Adult Flatfoot Research Articles

Hindfoot Alignment Valgus Moment Arm Increases in Adult Flatfoot with Achilles Tendon Contracture

Adult acquired flatfoot is often associated with Achilles tendon contracture and may be associated with isolated spring ligament insufficiency without Achilles tendon contracture. We have studied the hypothesis that standing valgus hindfoot alignment moment arm is increased in adult acquired flatfoot with Achilles tendon contracture when compared to adult acquired flatfoot without Achilles tendon contracture. The standing hindfoot alignment, standing lateral tibial-calcaneal angle, lateral talo-first metatarsal angle, lateral medial cuneiform arch height, and anteroposterior talonavicular coverage angle were measured in 22 patients with a clinical diagnosis of adult acquired flatfoot with one foot with clinical Achilles tendon contracture and one without that diagnosis. We compared the adult acquired flatfoot group to a control group of 15 patients with no foot or ankle deformities or previous foot or ankle surgeries. In patients with flatfoot and Achilles tendon contracture, there was a significantly increased valgus hindfoot alignment, talo-first metatarsal angle, talonavicular coverage angle, tibiocalcaneal angle and a decreased arch height when compared to the control group. In all flatfeet, we found an increased tibiocalcaneal angle. In both flatfoot groups, an increasing tibiocalcaneal angle and an increasing talo-first metatarsal angle was correlated to a decreasing arch height. In adult acquired flatfoot without Achilles tendon contracture diagnosed by clinical exam, an increasing talonavicular coverage angle was correlated to an increasing talo-first metatarsal angle and a decreasing arch height. Adults with flatfoot and Achilles tendon contracture have a significantly increased standing hindfoot valgus alignment moment arm and other associated deformities.

Correlation of Harris Mats, Physical Exam, Pictures, and Radiographic Measurements in Adult Flatfoot Deformity

In many reports describing flatfoot deformities, the abnormality is described using observations from physical examination, radiographs, or foot imprints. Correlation of these measurements is often lacking, making determination of the magnitude of the deformity or its surgical correction difficult to quantify. Weightbearing AP and lateral radiographs were obtained on 25 patients (39 feet) with a clinically apparent flatfoot deformity and an asymptomatic control group of 28 subjects (56 feet). Radiographs were examined for the lateral talometatarsal angle, the lateral talocalcaneal angle, calcaneal pitch, first metatarsocuneiform height, medial cuneiform -fifth metatarsal height, metatarsus primus elevatus, plantar gapping at the first metatarsocuneiform joint, the AP talonavicular coverage angle, and the metatarsus adductus angle. Harris mat imprints were obtained on each foot and measured for the magnitude of the flatfoot deformity. Physical examination included the subjective appearance to the examiner of the degree of pes planus (none, mild, moderate, severe), hindfoot valgus, and ankle range of motion. Photographs of the hindfoot were obtained in a standardized manner, and hindfoot valgus was measured from these photos and compared to the measured hindfoot valgus on the physical exam. Statistically significant differences between the two groups were found in the lateral talometatarsal angle, lateral talocalcaneal angle, calcaneal pitch, first metatarsocuneiform height, the AP talonavicular coverage angle, Harris mat imprint score, subjective pes planus score, hindfoot valgus measurement from both photographs and physical examination, ankle range of motion (all with a p value less than 0.01), and the metatarsus adductus angle (p = 0.019). No patient in the control group and 14 (36%) in the flatfoot group had evidence of plantar gapping at the first metatarsocuneiform joint. In the flatfoot group, statistically significant correlations were demonstrated between the Harris mat score and heel valgus as measured by photographic and physical examination, subjective pes planus grading by physical exam, the lateral talometatarsal angle, and the first metatarsocuneiform height. This study validates the use of the Harris mat imprint as an effective method of quantifying the magnitude of a flatfoot deformity. We also found a statistically significant decrease in ankle range of motion in the flatfoot group, indicating that tightness of the gastrocsoleus complex is part of the pathophysiology of flatfoot deformity.

Dealing With Lateral Skin Deficiency in Rigid Adult Flatfoot

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Single Medial Approach to Modified Double Arthrodesis in Rigid Flatfoot with Lateral Deficient Skin

Triple arthrodesis through a two-incision approach is the traditional surgical treatment of fixed flatfoot in adults. However, since it limits motion and forces the remaining joints to absorb more load, long-term studies report diminishing results over time from symptomatic breakdown of adjacent joints. In addition, wound-healing problems have been reported in up one-third of patients undergoing a major flatfoot reconstruction which are more commonly associated with the anterolateral approaches. Therefore, since 2003, we have been interested in selective arthrodesis of the subtalar and talonavicular joints sparing the uninvolved calcaneocuboid joint and the lateral skin. We have performed this procedure in 11 patients (14 feet) who had deficient lateral skin and a fixed hindfoot valgus deformity where adequate correction may have led to lateral wound complication. They were followed in a prospective fashion and assessed at a minimum of 6 months followup. Wound healing occurred without any complications in all cases. Evaluation was performed at an average of 21.5 (range, 6 to 50) months. Significant radiographic improvements were observed on each measurement: anteroposterior talonavicular coverage angle improved from 38.5 degrees to 7 degrees, lateral talo-first metatarsal angle improved from 21 degrees to 0 degrees, hindfoot frontal alignment angle improved from 18 degrees to 7.5 degrees. All patients had an asymptomatic calcaneocuboid joint. Arthrodesis of the subtalar and talonavicular joints through a medial approach combined with peroneal lengthening is a reliable procedure for the treatment of rigid flatfoot with deficient lateral skin without calcaneocuboid joint degeneration.

Changes in Histoanatomical Distribution Of Types I, III And V Collagen Promote Adaptative Remodeling in Posterior Tibial Tendon Rupture

Posterior tibial tendon dysfunction is a common cause of adult flat foot deformity, and its etiology is unknown. In this study, we characterized the morphologic pattern and distribution of types I, III and V collagen in posterior tibial tendon dysfunction. Tendon samples from patients with and without posterior tibial tendon dysfunction were stained by immunofluorescence using antibodies against types I, III and V collagen. Control samples showed that type V deposited near the vessels only, while surgically obtained specimens displayed type V collagen surrounding other types of collagen fibers in thicker adventitial layers. Type III collagen levels were also increased in pathological specimens. On the other hand, amounts of collagen type I, which represents 95% of the total collagen amount in normal tendon, were decreased in pathological specimens. Fibrillogenesis in posterior tibial tendon dysfunction is altered due to higher expression of types III and V collagen and a decreased amount of collagen type I, which renders the originating fibrils structurally less resistant to mechanical forces.

Radiographic correlation of symptomatic and asymptomatic flexible flatfoot in young male adults

The purpose was to evaluate the value of radiology to distinguish between symptomatic and asymptomatic flexible flatfeet in young male adults. Among young male army recruits, 56 feet of 28 recruits were diagnosed as otherwise normal, flexible flatfoot with invisible longitudinal arch on stance and either symptomatic or asymptomatic unilaterally or bilaterally. The talus-first metatarsal and calcaneal pitch angles were measured on weight-bearing lateral radiographs, and the results were evaluated statistically. The talus-first metatarsal angle showed statistical significance in both non-parametric and logistic regression tests, but the calcaneal pitch angle showed statistical significance only in non-parametric test between symptomatic and asymptomatic flatfoot groups. Although the single gender and number of samples limit the applicability of our study, these results caused us to make an interpretation that increased talus-first metatarsal angle might be an important risk factor of being symptomatic in otherwise normal flexible flatfoot.

Résultats à long terme du traitement du pied plat valgus de l’adulte par arthrodèse médiotarsienne

Purpose of the study Arthrodesis proposed for the surgical treatment of reducible pes planovalgus (flatfoot) in adults is designed to relieve pain and correct the deformity. The purpose of this work was to present the radiological and clinical results obtained with midtarsal arthrodesis performed in 22 cases of pes planovalgus. Material and methods This study concerned 22 cases of reducible flatfoot (Johnson grade 2) in 19 patients (11 males, 8 females, mean age 43 years, age range 15-75 years). Clinical outcome was assessed in terms of pain, function and motion using the AOFAS and Mann classifications. Radiological assessment (loaded anteroposterior and lateral views with Méary cerclage) noted the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints. Results Mean follow-up was 7 years 4 months (range 6 months-20 years 3 months). Two nonunions resolved favorable after cancellous grafting. The Kitaoka score was 73.5/100 points (range 53-94). Pain and function improved from 2.8 to 1.1 points (/4 points) and from 3.45 to 1.6 points (/4) on the Mann scale. Flexion-extension remained unchanged. The foot was aligned correctly in 68% of cases. The mean talar slope and the talocalcaneal divergence were normal at last follow-up but there was a persistent undercorrection of the Djian angle in 68% of the feet and a break in the Méary line in 41%. Calcaneal valgus was reduced 6.6° (16.6 to 10°) but the podoscope footprint was still the flatfoot type in 86% of the feet. For 50%, the neighboring joints presented progressive osteoarthritic degeneration. Subjectively the patients were very satisfied or satisfied with minor reservations for 73%. None of the patients was disappointed with the results. The objective outcome was excellent or good in 68% of the feet. Discussion and conclusion The results in terms of pain relief, function, motion, complications, and rate of satisfaction were comparable with results presented in the literature. Midtarsal arthrodesis provides effective pain relief and satisfactory functional recovery without creating any morbidity greater than simple talonavicular fusion. Nevertheless, it was noted that while correct alignment is achieved in the majority of cases, the clinical and radiological restoration of plantar cavum is limited. Furthermore compensatory hypermobility of the adjacent joints leads to the development of moderate osteoarthritic remodeling which remains asymptomatic more than seven years after the operation.

A biomechanical analysis of the effect of lateral column lengthening calcaneal osteotomy on the flat foot

Biomechanical models have been used to study the plantar aponeurosis, medial arch height, subtalar motion, medial displacement calcaneal osteotomy, subtalar arthroereisis and the distribution of forces in the normal and flat foot. The objective was to examine the hypothesis that increased load on the medial arch in the adult flat foot can be reduced through a 10mm lateral column lengthening calcaneal osteotomy 10 mm proximal from the calcaneal cuboid joint. A three dimensional multisegment biomechanical model was used with anatomical data from a normal foot, a flat foot and a foot corrected with a 10mm lateral column lengthening calcaneal osteotomy. The response of a normal foot, a flat foot and a flat foot with a 10mm lateral column lengthening calcaneal osteotomy to an applied load of 683 N was analyzed using the biomechanical model. Data for the biomechanical model was obtained from a cadaver foot using the direct linear transformation method. Direct linear transformation uses multiple cameras to determine the spatial location of anatomical landmarks. Load on the first metatarsal increases to 37% body weight in the flat foot compared to 12% for the normal foot and the moment about the talo-navicular joint increases from 5.6 N m to 21.6 N m. Lateral column lengthening shifts the load toward the lateral column, decreasing load on the first metatarsal to 10% and decreasing the moment about the talo-navicular joint to 8.1 N m. The analysis shows that a 10mm lateral column lengthening calcaneal osteotomy reduces the excess force on the medial arch in an adult flat foot and adds biomechanical rationale to this clinical procedure.

Randomized Prospective Study Comparing Tri-Cortical Iliac Crest Autograft to Allograft in the Lateral Column Lengthening Component for Operative Correction of Adult Acquired Flatfoot Deformity

Operative treatment of stage II posterior tibial tendon insufficiency (PTTI) is controversial. Many soft-tissue and bony procedures and various combinations of the two have been reported for treatment of stage II PTTI. Orthopaedists recognize the lateral column lengthening component of the procedure as a successful reconstructive technique. The use of cortical allograft for lateral column lengthening in the correction of pes planus in the pediatric patient population has been routine. In the adult population, however, tricortical iliac crest autograft has been the bone graft of choice. Harvest of this autograft can precipitate significant morbidity and cost. Therefore, we undertook this randomized controlled trial to compare graft incorporation and healing of allograft and autograft in the lateral column lengthening component of adult flatfoot reconstruction. Lateral column lengthening was done as a component of operative correction for stage II PTTI in adult patients (older than 18 years) by two surgeons using similar procedures. The patients were randomized to either the allograft or autograft procedures. The primary endpoint was graft incorporation and healing as assessed by radiographs. The study included 33 randomized feet in 31 patients. We followed 18 feet in the allograft group and 15 in the autograft group to the point of union. There were 21 women and 10 men. There were no delayed unions, nonunions, or hardware failures. All patients in both groups achieved bony union by the 12-week followup evaluation. Two superficial foot infections were successfully treated with oral antibiotics. Two patients in the autograft group continued to have hip donor site pain at 3 months. This study suggests that union rates of allograft and autograft (iliac crest bone graft) are equal. The use of allograft in the lateral column lengthening component of operative correction of adult stage II PTTI appears to be a viable alternative to the use of iliac crest autograft and eliminates the morbidity and increased cost associated with autograft harvest.

Spring Ligament Reconstruction for Posterior Tibial Tendon Insufficiency

Adult flat foot deformity, resulting from posterior tibial tendon (PTT) insufficiency has been treated traditionally with a combination of bony and soft tissue procedures with variable outcomes. Many techniques advocate repair of the spring ligament to optimize outcome. In cases of long standing PTT deficiency, however, the spring ligament may be significantly attenuated; compromising potential repair as a useful surgical strategy. The current authors describe a simple technique that uses the distal stump of the PTT to reconstruct and augment the spring ligament fibrocartilage complex. The advantage of this technique is the use of existing autogenous tissue to provide reconstruction of the attenuated spring ligament. The construct provides a broad proximal support; preventing midtarsal pronation and abduction by its Y shaped configuration without donor site morbidity.

Radiographic Assessment of Adult Flatfoot

Radiographic Assessment of Adult Flatfoot

Current Concept Review: Acquired Adult Flatfoot Deformity

Current Concept Review: Acquired Adult Flatfoot Deformity

Radiographic Assessment of Adult Flatfoot

The accurate measurement of flatfoot on standing radiographs allows correct diagnosis of the condition and evaluation of reconstructive procedures. The standing radiographic measurements of patients with symptomatic, adult flatfoot were compared to controls using blinded observers. On the lateral radiograph, the talar-to-first metatarsal angle, the calcaneal pitch angle, and the medial cuneiform-fifth metatarsal height differed significantly between the patient group and the controls. The difference in the talar-to-first metatarsal angles on lateral radiographs was the most statistically significant (patient group 21.1 +/- 10.8 degrees and control 7.1 +/- 10.7 degrees, p < 0.0001) with good correlation between readings (intraobserver 0.75, interobserver 0.83). On the anteroposterior (AP) radiograph, the talar head uncoverage distance was the most significantly different measurement between these groups. These findings support the hypothesis that the talar-first metatarsal angle is an accurate radiographic identifier of patients with symptomatic, adult flatfoot.

ARTHRODESIS TECHNIQUES IN THE MANAGEMENT OF STAGE-II AND III ACQUIRED ADULT FLATFOOT DEFORMITY

The proper management of acquired flatfoot deformity requires obtaining a careful patient history and physical examination of the foot, ankle, and lower extremity. Accurate assessment of foot flexibility and localization of pain will aid in decision making. Nonsurgical management may not be successful in patients with advanced disease, particularly with the development of degenerative changes. Surgical management of advanced acquired adult flatfoot deformity (stages III and IV) is indicated with failure of nonsurgical management and consists primarily of arthrodesis for the foot component of the deformity. The foot component may include the subtalar, talonavicular, calcaneocuboid, or tibiotalar joints, or a combination of these joints. Adjunctive procedures, such as Achilles tendon lengthening, medial displacement calcaneal osteotomy, lateral column lengthening, and plantar flexion osteotomy of the first ray are useful in correcting residual deformities after hindfoot realignment. Proper selection of surgical procedures will maximize the potential for a good outcome. It is critical to correct all components of the deformity simultaneously in order to minimize recurrence of the deformity.

Diagnosis and treatment of adult flatfoot

Foot and ankle specialists agree that flatfoot is a frequently encountered pathology in the adult population. For the purpose of this document, adult flatfoot is defined as a foot condition that persists or develops after skeletal maturity and is characterized by partial or complete loss (collapse) of the medial longitudinal arch. Adult flatfoot may present as an incidental finding or as a symptomatic condition with clinical consequences ranging from mild limitations to severe disability and pain causing major life impediments. Adult flatfoot encompasses a wide variety of pathologic etiologies that may include a benign process reflecting continuation of a congenital problem, trauma, or a condition associated with systemic pathology. The adult flatfoot is often a complex disorder with a diversity of symptoms and various degrees of deformity. Pathology and symptoms are caused by structural loading

A biomechanical model of the effect of subtalar arthroereisis on the adult flexible flat foot

Objective. The hypothesis tested was that the increased load on the medial arch in the adult flat foot can be reduced through a 6 mm subtalar arthroereisis. Design. A three-dimensional multisegment biomechanical model was used in conjunction with experimental data and data from the literature. Background. Biomechanical models have been used to study the plantar fascia, medial arch height, subtalar motion, medial displacement calcaneal osteotomy and distribution of forces in the foot. Methods. Responses of a normal foot, a flat foot, and a flat foot with a subtalar arthroereisis to an applied load of 683 N were analyzed and the distribution of support among the metatarsal heads and the moment about various joints were computed. Results. The flattened foot results in an increase in the load on the head of the first metatarsal from 10% to 24% of the body weight, and an increase in the moment about the talo-navicular joint from 3.4 to 11.9 N m. Insertion of a 6 mm cylinder into the sinus tarsi, subtalar arthroereisis, results in a shift of the load back toward the lateral column, decreasing the load on the first metatarsal to 6% of the body weight and decreasing the moment about the talo-navicular joint to 6.0 N m. Conclusions. Our analysis indicates that a 6 mm subtalar arthroereisis in an adult flat foot model decreases the load on the medial arch. Relevance Our analysis adds a quantitative biomechanical rationale to subtalar arthroereisis for the treatment of the flat foot.

Surgical treatment of acquired flatfoot deformity: what is the state of practice among academic foot and ankle surgeons in 2002?

This study was performed to review the present approach to the surgical treatment of acquired flatfoot deformity among a cross section of academic foot and ankle surgeons in the United States. A typical case of stage II posterior tibial tendon dysfunction was developed. The hypothetical patient was a healthy 62-year-old male with a symptomatic acquired flatfoot deformity with posterior tibial tendon dysfunction. Nonoperative management had failed. A series of academic foot ankle surgeons were surveyed to identify their proposed operative treatment. Each surgeon surveyed was affiliated with an orthopaedic residency program and was directly responsible for teaching orthopaedic residents. Each surgeon had foot and ankle patients as the major component of their practice. The overall response rate was 81% (104/128). Ninety-seven percent (101/104) of respondents reported that they would employ some type of bony procedure in their surgical treatment. Eighty-eight percent (89/104) described techniques that would preserve the subtalar and talonavicular joints. These included a medializing calcaneal osteotomy in 73% (76/104), a lateral column lengthening in 41% (43/104), and a medial column stabilization (first tarsometatarsal and/or navicular cuneiform arthrodesis) in 15% (16/104). Twelve percent (12/104) reported that they would perform an arthrodesis of one or more of the hindfoot joints. Ninety-eight percent (102/104) of respondents reported that they would employ some type of soft-tissue procedure. Ninety-four percent (98/104) would augment the posterior tibial tendon, 53% (55/104) would formally repair the spring ligament, and 70% (73/104) would address a presumed equinus contracture. There is a wide variation in the approach to surgical treatment of stage II acquired adult flatfoot deformity among academic foot and ankle surgeons. Most surgeons employed a combination of bony and soft-tissue procedures that preserved the subtalar and talonavicular joints.

Surgical Management of Adult Flatfoot

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Hindfoot Arthrodesis for Flatfoot Deformity

Summary: Surgical management of the adult flatfoot includes soft tissue reconstructive/tendon substitution procedures, hindfoot osteotomies, and hindfoot arthrodesis. The extent of arthrodesis can range from subtalar fusion to triple arthrodesis. The determination of which surgical procedures to use depends on the nature of the deformity, its extent, and patient factors such as age, activity, expectations, and comorbid conditions.

A Surgical Alternative for the Painful Adult Flatfoot

A Surgical Alternative for the Painful Adult Flatfoot