformity while sparing the hindfoot joints, which may be particularly important in young or active patients. Short-term studies showed excellent results, but long-term results are lacking. In stage III disease, in which the deformity is fixed, arthrodesis is the procedure of choice. Isolated talonavicular arthrodesis has been shown to correct nearly all aspects of the deformity with long-lasting results. This procedure results in nearly complete lack of hindfoot motion and may predispose the patient to adjacent joint arthrosis. In a patient who has stage III disease with arthrosis confined to the talonavicular joint, isolated talonavicular arthrodesis may be considered. This clinical situation is rare, and, in most patients, a triple arthrodesis is probably preferred. If residual deformity is present after these procedures, it must be addressed. Residual medial column instability may be addressed by adding a selective arthrodesis of the naviculo-cuneiform or first metatarsocuneiform joint, whereas residual forefoot varus or supination may be addressed with selected midfoot fusions with or without a cuneiform osteotomy.     

Die supramalleoläre, subtraktive, valgisierende Tibiaosteotomie bei Varusarthrose des Sprunggelenks

OBJECTIVE: The aim of supramalleolar osteotomy of the tibia in the management of varus deformity of the upper ankle joint is to shift load bearing away from the severely degenerated medial part of the joint to the lateral part and thus restore physiological alignment of the hindfoot and a plantigrade foot. The intention is to reduce pain and to postpone the need for total endoprosthesis or arthrodesis. INDICATIONS: Painful degeneration of the ankle joint with varus deformity that has proven resistant to conservative treatment, i.e., > 15 degrees axial malalignment of the tibiotalar joint axis. CONTRAINDICATIONS: Severe ankle joint degeneration that restricts movement. Florid infections. Extensive bone and soft-tissue defects. Osteonecrosis of the talus with necrotic regions > 50%. SURGICAL TECHNIQUE: Anterior approach to the upper ankle joint and supramalleolar wedge-shaped resection of a predetermined bone wedge with lateral base. The desired correction is precisely calculated during preoperative planning. Subsequently, lateral approach over the distal fibula. Resection of a more proximal segment from the fibula. Closure of the tibial osteotomy (closed wedge) and osteosynthesis of the fibula. RESULTS: A supramalleolar valgus osteotomy (closed wedge) was performed in 27 patients from 2002 to 2006. Preoperatively, there was an average varus deformity of 27 degrees , which was corrected to 6 degrees on average postoperatively. 21 patients were very satisfied at follow-up, three patients required joint replacement during the later course, and another three patients needed arthrodesis.     

The Cotton osteotomy: indications and techniques

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by an incompetent posterior tibial tendon that results in a flexible pes planovalgus deformity. As the hindfoot drifts into valgus, compensatory varus develops in the forefoot. Alternatively, in some cases medial column instability can result in primary forefoot varus that drives the hindfoot into valgus. Recently, there has been increasing awareness of the importance of forefoot varus in PTTD.     

Supramalleolar lateral closing wedge osteotomy for the treatment of varus ankle arthrosis

BACKGROUND: Medial ankle joint pain with localized cartilage degeneration due to medial joint overload in varus malalignment of the hindfoot lends itself to treatment by lateral closing wedge supramalleolar osteotomy. METHODS: From 1998 to 2003, nine patients between the ages of 21 to 59 years were operated. The etiology of the malalignment and degeneration was posttraumatic in eight and childhood osteomyelitis in one. Preoperative and postoperative standing radiographs were analyzed to determine the correction of the deformity and the grade of degeneration. Function and pain were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. The average followup was 56 (range 15 to 88) months. RESULTS: The average time to osseous union was 10 +/- 3.31 weeks. There were no operative or postoperative complications. The average AOFAS score improved from 48 +/- 16.0 preoperatively to 74 +/- 11.7 postoperatively (p<0.004). The average pain subscore improved from 16 +/- 8.8 to 30 +/- 7.1 (p<0.008). The average tibial-ankle surface angle improved from 6.9 +/- 3.8 degrees of varus preoperatively to 0.6 +/- 1.9 degrees of valgus postoperatively (p<0.004). In the sagittal plane, the tibial-lateral-surface angle remained unchanged. At the final followup, two patients showed progression of radiographic ankle arthrosis grades. In one patient, it rose from grade 0 to I. In the other patient it advanced from grade II to III, with subsequent ankle arthrodesis required 16 months after the index procedure. Seven patients returned to their previous work. CONCLUSIONS: Lateral supramalleolar closing wedge osteotomy was an easy and safe procedure, effectively correcting hindfoot malalignment, relieving pain, restoring function, and halting progression of the degeneration in the short-term to mid-term in seven of nine patients.     

Patient specific computational models to optimize surgical correction for flatfoot deformity

Several surgically corrective procedures are considered to treat Adult Acquired Flatfoot Deformity (AAFD) patients, relieve pain, and restore function. Procedure selection is based on best practices and surgeon preference. Recent research created patient specific models of AAFD to explore their predictive capabilities and examine effectiveness of the surgical procedure used to treat the deformity. The models’ behavior was governed solely by patient bodyweight, soft tissue constraints, muscle loading, and joint contact without the assumption of idealized joints. The current work expanded those models to determine if an alternate procedure would be more effective for the individual. All procedures incorporated first a tendon transfer and then included one hindfoot procedure, the Medializing Calcaneal Osteotomy (MCO), and one of three lateral column procedures: Evans osteotomy, Calcaneocuboid Distraction Arthrodesis (CCDA), Z osteotomy, and the combination procedures MCO & Evans osteotomy, MCO & CCDA, and MCO & Z osteotomy. The combination MCO & Evans and MCO & Z procedures were shown to provide the greatest amount of correction for both forefoot abduction and hindfoot valgus. However, these two procedures significantly increased joint contact force, specifically at the calcaneocuboid joint, and ground reaction force along the lateral column. With exception to the lateral bands of the plantar fascia and middle spring ligament, the strain present in the plantar fascia, spring, and deltoid ligaments decreased after all procedures. The use of patient specific computational models provided the ability to investigate effects of alternate surgical corrections on restoring biomechanical function in these flatfoot patients. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1523–1531, 2017.

     

Posterior tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.     

Ankle valgus and clubfeet.

Congenital equinovarus is a complex deformity that involves the ankle as well as the foot. Although equinus is the obvious and presenting ankle deformity that is typically addressed with serial manipulation, casts, and surgery, ankle valgus is a more insidious and often overlooked problem that evolves with growth. With a high prevalence (67% in this series), it may, in some cases, ameliorate the effects of residual hindfoot varus. More commonly, it may result in prominence of the medial malleolus, lateral shift of the ground reactive forces, compression of the lateral portion of the distal tibial epiphysis, fibular impingement, and excessive shoe wear. If mistaken for hindfoot valgus ("overcorrected clubfoot"), inappropriate hindfoot surgery may result. Although one may temporize with orthoses, definitive treatment options include medial malleolar epiphysiodesis or, in mature patients, supramalleolar osteotomy. We recommend a weight-bearing anteroposterior radiograph of the ankles in any patient presenting with valgus and suspected of having overcorrected congenital equinovarus, particularly if surgical intervention is being contemplated. If valgus deformity is noted in the ankle, hindfoot surgery may be contraindicated.     

Lateral Column Lengthening for Revision Triple and Double Arthrodesis and Severe End-Stage Flatfoot Deformity

Few options exist for the treatment of revision and severe cases of end-stage flatfoot deformity. Triple arthrodesis or medial-approach double arthrodesis have been the standard but often do not provide enough correction of the deformity. Lateral column lengthening is a powerful procedure performed either with an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis that can be used as an adjunct in realigning the flatfoot. We performed a retrospective radiographic review and looked at 11 consecutive cases of patients who underwent hindfoot arthrodesis with a lateral column lengthening procedure. We matched these patients with 11 control patients who underwent isolated medial-approach double arthrodesis. For the patients who underwent a lateral column lengthening procedure, we found a significant improvement in calcaneal inclination angle (p = .001) and greater correction in talar declination angle, cuboid abduction angle, and talocalcaneal angle when compared with the control group. Lateral column lengthening is a useful adjunct to hindfoot arthrodesis in the correction of revision and severe end-stage flatfoot deformity.