current concepts on the operative management of AAFD

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Current Concepts on the Operative Management of
Adult Acquired Flatfoot
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INTRODUCTION

• AAFD is a common deformity that is encountered by
  orthopedic surgeons.
• The pathophysiology is still debated.
• A clear understanding of the normal function of
  the PTT and the static restraints of the medial
  longitudinal arch is essential to understanding
  the operative and non-operative TTT options for
  AAFD.

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AIM OF THE WORK

• The aim of this essay is to highlight the recent
  trends in understanding of the pathophysiology of
  AAFD and increase the awareness among orthopedic
  surgeons regarding its evaluation and management.

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RELEVANT ANATOMY

• The human foot is a complex structure adapted to
  allow orthograde bipedal stance, locomotion.
• The foot

FOREFOOT
HINDFOOT
MIDFOOT
ARCHES OF THE FOOT
Medial longitudinal arch.
Lateral longitudinal arch
Transvers arch
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ARCHES OF THE FOOT
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Medial longitudinal arch.
Posterior pillar
Anterior pillar
Posterior part of inferior calcaneal surface.
The three metatarsal heads
A tie beam
The plantar aponeurosis
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Short Muscles of Sole of the Foot
Tendons of Long Muscles
STRUCTURES SUPPORTING THE ARCHES
Ligaments
Bony Arrangement
Plantar Aponeurosis
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RELEVANT BIOMECHANICS
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• Phases of the walking cycle. Stance phase
  constitutes approximately 62 of the cycle, and
  swing phase 38.

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Biomechanics of flatfoot

• The weight bearing axis passes through the
  anterior superior iliac spine down through the
  patella to the middle of the foot at the level of
  the second metatarsal.
• The weight-bearing axis is shifted medially, thus
  disrupting the entire kinetic chain of the lower
  extremity.

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PATHOPHYSIOLOGY OF ADULT ACQUIRED FLATFOOT
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Causes of AAFD

• Loss of the supporting structures
• 1. PTTD.
• 2. Tear of the spring ligament (rare).
• 3. Tibialis anterior rupture (rare).
• Degenerative changes secondary to
• 1. Inflammatory arthropathy.
• 2. Osteoarthropathy.
• 3. Fractures.
• Charcot foot secondary to
• 1. Diabetes mellitus.
• 3. Profound peripheral neuritis of any
  cause.

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Inflammatory changes in the PTT.
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Post-traumatic flatfoot deformity
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AAFD 2ry to Arthritic Deformity

• In RA, soft tissue inflammation occurs with
  subsequent erosion of the talonavicular and
  subtalar joints and possible PTTD.
• AAFD 2ry to Osteoarthrosis
• Degenerative changes with loss of joint space,
  irregularity depression of the articular
  surface leading to collapse of the medial
  longitudinal arch.

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AAFD 2ry to Charcot Foot

• Diabetes mellitus is the most common cause of
  this disorder.

• AAFD 2ry to Plantar Fascia Rupture
• Post traumatic or spontaneous rupture may occur
  with subsequent limited flattening of the
  longitudinal arch.

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CLINICAL PRESENTATION OF ADULT ACQUIRED
FLATFOOT
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HISTORY

• May include feet tire easily pain and swelling
  over the collapsed medial longitudinal arch, an
  insidious onset of the bilateral or unilateral
  deformity.
• SYMPTOMS SIGNS
• Pain.
• Swelling deformity.

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PHYSICAL EXAMINATION

• A full general examination MSK examination is
  due.
• INSPECTION
• Walking Gait
• A toe-in gait in an attempt to shift the
  weight-bearing axis laterally.
• While standing
• Limb alignment(genu valgum in flatfeet).
• Foot (flatfoot) - heel valgus, low arch,
  forefoot abduction supination.

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• Standing on tiptoe
• Differentiate between flexible and rigid
  flatfeet.
• Too many toes sign
• From behind more toes are seen on the lateral
  side of the leg.
• While sitting
• Patient to be asked to locate the primary
  focus of pain.

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Too many toes sign
Single heel raise test
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• PALPATION AND STABILITY
• Bony prominences ankle ligaments
• Stability of the lateral ankle ligaments to be
  assessed with anterior drawer test.
• NEUROVASCULAR EXAMINATION.
• RANGE OF MOTION.
• Contracture of Achilles tendon.
• MUSCLE TESTS.

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INVESTIGATIONS
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I. RADIOGRAPHIC INVESTIGATIONS

• Plain radiographs.
• Computed tomography.
• Magnetic resonance imaging.

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Type II tear of the PTT.
Type I tear of the PTT.
Type III tear of the PTT.
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Degenerative subchondral cyst involving the
anterior aspect of the posterior facet of the
subtalar joint.
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RA, lateral weight-bearing radiographs. (a)
Planter flexion of talar head and instability of
talonavicular joint. (B) The talonavicular
joint is minimally affected instability of
subtalar joint.
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Charcot foot episodes result in AAFD with mid
foot joint destruction.
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II. LABORATORY INVESTIGATIONS

• Serologic testing
• In diabetic patients RA, useful information
  may be obtained through CBC, ESR, uric acid,
  blood glucose glycohemoglobin.

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MANAGEMENT OF ADULT ACQUIRED FLATFOOT
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Initial Treatment

• A symptomatic flatfoot TTT entails
• Patient education, discussion of the
  prognosis, observation of the condition.
• The symptomatic flatfoot TTT is directed at
• Resisting the deformity limiting pronatory
  compensation.

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Operative Treatment

• The surgical procedure chosen should address all
  the fixed and dynamic deformities for the
  individual patient.
• Indications
• After failure of 36 months of conservative
  management.

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A-PTTD

• Surgical treatment of PTTD is appropriate to
  prevent progression of disease.
• Johnson and Strom recommended 3 to 6 weeks of
  conservative care before surgery.
• Longer delays increase the risk of progression to
  advanced stages.

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Tenosynovectomy

• Indications
• Inflammatory changes in the PTT but no
  deformity.
• Either open or endoscopically.
• The goals are to decrease pain and to remove any
  of the inflammatory tissue.

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A
C
B

• The incision mark .
• (B) The tendon sheath is then opened.
• (C) There is extensive tenosynovitis along the
  PTT, Involved tissue was removed by sharp
  dissection.

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Flexor Digitorum Longus Tendon Transfer

• Indication
• A flexible AAFD and a reducible subtalar joint
  with or without forefoot supination.

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B
A
C
D
The steps in the FDL transfer for PTT rupture.
A, The severely torn PTT tendon is cut, leaving a
2-cm stump distally. B, The sheath of the FDL is
opened. C, The FDL is cut distally, and a 4.5-mm
drill hole is made in the navicular. D, The FDL
is passed through the drill hole from plantar to
dorsal and then sutured to the underside of the
stump of the PTT.
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Medial Displacement Calcaneal Osteotomy

• It corrects the hindfoot valgus alignment,
  resulting in restoration of the medial arch as
  shown in the following schematic diagram.

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Medial Displacement Calcaneal osteotomy (Pridie
Koutsogiannis). A, Normal relationship of talus
to calcaneus. B, Relationship of talus to
calcaneus and weight bearing axis falling medial
to calcaneus in pes planus deformity. C,
Displacement osteotomy of calcaneus to realign
hindfoot weight bearing properly.
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Intraoperative image showing the medializing
correction and fixated with one cannulated screw.
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Lateral Column Lengthening in AAFD Using A
Titanium Metal Foam Wedge Implant

• Lateral column lengthening is used for treatment
  of stage IIB PTTD.
• Evans first described an opening wedge osteotomy
  of the anterior os calcis with tricortical iliac
  crest bone graft in flatfoot correction.

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• Biofoam Cancellous Titanium has a larger pore
  size comparable with trabecular bone, lower
  modulus of elasticity, and improved surface
  characteristics.

Biofoam Evans wedge
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• Exposure of the anterior process of the calcaneus
  through a lateral incision, superior to the
  peroneal tendons.

The Biofoam Evans wedge is placed in the
osteotomy with the inserter.
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Postop. AP view showing restoration of TN
congruency after placement of Biofoam Evans wedge
and medial displacement calcaneal osteotomy.
Postop. Lateral view showing Biofoam Evans wedge
in place with TN congruency.
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The Cotton Osteotomy

• A powerful surgical adjunctive procedure in TTT
  of collapsing pes planovalgus with persistent
  rigid forefoot varus deformity.
• A key benefit is preservation of adjacent joint
  function.

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The goal is to limit dorsal and plantar cuneiform
ligamentous disruption
A microsagittal saw is used for the osteotomy.
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Graft preparation from a tricortical iliac crest
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1. Posto. radiographs showing the centrally placed
   Cotton osteotomy and graft placement.
2. An Evans calcaneal osteotomy, FDLT transfer, and
   a PTT advancement were concomitantly performed

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Deltoid Ligament Reconstruction

• Indications
• Stage IV flatfoot with reducible deformity
  without severe ankle arthritis.
• Contraindications
• Bone on bone ankle arthrosis.

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Schematic drawing showing graft placement on
medial view of the ankle.
Schematic drawing showing graft placement on a
mortise view of the ankle.
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Schematic drawing demonstrating preparation of
Achilles tendon allograft.
AP ankle radiograph taken before (A) and after
(B) deltoid ligament reconstruction.
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ARTHRODESIS PROCEDURES

• Subtalar Arthrodesis.
• Triple Arthrodesis.

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Triple Arthrodesis

• Indications
• Severe flexible flatfoot deformity,
• Rigid flatfoot deformity,
• Posttraumatic arthritis,
• Inflammatory arthritis.

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Incision mark for lateral access to the subtalar
joint for a triple arthrodesis
Incision mark for access to the talar neck
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Standard cannulated screw fixation for a triple
arthrodesis
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Minimally Invasive Surgical Treatment of AAFD
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Tendoscopy of PTT

• The surgical modality of choice for radical
  removal of inflamed synovium.
• Advantages
• Localization of the problem is made easier rather
  than open method,
• The size of the incision for repair of the
  rupture can be minimized.

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b
a)
c

• PT tendoscopy, revealing
• (a) Superficial tear of the PTT. (b) Rupture
  demonstrated with the arthroscopic probe.
• (c) Repair of the rupture through a mini open
  repair.

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Percutaneus Calcaneal Displacement Osteotomy

• Has been developed to help avoid the
  complications commonly seen with the traditional
  standard open calcaneal osteotomy.

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a
b

• The first stab incision is made on the medial
  side down to the calcaneus to perform the medial
  tunnel for the gigli saw.
• The gigli saw in place in the medial tunnel.

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Performing percutaneous calcaneal displacement
osteotomy, note the surgeons arms are spread to
not harm the skin of the inferior incisions with
the gigli saw.
Lateral view of the foot with fluoroscopy to view
the placement of the gigli saw before performing
the osteotomy.
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A fluoroscopic view of the foot after the
osteotomy is made
An interoperative view of the foot with the
posterior aspect of the calcaneus after the
osteotomy is performed.
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Postoperative percutaneous calcaneal osteotomy
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Arthroscopic Triple Arthrodesis

• It comprises arthroscopic subtalar arthrodesis
  arthroscopic midtarsal arthrodesis.
• Advantages
• Better intra-articular visualization.
• Minimal bone removal.
• Better fusion surface preparation.

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• Subtalar arthroscopy portals.
• The articular cartilage is denuded,leaving the
  subchondral bone intact.
• Micro-fracture of the subchondral bone with
  arthroscopic awl.

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Calcaneocuboid arthroscopy.
Talonavicular arthroscopy
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Risks of Surgical Intervention

• Wound complications including
• Skin necrosis
• Infection
• Predisposing factors for development of these
  complications include
• Patient tissue quality
• lack of subcutaneous tissue
• Postoperative swelling
• Meticulous handling of skin edges.

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SUMMARY AND CONCLUSION
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• The human foot is a complex structure has two
  longitudinal arches (medial lateral) and one
  transverse arch.
• Arches are maintained by tight compact
  arrangement of the bones bound together by
  ligaments.
• Muscles are dynamic stabilizers.
• PTTD is the most common cause of AAFD.

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• AAFD causes include PTTD, RA, AO,
  neuro-arthropathy, posttraumatic deformity,
  neurologic weakness, plantar fascia rupture.
• More detailed classification systems have been
  developed in recent years to help clarify
  treatment recommendations.
• Diagnosis of AAFD depends on careful clinical and
  radiological assessment.

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• The rigid AAFD is almost always pathologic and
  requires treatment.
• The nonsurgical TTT of AAFD includes initial
  immobilization, NSAIDs, physical therapy, bracing
  (LAFO)
• Operative care is not without inherent risks and
  requires a prolonged period of convalescence.
• Combination procedures are now more prevalent.

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• Minimally invasive surgical ttt has advantages
  of
• Preservation of blood supply,
• Decreased skin problems,
• Decreased infection,
• Decreased postoperative pain,
• Decreased time until union,
• Early weight bearing early return to work.

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