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

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Abstract

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.

Section snippets

Soft tissue procedures

Tendon rerouting procedures are designed to alter the force vectors. Flexor digitorum longus (FDL) transfer to the posterior tibial tendon (PTT) is the most commonly performed tendon rerouting procedure.2, 3, 4, 5, 6 Other techniques include spring ligament reconstruction7, 8 and Young suspension.9 The Young suspension reroutes the tibialis anterior tendon along an osseous groove at the plantar-medial surface of the medial cuneiform and navicular, but leaves its insertion intact. To do this,

First tarsometatarsal arthrodesis

In cases of an acute “sag” of the tarsometatarsal joint, arthrodesis can be a helpful adjunct. First tarsometatarsal (TMT) osteotomy and fusion is performed through a dorsal incision centered over the first TMT joint.11, 12 Apply a tourniquet to the thigh. Develop the interval between the extensor hallucis longus and brevis. Making sure to maintain the thin periosteal tissue and joint capsule for later closure over the osteotomy, raise the medial and lateral subperiosteal flaps. Marking these

Calcaneal osteotomy

As stated previously, it is unreasonable to think that one single procedure could be capable of correcting all forms of acquired adult flatfoot. Obviously, multiple surgical procedures exist15 and are more or less suitable in any given case. The surgeon must always weigh the benefits and drawbacks accordingly, then select the most appropriate method of treatment. In complex cases of flatfoot, one or more of the above procedures can be used in combination with a calcaneus tuberosity osteotomy,16

Postoperative management

Cover all wounds with xeroform, bacitracin, and sterile dry gauze dressings held with sterile under-cast padding. For the first 2 weeks after the operation, use a three-sided plaster splint or SLC with the anterior strip removed. After 2 weeks, change from this arrangement to a regular SLC for 4 to 6 more weeks. The patient must remain nonweight-bearing during this period. When the short cast is removed, radiographs are necessary to check healing. Then the patient is placed in a below knee

Summary

Treating flatfoot deformity without sacrificing complex hindfoot motion is a challenge to even the most skillful surgeon. During the preoperative period, it is important to discuss the postoperative course with the patient so that they know what to reasonably expect from their treatment. For example, swelling can persist for a year or more, and it can take 18 to 24 months for the patient to fully realize the benefits of the corrective surgery. Clear communication between the surgeon and the

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