Case for small group discussion Flatfoot deformity Case for small group discussion Stage II flatfoot reconstruction—all Australian AOTrauma—Foot & Ankle Module 9: Acquired flatfoot deformity Andrew Wines, AU

Case description 55-year-old woman Progressive flatfoot deformity Pain over the posterior tibial tendon Physical examination shows a mobile hindfoot

Heel cord lengthening Triple cut: Medial, lateral, medial distal to proximal Quick and easy Rupture Gastrocnemius lengthening

Medializing osteotomy Medial calcaneal slide

Medializing osteotomy—intraoperative x-rays

Sinus tarsi implant insertion Internal orthotic: Decreases tendency of talus to rotate medially and plantarward Improves talonavicular coverage

Flexor digitorum longus (FDL) tendon transfer FDL harvested at knot of Henry Weave through tibialis posterior tendon Inserted into tuberosity of navicular: Interosseous suture

Postoperative management Splint for 2 weeks: Anticoagulation therapy (LMWH) Walking boot for 4 weeks: Weight bearing as tolerated ROM exercises Physical therapy LMWH—Low molecular weight heparin

Treatment—late stage II disease Arthroereisis (sinus tarsi spacer)

Complications Displacement Overcorrection (overstuffing) Undercorrection Pain

Take-home messages Achilles lengthening must be considered in the treatment of flatfoot Subtalar arthroereisis (with a sinus tarsi implant or screw) may be an alternative or an augmentation to a medial displacement calcaneal osteotomy Be aware of sinus tarsi spacer complications