Case for small group discussion Planovalgus foot Case for small group discussion AOTrauma—Foot & Ankle Module 9: Acquired flatfoot deformity Stefan Rammelt and Hans Zwipp, DE

Painful deformity 72-year-old active man Increasing pain and deformity over the previous 5 years Predominately left side Pain over sinus tarsi, less pronounced on medial side

Preoperative x-rays

Correction—lateral column lengthening Principle: Reference: Hansen ST Jr. Functional Reconstruction of the Foot and Ankle.  Philadelphia: Lippincott Williams & Wilkins; 2000.

Operative technique Fixation of anterior process (K-wire) Osteotomy Distraction Control of alignment Bone block interposition Screw fixation

Radiographic parameters Preoperative x-ray Talometatarsal (TMT) axis (lateral view) MT V-to-cuneiform I distance Navicular-to-floor distance (NFD) 30° 14 mm -1 mm Follow-up x-ray 8° 29 mm 8 mm

Radiographic parameters Preoperative x-ray Follow-up x-ray TMT axis (AP view) Talonavicular (TN) coverage angle, TN coverage 4° 8° 34° 27°

Additional procedures Gastrocnemius recession Exploration/debridement of posterior tibial tendon if symptomatic Correction of hallux valgus with hypermobile 1st ray (Lapidus procedure) Reference: Zwipp H, Rammelt S. [Modified Evans osteotomy for the operative treatment of acquired pes planovalgus]. Oper Orthop Traumatol. 2006 Jun;18(2):182–197. Zwipp H et al. Oper Orthop Traumatol. 2006;18:182–197. Hansen ST Jr. Functional Reconstruction of the Foot and Ankle; 2000.

Take-home messages Lateral column lengthening results in 3-D correction of flatfoot (dorsolateral peritalar subluxation) Add gastrocnemius recession generously Add further procedures as required