Adult acquired flat foot deformity

1. Adult-Acquired Flatfoot Deformity
DR.PONNILAVAN

2. INTRODUCTION
• Adult-acquired flatfoot deformity is a complex deformity associated
with the collapse of the medial longitudinal arch.
• Posterior tibial tendon dysfunction remains the most common
etiology.

3. ANATOMY

4. ORGIN AND INSERTION

5. Pathophysiology
‘Posterior tibial tendon is crucial for effective gait’
as its contraction facilitates hindfoot inversion, in turn
locking the transverse tarsal joints and creating a rigid platform for
push off.

6. Posterior tibial tendon is supplemented by
• Foot’s osseous architecture
• Spring ligament (plantar calcaneonavicular ligament)
• Deltoid ligament
• Plantar fascia and
• Talonavicular capsule.

7. Insufficiency of the posterior tibial tendon
• Collapse of the medial arch and excessive valgus deviation of the
hindfoot.
• The midfoot becomes abducted at the transverse tarsal joint, with
uncovering of the talar head.
• The vector of pull of the Achilles tendon subsequently becomes
lateral to the axis of the subtalar joint and accentuates eversion.
• Progressive stretching of the medial soft-tissue structures further
accentuates the hind foot valgus deformity, and equinus deformity
may ensue because of an Achilles contracture.

8. Adult-Acquired Flatfoot Deformity
• In 1989 ,Johnson and strom classified the condition of posterior
tibialis tendon disfuction
• 3 stages

9. Johnson and strom classification
• Stage 1 :flat but correctible arch without deformities
• Stage 2 :flexible deformities and non arthritic joints [stage 2 is
subdivided into stage 2a and 2 b]
• Stage 3 :arthritic joints
Myerson added stage 4
• Stage 4:ankle involvement

10. CLASSIFICATION

11. ETIOLOGY

12. SYMPTOMS
• Medial ankle/foot pain
• Weakness
• Progressive loss of arch
• Lateral ankle pain due to sub
fibular impingement is a late
symptom[advanced]

13. • Range of motion single-limb heel rise
Unable to perform in stages II,III,IV.
• Posterior tibial power reduced
• Flexible or fixed flexible deformities are passively correctable to a
plantigrade foot[stage II]
• Rigid deformities are not correctable [stages III and IV]

14. Diagnosis of AAFD 5 KEYS
• Symptoms and deformity
• Single limb heel raise test
• Too many toes sign
• Mobility of talonavicular and calcaneocuboid joints
• Weight bearing x-ray

15. 1.Symptoms and deformity
• Medial pain =AAFD stage 1 and 2a
• Lateral pain =AAFD stage 2 b
No/mild correctible deformity –stage 1
Forefoot abduction and hinfoot valgus –stage 2 and stage 3
Ankle deformity –stage 4

16. 2]Single limb heel raise test
Negative =tibialis posterior intact =stage 1 ,2a
Positive =tibialis posterior insufficiency =stage 2b and beyond

17. Single limb heel raise test

18. 3]too many toes sign
Negative =no heel valgus
Positive =heel valgus=stage 2 and beyond

19. Too many toe sign=heel valgus

20. 4]mobility at talonavicular and
calcaneocuboid joint
Mobile joints =AAFD stage 2
Immobile joints=AAFD stage 3 / stage 4[stiff/arthritic]

21. 5]weight bearing x-rays :2 views
On ankle lateral view=flattening of arch =severity of deformity
Watch for talo-first-metatarsal angle.
Normal-0 degree
Moderate- 15-30 degree
Severe->30 degree

22. talo-first-
metatarsal angle
• The lateral talus-first
metatarsal Meary
angle, which is the
angle between the
longitudinal axes of
the talus and first
metatarsal
• measure 0 +/- 10
degrees and is
elevated in flatfoot
deformity (often >20
degrees, apex
directed plantarly)

23. The lateral
talocalcaneal angle,
which is the angle
between a line
bisecting the talus
and a line bisecting
the calcaneus
(normal, 25° to 45°)

24. Calcaneal pitch, which
is the angle between
a line drawn along the
most inferior part of
the calcaneus and the
supporting surface or
the transverse plane
(normal, 10° to 20°).

25. Weight bearing AP view
• Talar head uncoverage =forefoot abduction
• Talar uncoverage expressed by the percentage of the talus that is not
in contact with the navicular medially

26. Weight bearing
anteroposterior radiograph
Talonavicular coverage angle, measured as
the angle between a line connecting the
articular surface of the talus and a line
connecting the articular surface of the
navicular

27. Weight bearing
anteroposterior radiograph
Talonavicular uncoverage percentage,
measured as the percentage of the talar
head articular surface not covered by the
navicular (dashed line) over the entire
extent of the talar head articular surface

28. Weight bearing
anteroposterior radiograph
Talo–first metatarsal angle, which is the
angle between the axis of the first
metatarsal and the axis of the talus

29. Other xray parameters:by studies
Standing ankle radiographs- lateral talar tilt and ankle arthritis, which
can occur in the later stages of flatfoot deformity.

30. Other xray parameters:by studies
Arch height :
Distance between the medial cuneiform and the base of the fifth
metatarsal may be more clinically useful to differentiate between
normal feet (17 mm) and flatfeet (6 mm).

31. Operative parameter: Hindfoot alignment
x-ray
• Saltzman views
• Hindfoot moment arm: is measured by the shortest distance between
the midtibial axis and the most inferior portion of the calcaneus
(normal, –3 mm [varus]; flatfoot, >+10 mm [valgus]).
• Hindfoot alignment angle: is formed by the intersection of the
longitudinal axis of the tibial shaft and the axis of the calcaneal
tuberosity (normal, 5 degrees; flatfoot, 22 degrees)

32. Hindfoot
alignment x-ray
Intersection of the
longitudinal axis of the
tibial shaft and the axis
of the calcaneal
tuberosity.

33. MRI Evaluation
• MRI is not routinely needed
• However, it can be used to :
1. Evaluate the spring ligament and the degree of damage to the
posterior tibial tendon
2. To identify sites of intraosseous edema, which may be associated
with impingement
3. A preoperative diagnosis of a spring ligament rupture in patients
with severe abduction deformity.

34. Ultrasound
Evaluation
To evaluate the condition
of the posterior tibial
tendon and other soft-
tissue structures including
the spring ligament.

35. Tendoscopic
Evaluation • Tendoscopy is a minimally invasive modality that can be utilized to evaluate
tendon pathology, particularly in patients with suggestive symptoms.

36. Management

37. AAFD STAGE 1
• No deformity:flat but correctable arch
• Single toe raise is possible
• Normal radiology

38. AAFD STAGE 1:management
‘Essentially treatment is conservative’
Rest to tendon to reduce inflammation
• NSAIDS
• Systemic disease :treat accordingly
• Physical therapy-strengthening ,theraband,cryotherapy,iontophoresis.
• Orthotics –semi rigid, medial heel wedge ,medial column post
• ONLY SURGICAL PROCEDURE FOR STAGE 1:TENOSYNOVECTOMY OF
TIBIALIS POSTERIOR

39. THERABAND

40. Iontophoresis: to decrease sweat

41. Medial heel wedge

42. Medial column post

43. TENOSYNOVECTOMY OF TIBIALIS POSTERIOR
• To perform an open synovectomy completely removing the inflamed
synovium,
• Requiring a large 6-cm medial ankle incision.
• Postoperative management included plaster cast immobilization for 3
weeks, followed by a boot with controlled ankle movement for
another 3 weeks
• Now the standard is beginning to shift to Posterior tibialis tendon by
endoscopy, which has proved to be an efficient way to treat
tenosynovitis occurring in stage I and II AAFD.

44. Open vs endoscopic

45. Stage 2
• Flexible planovalgus deformity
• Incompetent tibialis posterior
• Non-arthritic hindfoot joints
• Radiology :
Forefoot abduction
Subluxated talonavicular joint
Reduced arch height

46. Stage 2a vs stage 2b
Stage 2a
• Less than 30% medial talar head uncoverage [or no lateral
incongruence]
• No clinical forefoot abduction
Stage 2b
• More than 30% medial talar head uncoverage or lateral incongruence
• Significant clinical forefoot abduction.

47. Stage 2a vs
stage 2b

48. Management of stage 2
‘essentially conservative!’
• Goals:
Deformity correction
Tendon protection
Conservative management first line: try for at least 4 -6 months
Young patients and cases with severe deformity –less likely to respond

49. Stage 2:conservative
Rest to tendon to reduce inflammation
• NSAIDS
• Systemic disease :treat accordingly
• Physical therapy-strengthening ,theraband,cryotherapy,iontophoresis.
• Orthotics –semi rigid, medial heel wedge ,medial column post
• UCBL,Foot mould ,pop cast or AFO.
BUT NO LOCAL STEROIDS

50. UCBL-University of California-Berkeley Lab

51. ANKLE FOOT ORTHOSIS

52. STAGE 2:MANAGEMENT
• When to do surgery?
Only after failure of 4 to 6 months of conservative care
• What surgery ?
Joint sparing procedures are the procedure of choice
In very late cases of AAFD stage 2 with subtalar arthritis joint sacrificing procedures are
done

53. Joint sparing surgery
• Tenodesis of tendon of tibialis posterior with tendon of flexor
digitorum longus.
• Transfer of flexor digitorum longus tendon

54. Joint sparing surgery
Medializing sliding calcaneal osteotomy[MCO]
‘Done in all cases of hindfoot valgus’
• Shifts weight bearing axis of tendoachilles
• Addresses hindfoot valgus
• Preserves hindfoot motion
• Usually combined with:
 Posterior tibial tendon augmentation [FDL]

55. Medializing sliding calcaneal osteotomy[MCO]
CASE

56. Medializing sliding calcaneal osteotomy[MCO]
CASE

57. Medializing
sliding calcaneal
osteotomy[MCO]
POST-OP

58. 3]LATERAL COLUMN LENGTHENING: When!!!
• Forefoot abduction greater than 15 degree talo-first metatarsal angle
on lateral xray.
• More than 25% of talar head uncovering on AP X-RAY
• Overweight patients
What are the procedures?
1. Calcaneocuboid distraction arthrodesis
2. Evan’s procedure

59. Calcaneocuboid
distraction arthrodesis
when??
• Powerful correction is needed
• Adult and long standing cases
• How?
in anterior part of calcaneum
osteotomy is done ,and graft is
taken and placed ,so that
lenghthening is achieved.

60. Evan’s osteotomy.
When??
• Younger age agroup
• To save calcaneocuboid joint
• How?
osteotomy at the body of
calcaneus between the anterior and
middle facet of the subtalar joint

61. 4]Cotton osteotomy
Plantar flexion open wedge medial cuneiform osteotomy
When it is done?
Collapse through talonavicular joint on x-ray of weight bearing axis.

62. Management :stage III
‘essentially surgical’
• Rigid deformity
• Disruption of posterior tibial tendon
• Lateral pain
• Radiology:
Degenerative changes in triple joint complex
• What:
1. Subtalar arthrodesis
2. Double arthrodesis
3. Triple arthrodesis

63. Subtalar arthrodesis

64. Double
arthrodesis
• Isolated arthritis of talonavicular
and subtalar joint with minimum
valgus deformity at heel

65. Triple
arthrodesis
• If pes planovalgus deformity is
fixed with arthritis in all three
joints .
• Rare conditions:
arthritis of 1 st tarsometatarsal
joint =1st metatarsocuneiform
arthrodesis is done

66. Stage IV:MANAGEMENT
• Deltoid ligament is insufficient, leading to lateral talar tilt and
tibiotalar valgus deformity.
• STAGE IVA:Tibiotalar involvement with a flexible flatfoot.
• STAGE IVB:rigid foot deformity in the setting of ankle joint
involvement
• Radiology:
• Lateral talar tilt +/- ankle arthritis

67. Stage IV:MANAGEMENT
• Medializing calcaneal Osteotomy/Lateral column lengthening (IVa)
• Double/triple arthrodesis (IVb)
• Deltoid ligament reconstruction
• Total ankle arthroplasty
• Ankle fusion
• Gastrocnemius recession or Achilles tendon lengthening

68. Deltoid ligament
reconstruction
• Supplement to other
reconstructive procedures.
• Improved clinical outcomes as well
as correction of valgus talar tilt by
5 degrees.
• Deltoid ligament reconstruction
techniques using peroneus longus
autograft and anterior tibial
tendon graft is done

69. Gastrocnemius recession or Achilles tendon
lengthening
• Supplemented with all reconstructive procedures where Equinus
contracture is present.
Gastrocnemius recession -for isolated gastrocnemius tightness.
Achilles lengthening -for gastrocnemius-soleus tightness.
These are both adjunct procedures for AAFD and are not done in
isolation

70. SUMMARY

72. SOURCE

73. THANK YOU