1. 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

2. 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

3. 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 Aug;29(8):781–786.
Lin et al. Foot Ankle Int. 2008;29:781–786

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

5. Preoperative x-ray
Dorsolateral peritalar subluxation

6. Preoperative x-ray
Dorsolateral peritalar subluxation
Meary’s angle

7. 30% uncovered?

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

9. 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….

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

11. Acute or chronic rupture

12. Healthy tendon after debriding ruptured tendon area

13. 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….

14. 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….

15. 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….

16. 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

17. Well healed cuneifrom osteotomy
Note medialization of calcaneus

18. Preoperative
x-ray
Decreased uncoverage angle
Postoperative
x-ray

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

20. 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

21. 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!!!!!