Case for small group discussion Flexible flatfoot Case for small group discussion Learning points: True all American R/o tarsal coalition May take bone graft from the calcaneus AOTrauma—Foot & Ankle Module 9: Acquired flatfoot deformity Arthur Manoli II, US

Case description 16-year-old female snowboarder Painful feet, right > left Failed orthotics, stretching Pain on subtalar movement

Preoperative x-ray

Preoperative x-ray

Preoperative CT scans Rule out tarsal coalition (if uncertain) Talonavicular and talocalcaneal

Surgical plan Tendon Achilles lengthening (TAL) Double calcaneal osteotomy with bone graft for the Evans, first metatarsal (MT) harvested from the medial calcaneal osteotomy (or iliac crest) Flexor digitorum longus (FDL) transfer to Tibialis Posterior Medial column procedure if needed: First TMT fusion in plantar flexion Alternatively, MT osteotomy “All American”

Bone graft harvest from calcaneus Do the Evans first so you know how much bone graft to harvest

6 months postoperative

6 months postoperative 6 mos postop

Take-home messages Always rule out tarsal coalition prior to a flatfoot reconstruction Bone graft may be harvested from the medializing calcaneal osteotomy If the Evans procedure does not give enough correction, add a medial column plantar flexion or stabilizing procedure Consider gastrocnemius lengthening if equinus present