Functional bracing of the adult acquired flatfoot

This article reviews the current orthotic and pedorthic management of adult acquired flatfoot and associated secondary pathology. Appropriate footwear, footwear modifications, custom foot orthoses, and ankle foot orthoses are highlighted for the treatment of this often seen foot disorder. As this pathology progresses through its various stages, the discussion provides conservative and postoperative alternatives for treatment of even the most affected feet.     

Complications of midfoot and hindfoot arthrodesis

Midfoot and hindfoot arthrodeses traditionally have been done to treat deformities resulting from paralytic disorders, residual clubfoot deformity, and posttraumatic arthritis. The surgical indications for midfoot and hindfoot arthrodeses more recently have been expanded to include painful arthritic deformities associated with neuroarthropathy, seropositive or seronegative arthropathies, and neurologic disorders. Regardless of the joint fused or the technique used, the goal of each remains similar: the creation of a painless, plantigrade foot capable of being fitted into, at the very least, a custom shoe. The aim of the current study is to describe the major complications associated with midfoot and hindfoot fusions in adults, and the prevention and the treatment of these complications.     

Midfoot arthrodesis for adult acquired flatfoot

BackgroundAdult acquired flatfoot is a common pathologic condition seen by orthopedic foot and ankle surgeons. The condition covers a spectrum ranging from mild discomfort to severe debilitating hindfoot arthritis and deformity. A multitude of treatment options has been proposed.MethodsWe conducted an extensive review of the literature and our experience from three large centers for foot and ankle surgery. Arthrodesis of the midfoot for adult acquired flatfoot is reviewed in detail.Results and ConclusionsMidfoot arthrodesis is best suited for flexible deformity with loss of the integrity and support of the medial column. Arthrodesis of the navicular cuneiform and first tarsometatarsal joints, either alone or in combination with other procedures, restores stability to the medial column and arch with minimal impact on normal gait.     

Management of the rigid adult acquired flatfoot deformity

The optimal management of the adult acquired flatfoot requires careful assessment of the deformity. Although it is essential to recognize the location and degree of malalignment, it is of equal importance to appreciate whether the deformity is flexible or rigid. For patients undergoing surgery for a flexible flatfoot, various soft tissue procedures and bony osteotomies may be used to restore alignment while preserving joint motion. However, for patients undergoing surgery for a rigid deformity, such procedures are indicated less often, and arthrodesis is usually necessary.     

Treatment of adult acquired pes plano abductovalgus (flatfoot deformity): procedures that preserve complex hindfoot motion

Treatment of adult acquired flatfoot deformity with supple hindfoot motion can be problematic. Historically, triple arthrodesis for structural correction has been the standard of care, thus sacrificing hindfoot motion. We present newer techniques that provide excellent correction while maintaining hindfoot motion which may further protect the function of adjacent motion segments.     

Talonavicular arthrodesis for the acquired flatfoot in the adult

The acquired painful flatfoot in the adult is a syndrome that commonly is disabling and progressive. Patients should benefit from a surgical technique that can provide correction of the major deformities and lasting stability with limited surgical morbidity. Twenty-nine patients treated with a talonavicular arthrodesis for this disorder were followed up a minimum of 12 months and an average of 26 months. Twenty-five patients (86%) were satisfied with no or minor reservations and achieved good or excellent results. A talonavicular arthrodesis, by addressing the instability at its focal point, appears to achieve these goals with one surgical procedure.     

Biomechanics and clinical analysis of the adult acquired flatfoot

The adult acquired flatfoot is a deformity that results from the loss of dynamic and static supportive structures of the medial longitudinal arch. The severity of the deformity is dependent upon the role of ligamentous disruption on the hindfoot that can be determined by careful clinical examination. Treatment of the adult flatfoot requires an understanding of the biomechanical effects of deforming forces, tendon dysfunction, ligament disruption, and joint sublaxation.     

Treatment of stage 3 adult acquired flatfoot

Stage 3 adult acquired flatfoot occurs when chronic posterior tibial tendon insufficiency results in fixed hindfoot valgus or fixed forefoot abduction and supination. Nonoperative management results in limited success. Corrective fusion is the treatment of choice. Although a variety of arthrodeses have been employed, triple arthrodesis remains the gold standard.     

Treatment of stage 4 adult acquired flatfoot

Stage 4 PTT dysfunction is a rare anatomic condition in which fixed hindfoot valgus is associated with valgus tilting of the talus within the ankle mortise. Success with nonoperative management is the exception rather than the rule. The surgical options are a tibiotalocalcaneal fusion or a pantalar fusion; however, there are few results reported in the adult acquired flatfoot population. Valgus talar tilting after triple arthrodesis may be the challenge of the future.     

Subtalar repositional arthrodesis for adult acquired flatfoot

Arthrodesis of the subtalar joint is well recognized treatment option for moderate or severe flatfoot associated with adult acquired flatfoot secondary to posterior tibial tendon dysfunction. The success of the subtalar arthrodesis is dependent on restoration of normal bony relationships in the hindfoot and midfoot. For this reason, a distinction is made between a repositional arthrodesis and the traditional in situ type of arthrodesis. An in vitro study of the adult acquired flatfoot identifies an anteroposterior subluxation of the subtalar articulation that can be corrected durably and reliably through a repositional talocalcaneal arthrodesis. Intraoperative reduction techniques are useful in obtaining reduction of the peritalar subluxation. There are certain clinical features that help identify patients with flatfoot deformities who are good candidates for subtalar fusion. As the pathoanatomy of the flatfoot deformity is better elucidated, treatment techniques are modified to better address the key elements of the deformity. A repositional subtalar arthrodesis was shown to produce excellent correction in a moderate to severe in vitro flatfoot example in the authors' clinical series.     

Analysis of biomechanical stresses caused by hindfoot joint arthrodesis in the treatment of adult acquired flatfoot deformity: A finite element study

BackgroundTreatments of adult acquired flatfoot deformity in early stages (I–IIa–IIb) are focused on strengthening tendons, in isolation or combined with osteotomies, but in stage III, rigidity of foot deformity requires more restrictive procedures such as hindfoot joint arthrodesis. Few experimental studies have assessed the biomechanical effects of these treatments, because of the difficulty of measuring these parameters in cadavers. Our objective was to quantify the biomechanical stress caused by both isolated hindfoot arthrodesis and triple arthrodesis on the main tissues that support the plantar arch.MethodsAn innovative finite element model was used to evaluate some flatfoot scenarios treated with isolated hindfoot arthrodesis and triple arthrodesis.Results and conclusionsWhen arthrodeses are done in situ, talonavicular seems a good option, possible superior to subtalar and at least equivalent to triple. Calcaneocuboid arthrodesis reduces significantly both fascia plantar and spring ligament stresses but concentrates higher stresses around the fused joint.     

The surgical management of equinus in the adult acquired flatfoot

Ankle joint equinus plays a significant role in the pathogenesis of adult and pediatric flatfoot. The surgical management of ankle equinus is a widely debated topic, and procedure selection is often based on surgeon preference because there is no consensus regarding the superiority of a single procedure. Gastrocnemius recession offers acceptable cosmesis and minimizes perceived weakness, yet requires increased operating time and is indicated only in mild to moderate contractures. Whereas tendo-achilles lengthening is efficient and technically undemanding, and one may achieve large amounts of required length, final length is sometimes unpredictable and may markedly decrease posterior muscle group strength.     

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.     

Outcomes of midfoot and hindfoot fractures in multitrauma patients

Introduction

Multitrauma patients suffering hindfoot fractures, including calcaneal and talar fractures, often result in poor outcomes. However, less is known about the outcomes following midfoot fracture in the mutitrauma population. This study aims to describe the epidemiology of midfoot fractures in multitrauma patients and to compare the outcomes of midfoot and hindfoot fractures in this population.

Posterior calcaneal displacement osteotomy for the adult acquired flatfoot

The posterior calcaneal displacement osteotomy with flexor digitorum longus tendon transfer is an accepted approach to the stage II posterior tibial tendon dysfunction flatfoot. This reconstructive osteotomy provides a viable alternative to isolated hindfoot arthrodesis procedures. Proper patient selection and sound surgical technique ensure favorable postoperative results. Complications, though limited, may include sural neuritis, peroneal tendonitis, undercorrection, and peritalar arthrosis.     

Principles of arthrodesis and advances in fixation for the adult acquired flatfoot

Arthrodesis continues to be the procedure of choice in treatment of the end-stage adult acquired flatfoot. Its goals are to provide pain relief, correct the deformity, and improve function and stability. A better understanding of anatomy and operative technique has led to significant refinements and advances in fixation. These devices have proved useful in arthrodesing and tenodesing procedures. The principles in achieving a sound arthrodesis and the various forms of fixation are discussed in detail.     

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.