1. Adult Acquired Flatfoot Deformity Management Algorithm
Haroon Majeed
MBBS; MRCS; MSc; FEBOT; FRCS (Tr & Orth)
Senior Fellow Foot & Ankle Surgery
Wrightington Hospital, Wigan, England UK
December 2017

2. Stages of Flatfoot Deformity
Johnson and Strom
modified by Myerson

3. Management Options
Conservative
Surgical

4. Conservative treatment
First line of management for all stages

5. Conservative treatment
(mild/moderate flexible deformity)
Stage I/IIa
Supportive semi-rigid molded foot orthoses
Stabilization and control of affected joints
Stretching of the Achilles (gastroc)
Strengthening of the posterior tibial tendon

6. Conservative treatment (severe correctable deformity) Stage IIb
Rigid/semi-rigid orthoses
Basic mold made out of polypropylene
Posted at hindfoot, forefoot or both,
depending on hindfoot–forefoot
relationships evaluated with the
subtalar joint in neutral position

7. Severe correctable deformities not controlled by foot orthoses
Ankle Foot Orthosis
Hinged
Not hinged (Richie Brace)
Well-fitted, custom-molded leather and polypropylene orthosis - effective for relieving symptoms

8. Literature Nielson et al. 2011 – 64 patients – Stage I
Physio, NSAIDs, Orthoses
87% cases not requiring surgical intervention
Alvarez et al – 47 patients – Stage I/II
Physio, stretching exercises, orthoses
89% satisfactied

9. Surgical treatment
Symptomatic patients not controlled by conservative treatment
Clear progression of the pathology
Duration of conservative treatment ?

10. Surgical Algorithm – Painful Pes Planus
Patient Factors
Age
Obesity
FLEXIBLE
DJD
NOT FLEXIBLE
Selective
fusion
FDL transfer
Hindfoot
Valgus
Dominant
Forefoot abduction Dominant
Triple fusion
Achilles tendon contracture
MCDO
Ligament repairs
Lateral Column Lengthening
Double cut/triple cut or Open TA lengthening
CC distraction fusion
Evans Procedure
Fixed forefoot supination – plantarflexion medial column fusions

11. Most frequently bone and soft tissue procedures combined
Surgical treatment
(Flexible vs Rigid)
Tendon repair/transfer
Tendon lengthening & ligamentous
repair
Osteotomies – (arthroereisis)
Arthrodesis
Most frequently bone and soft tissue procedures combined

12. Soft tissue procedures
PTT mildly elongated
?Debridement
Detached and re-attached with appropriate tension
Augmented with a side to side
FDL tenodesis 12

13. Soft tissue procedures
PTT degenerative/elongated/ruptured
FDL transfer into navicular
PT and FDL like-phase tendons
FDL most expendable of all flexors 13

14. Soft tissues procedures
Medial structures
assess and repair
- spring lig.
- deltoid lig. 14

15. Soft tissues procedures
Achilles tendon lengthening
Gold standard:
percutaneous TA
triceps fascia section
open lengthening if significant 15

16. Gastrocnemius lengthening
Ankle dorsiflexion
15-20° =
Gastrocnemius lengthening 4-5 cm
4-5 cm 16

17. Flexible Deformities
Isolated repair of tendons and ligaments
- Insufficient correction of bony
malalignment
- Loss of primary correction
calcaneal osteotomies and arthroereisis assist adequate mechanical control of deforming forces

18. Reduces the gastrocnemius
valgus moment
Improves the mechanical axis
of the lower limb
Achilles tendon
insertion
moves medially

20. Arthroereisis – limited role for flexible flatfeet
Small series with good short term outcomes
High incidence of sinus tarsi pain

21. Stage IIa Treatment of choice
Medializing calcaneal osteotomy + FDL transfer +/- TA lengthening

22. Stage IIb Treatment of choice +/- Lateral column lengthening
Medializing calcaneal osteotomy + FDL transfer +/- TA lengthening
+/- Lateral column lengthening
CC distraction
Lateral opening wedge osteotomy (Evan’s)

23. Osteotomy 10 mm from CC joint open wedge - graft - internal fixation
combined with medial reconstruction
1 cm
4mm

24. Rationale correction of midfoot abduction and supination
increases talar head coverage
decreases lateral fibular impingment
restricts rotation and further subluxation at TN joint
controversial – lateral sided pain 45%
Deland et al. 2006
double threaded screw
plate

25. Staples

26. Literature Myerson et al.
129 patients, stage II
Significant radiographic correction
91% patient-satisfaction
97% pain relief
94% improvement of function
87% improvement in the arch of the foot
84% patients were able to wear shoes comfortably without shoe modifications or orthotic arch support
Excellent functional outcomes in other studies

27. Stage III Triple arthrodesis ST and TN +/- CC (double fusion)
In case of fixed deformities and DJD
provides a plantigrade & reasonably
painless foot
Consider isolated (ST, TN) fusion
in selected cases

28. Neutral forefoot
Beware of 1st ray elevation
?1st TMT fusion/MT osteotomy

29. Stage IV - Pantalar fusion
Example of 68 year old female, reumatoid with rigid flatfoot and secondary arthrosis ankle joint and hindfoot. Treatment: pantalar fusion. 29

30. Stage IV Triple fusion + total ankle replacement in selected patients
Alternative option
Triple fusion + total ankle replacement in selected patients

31. Surgical Algorithm – Painful Pes Planus
Patient Factors
Age
Obesity
FLEXIBLE
DJD
NOT FLEXIBLE
Selective
fusion
FDL transfer
Hindfoot
Valgus
Dominant
Forefoot abduction Dominant
Triple fusion
Achilles tendon contracture
MCDO
Ligament repairs
Lateral Column Lengthening
Double cut/triple cut or Open TA lengthening
CC distraction fusion
Evans Procedure
Fixed forefoot supination – plantarflexion medial column fusions

32. Summary Stage I Conservative Insoles, rehab, stretching Loss of weight
? Debridement
Stage II
IIa: Med. Disp. Cal. Osteotomy, FDL transfer, TA lengthening
IIb: as per IIa +/- Lateral column lengthening
Stage III
Hind foot arthrodeses with malalignment correction
Stage IV
Pantalar fusion

33. Take Home Message
Soft tissue involvement to be considered, properly managed and combined with bony procedures
Exceptions are selected patients
with stage I (without flatfoot)
Osteotomies: mechanical control of the peritalar joint complex 33

34. Take Home Message
Good results at long term for calcaneal OT and FDL transfer
Arthrodesis in case of DJD/fixed deformities/major instability provides a reasonable painless foot if plantigrade 34

35. Questions?
Thank You!