Flatfoot

PURPOSE: Stage II posterior tibial tendon dysfunction (PTTD) can be treated by flexor digitorum longus (FDL) tendon transfer and medial displacement calcaneal osteotomy (MDCO). Numerous authors have studied the clinical and radiographic results of this procedure. However, little is known about the kinematic changes. Therefore, the purpose of this study was to assess plantar-pressure distribution in these patients. METHODS: Seventy-three patients with PTTD stage II underwent FDL tendon transfer and MDCO...

Posterior tibial tendon dysfunction (PTTD) has been approached with a multitude of surgical techniques. This article outlines the current understanding of the flexor digitorum longus transfer and flexor hallucis longus transfer in the context of various osteotomy techniques for the correction of stage II PTTD. Pertinent clinical literature and scientific evidence will also be compared and analyzed.

Nonoperative therapy for adult-acquired flatfoot is a reasonable treatment option that is likely to be beneficial for most patients. In this article, we describe the results of a retrospective cohort study that focused on nonoperative measures, including bracing, physical therapy, and anti-inflammatory medications, used to treat adult-acquired flatfoot in 64 consecutive patients. The results revealed the incidence of successful nonsurgical treatment to be 87.5% (56 of 64 patients), over the 27-month observation period...

HYPOTHESES/PURPOSE: The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy. METHODS: We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading...

The authors retrospectively reviewed 24 patients who underwent posterior calcaneal displacement osteotomy (PCDO) for posterior tibial tendon dysfunction and adult acquired flatfoot deformity from 1991 to 1996. The average follow-up was 27 months. Analysis consisted of preoperative and postoperative evaluation of radiographs, as well as postoperative subjective results. Ancillary procedures included flexor digitorum longus tendon transfer (n = 19), tendo Achilles lengthening (n = 21), tibialis anterior tendon transfer (n = 5), naviculocuneiform joint arthrodesis (n = 4), and first metatarsocunieform joint arthrodesis (n = 1)...

This article reviews the indications and the operative technique for the medial calcaneal slide osteotomy for the treatment of posterior tibial insufficiency. Patient selection, expected results, and complications of this technique are discussed. When used in combination with flexor digitorum longus transfer, the medial calcaneal slide osteotomy is an effective method of treatment for the adult acquired flatfoot associated with insufficiency of the posterior tibial tendon.

The Evans calcaneal osteotomy is currently the premier procedure for lateral column lengthening of the flexible flatfoot deformity. It has withstood the test of time, proving itself an effective procedure for the correction of pediatric flexible flatfoot. Current understanding of the osteotomy has allowed the Evans calcaneal osteotomy to become a useful tool in the correction of the adult flexible flatfoot as well.

The use of a lamina spreader over converging pins facilitates opening of an Evans calcaneal osteotomy and allows for precise measurement of the recipient site. The technique of cortical bone pin insertion has been utilized when indicated by the authors a limited number of times (N = 10) and as such this will be the subject of a future scientific investigation. The authors feel the advantages of the cortical bone pins include ease of use, good resultant stability of the capital fragment, utilization of a material identical to that of the correcting graft, a more biologic form of absorbable internal fixation, and the avoidance of complications associated with percutaneous metallic fixation (Fig...

The Evans osteotomy has become an important option in the surgical treatment of adult pes planus deformity of multiple causes. Despite its increasing popularity, however, no single study, to our knowledge, has thoroughly examined the structures at risk when performing the Evans osteotomy on the adult foot. We performed the Evans osteotomy on 20 adult cadaver specimens to determine which soft tissues and bony structures were endangered by the procedure. We found that the optimal Evans osteotomy site should be exactly 10 mm proximal to the calcaneocuboid joint because this location best affords the opportunity of avoiding damage to the anterior or middle subtalar facets in those specimens with separate facets...

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.

The adult acquired flat foot requires assessment with unique casting and fabrication of support appliances. Conservative treatment is preferred as the initial protocol. Stabilization and control of affected joints can provide the patient with a decreased level of pain and an increased level of function. The orthosis design must acceptable to the patient's lifestyle to ensure compliancy.

Dysfunction of the tibialis posterior tendon evolves through a series of stages. The pain symptoms, clinical signs, and roentgenographic changes for each of these stages are characteristic. This staging system permits clarification and individualization of dysfunction, expected pathologic changes, and surgical treatment. The importance of the tibialis posterior tendon in normal hindfoot function and its treatment when injured are now being properly appreciated.

Since Johnson's and Strom's classification system in 1989 an increasingly complex array of deformities of the foot has been recognized in association with PTTR. This wide spectrum of deformity is not completely addressed by the current classification system, nor does it leave sufficient room for variation within a given treatment stage. Taking into account ankle and hindfoot valgus, forefoot supination, forefoot abduction, and medial column instability we present and discuss a refined classification for PTTR...

Many patients with foot and ankle deformities have concurrent deformities (osseous and soft tissue), with or without limb length discrepancies. Lower extremity deformities and limb length discrepancies typically result from trauma, congenital abnormality, avascular necrosis, previous surgery, nonunion, and malunion. Limb deformity correction requires extensive surgical experience because many considerations and factors apply to realignment. The considerations and factors regarding realignment are highlighted throughout this article...

Adult acquired flatfoot is generally characterized by loss of the longitudinal arch, hindfoot valgus, and forefoot abduction, but the precise deformity has not been adequately described at the level of individual joints. Simulated weightbearing CT scans and plain radiographs of 37 symptomatic flat feet were examined in this study. The degree of arthritic degeneration was assessed in the major hindfoot and midfoot joints, and the location of deformity was studied along the medial column of the arch. Moderate to severe degeneration was seen in about one-third of talonavicular, subtalar, and calcaneocuboid joints...

The authors provide a comprehensive classification and treatment algorithm for the adult flatfoot/posterior tibial tendon dysfunction. As well, the article provides a discussion as to the etiology, biomechanical implications, conservative treatment and surgical pearls of posterior tibial tendon dysfunction.

Nineteen patients with the clinical diagnosis of dysfunction of the posterior tibial tendon underwent surgical exploration. Four types of lesions were identified: avulsion of the tendon at the insertion (Group I), mid-substance rupture of the tendon (Group II), an in-continuity tear of the tendon (Group III), and no tendon tear, tenosynovitis only (Group IV). These conditions could not be separated preoperatively by clinical or radiographic means. The patients in Group I were treated by reinsertion of the tendon; in Group II, by flexor tendon transfer; and in Groups III and IV, by synovectomy...