Flatfoot reconstruction Case for small group discussion Learning points: Do not always need to sacrifice the PTT Acute ruptures can occur Option of a medial column procedure versus a lateral column procedure AOTrauma—Foot & Ankle Module 9: Acquired flatfoot deformity Christina Kabbash, US

Case description 40-year-old woman with an acute on chronic rupture of insertional posterior tibial tendon (PTT) tendonitis treated for 1 year with bracing, PTT, and activity modification Experienced acute ‘pop’ and arch collapse, pain improved a few days afterwards but had obvious right unilateral foot deformity Continued with bracing for a few months, was unable to progress to an orthotic

Success of bracing for stage II PTT Flexible flatfoot deformity with posterior tibial tendonitis 7 to 10-year follow-up of 14.9 months of bracing followed by progression to orthotics: 70% patients brace free 15% with brace 15% surgery Reference: Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: a 7- to 10-year follow-up. Foot Ankle Int. 2008 Aug;29(8):781–786. Lin et al. Foot Ankle Int. 2008;29:781–786

Flatfoot on one side only Leg-length discrepancy with pelvic tilt

Preoperative x-ray Dorsolateral peritalar subluxation

Preoperative x-ray Dorsolateral peritalar subluxation Meary’s angle

30% uncovered?

TN uncoverage angle Indicates degree of forefoot/midfoot abduction? Sometimes the lateral view does not show the amount of arch collapse seen clinically. Why?

Operative plan Tendon Achilles lengthening (TAL) Since it was a recent collapse, I was hoping to avoid overloading her lateral column with a double calcaneal osteotomy and instead performed an opening wedge cuneiform (Cotton) osteotomy The decision to excise or save the PTT depends on the findings at surgery….

Operative plan Tendon Achilles lengthening (TAL) Medial column incision to expose the PTT, flexor digitorum longus (FDL) tendon transfer, navicular tuberosity

Acute or chronic rupture

Healthy tendon after debriding ruptured tendon area

Operative plan Medializing calcaneal osteotomy—shift of 1 cm Since it was a recent collapse, I was hoping to avoid overloading the patient’s lateral column with a double calcaneal osteotomy and instead performed an opening wedge cuneiform (Cotton) osteotomy The decision to excise or save the PTT depends on the findings at surgery….

Operative plan What would your next step be? Correct arch collapse/midfoot abduction with lateral Evans procedure versus medial column osteotomy Since it was a recent collapse, I was hoping to avoid overloading her lateral column with a double calcaneal osteotomy and instead performed an opening wedge cuneiform (Cotton) osteotomy The decision to excise or save the PTT depends on the findings at surgery….

Operative plan Performed an opening wedge medial cuneiform osteotomy since the patient had very little midfoot abduction when standing—pronounced medial arch collapse Since it was a recent collapse, I was hoping to avoid overloading her lateral column with a double calcaneal osteotomy and instead performed an opening wedge cuneiform (Cotton) osteotomy The decision to excise or save the PTT depends on the findings at surgery….

2-week postoperative x-rays Medializing calcaneal osteotomy with plantar medial shift Cotton, FDL with tenodesis to distal stump PTT after debridement of PTT, spring ligament repair, TAL Cotton performed by centering osteotome on the lateral view and inserting to the plantar aspect under flouroscopy BEFORE levering to avoid fracture Cotton useful for juvenile hallux valgus when proximal first metatarsal (MT) growth plate is still open—would not want to do a first tarsometatarsal (TMT) fusion or a first MT osteotomy in this case

Well healed cuneifrom osteotomy Note medialization of calcaneus

Preoperative x-ray Decreased uncoverage angle Postoperative x-ray

TN angle and cuneiform arch height improved Some residual naviculocuneiform arthodesis (NC) sag

Take-home messages Acute on chronic rupture—acute progression of stage I to stage II PTT tendonitis Remaining PTT tendon relatively healthy—side-to-side tenodesis to the FDL tendon transfer Corrected heel valgus with medializing calcaneal osteotomy Corrected forefoot abduction and arch height with Cotton procedure: To avoid fracture of the cuneiform, confirm complete penetration of the cuneiform with osteotome before levering

Take-home messages Alternative medial column procedures include first metatarsal opening wedge plantar flexion osteotomy First tarsometatarsal fusion with plantar flexion (+/-) plantar displacement Not an option when the growth plate in the proximal 1st MT is still open!!!!!