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BACKGROUND The decision to offer surgery for Stage II posterior tibial tendon deficiency (PTTD) is a difficult one since orthotic treatment has been documented to be a viable alternative to surgery at this stage. Taking this into consideration we limited our treatment to bony realignment by a lengthening calcaneus Evans osteotomy and tendon balancing. The goal of the study was to clinically evaluate PTT functional recovery with this procedure. METHOD The patient population included 17 feet in 13 patients. Inclusion was limited to early Stage II PTTD flatfeet with grossly intact but deficient PTT. Deficiency was assessed by the lack of hindfoot inversion during single heel rise test. The surgical procedure included an Evans calcaneal opening wedge osteotomy with triceps surae and peroneus brevis tendon lengthening. PTT function at follow up was evaluated by an independent examiner. Evaluation was performed at an average of 4 (range, 2 to 6.3) years. RESULTS One case presented postoperative subtalar pain that required subtalar fusion. Every foot could perform a single heel rise with 13 feet having active inversion of the hindfoot during elevation. CONCLUSIONS The results of this study provide evidence of PTT functional recovery without augmentation in early Stage II. It challenges our understanding of early Stage II PTTD as well as the surgical guidelines recommending PTT augmentation at this specific stage.

Background:The objective of this study was to evaluate the bone rotation of each joint in the hindfoot and compare the load response in healthy feet with that in flatfeet by analyzing the reconstructive three-dimensional (3D) CT image data during weightbearing.Methods:CT scans of 21 healthy feet and 21 feet with flatfoot deformity were taken in non-load condition followed by full-body weightbearing load condition. The images of the hindfoot bones were reconstructed into 3D models. The volume merge method in three planes was used to calculate the position of the talus relative to the tibia in the tibiotalar joint, the navicular relative to the talus in talonavicular joint, and the calcaneus relative to the talus in the talocalcaneal joint.Results:The talar position difference to the load response relative to the tibia in the tibiotalar joint in a flatfoot was 1.7 degrees more plantarflexed in comparison to that in a healthy foot ( p = 0.031). The navicular position difference to the load response relative to the talus in the talonavicular joint was 2.3 degrees more everted ( p = 0.0034). The calcaneal position difference to the load response relative to the talus in the talocalcaneal joint was 1.1 degrees more dorsiflexed ( p = 0.0060) and 1.7 degrees more everted ( p = 0.0018).Conclusion:Referring to previous cadaver study, regarding not only the cadaveric foot, but also the live foot, joint instability occurred in the hindfoot with load in patients with flatfoot.Clinical Relevance:The method used in this study might be applied to clinical analysis of foot diseases such as the staging of flatfoot and to biomechanical analysis to evaluate the effects of foot surgery in the future. Level of Evidence: III

Background: The cause of navicular tuberosity pain in adolescents with flexible flatfeet is not well understood. We hypothesized that some of the navicular tuberosity pain may be related to insertional enthesopathy of the posterior tibial tendon at the navicular. Magnetic resonance imaging was performed to look for abnormal signal changes in a series of patients. Material and Method: Consecutive adolescent patients presenting with flexible flatfeet and navicular tuberosity pain were prospectively recruited. A detailed foot examination and body fat analysis was performed. Standing radiographs and Tekscan pedobarograph of both feet were obtained. Magnetic resonance examinations were performed on a 1.5-T whole-body magnetic resonance imaging system utilizing a standard extremity coil. Results: MRI abnormality was detected in 15 of the 36 feet in 18 adolescents examined. Abnormalities detected included thickening of the posterior tibial tendon insertion, marrow edema in the accessory navicular, marrow edema in the navicular tuberosity, and contrast enhancement at the posterior tibial tendon insertion site. Patients with MRI abnormalities were significantly taller, had a lower body mass index and a lower body fat percentage than those without MRI abnormality. Forward stepwise logistic regression analysis identified low body fat percentage and presence of an accessory navicular as independent predictors for abnormality on MRI. Conclusion: MRI abnormality was frequently detected in adolescents with painful flexible flatfeet. The MRI signal changes indicated an enthesopathy like process occurring at the posterior tibial tendon insertion to the navicular which could explain the origin of pain in flexible flatfeet patients without an accessory navicular. Early identification and appropriate treatment to prevent progression may be helpful. Level of Evidence: IV, Case Series

Background: To quantitate the association of Achilles tendon contracture (ATC) with adult acquired flatfoot, the authors hypothesized that the standing lateral tibial-calcaneal angle increases because of ATC. Methods: The standing lateral tibial-calcaneal angle, talo-first metatarsal angle, lateral talocalcaneal angle, lateral standing medial cuneiform, arch height, and anteroposterior talonavicular coverage angle were measured in 21 patients (25 feet) with clinical diagnoses of ATC and adult acquired flatfoot (AAF) and compared to the same measurements in a control group of 15 patients (30 feet) with no foot deformities or previous foot surgeries. Results: The mean lateral tibial-calcaneal angle in the control group was 64.43 degrees and in the AAF group 71.24 degrees ( p < 0.001). The mean lateral talo-first metatarsal angle in the control group was 11.77 degrees, and in the AAF group with ATC it was 25.80 degrees ( p < 0.001). The mean arch height in the control group was 17.90 mm and in the AAF group, 8.48 mm ( p < 0.001). In the ATC and AAF group an increasing standing lateral tibial-calcaneal angle was correlated with a decreasing lateral talo-calcaneal angle ( p = 0.044), and a decreasing arch height was correlated to an increasing lateral talo-first metatarsal angle ( p < 0.001). Conclusion: Adults with flatfeet and Achilles tendon contracture may have a statistically significant increase in the standing lateral tibial-calcaneal angle. This angle may be a reproducible measure of ATC. An increase in the standing lateral tibial-calcaneal angle may confirm and quantitate the clinical diagnosis of Achilles tendon contracture. Further studies with more patients are needed.

The purpose of this study was to determine the functional outcomes and radiographic results of adult patients who had an operation for flexible flatfeet without any hindfoot osteotomies or fusions.Twenty-eight feet in 23 patients with problems caused by their flexible flatfoot deformities had reconstructive foot and ankle surgery that included a subtalar arthroereisis (the restriction of the range of motion of a joint) with the Maxwell-Brancheau Arthroereisis (MBA) sinus tarsi implant. The American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot Scale and a patient assessment questionnaire were obtained from all patients before surgery and at final follow-up. Preoperative and postoperative standing radiographs were analyzed to determine radiographic correction of the deformities. The average followup was 44 months. The MBA implant was surgically removed in 11 of 28 feet (39%) because of sinus tarsi pain.The average preoperative AOFAS score was 52 and had improved to 87 (p0.00001) at final followup. The average response to four of five questions in the patient assessment had significantly improved (p0.05). On a 10-point scale, average patient satisfaction was 8.3 points; 78% said that they would have the surgery again. Correction after surgery was significant (p0.0001) in each of the three radiographic parameters evaluated for 'correction with MBA' and 'final correction.' With the numbers available, no significant differences could be detected after the MBA was removed. Complications included sinus tarsi pain in 46% (13) of the 28 feet in this study; after implant removal, 73% (8) of 11 feet had less discomfort than before surgery with AOFAS scores 80 or better.Reconstructive foot and ankle surgery that included a subtalar arthroereisis with the MBA sinus tarsi implant resulted in favorable clinical outcomes and patient satisfaction in 78% (18) of 23 patients. In spite of the high incidence of temporary sinus tarsi pain until the implant was removed, this operative approach compares favorably with other operations for flexible flatfoot deformities in adults.

In 1991, Viladot1described an implant for the treatment of painless flatfeet in children. This was inserted through a double approach to allow the talus to function while limiting its ability to slide off the calcaneus. The wineglass shaped prosthesis was inserted into the sinus tarsi with a tibialis posterior advancement and soft tissue correction to allow the foot to adopt a neutral position. This is in keeping with other procedures described for the correction of flatfoot. Viladot reported excellent results in 234 feet operated on in such a manner using clinical, radiological and photopodographic parameters. In Sheffield, over three years, 22 implants were inserted for similar painless flatfeet in children. The results were assessed using clinical, radiological and pedobarographic parameters.Viladot was able to demonstrate an improvement in all cases, clinically, radiologically and photopodographically with little or no discomfort and a return to preoperative levels of activity including sport. We found that in all cases, postoperative pain was a major feature which limited activity in all but 2 feet and which reduced the ability to take part in sport and other preoperative pastimes. Unlike Viladot, we were unable to demonstrate consistent improvements radiologically. Pedobarographically, the loading of the first metatarsal head remained unchanged and the centre of pressure was corrected in only 14%.

Nine patients (13 feet) were identified whose primary complaints were of atraumatic-onset, chronic pain in the hindfoot exacerbated with increased activity and who had the diagnosis of idiopathic rigid flatfeet. Eight of 11 were greater than the 95thpercentile in weight for their age. Exam under anesthesia showed moderate to significant improvement in hindfoot motion in 9 feet; 4 feet required fractional peroneal lengthenings. Only 5 of 11 patients have had sustained relief of pain and report unlimited activity level.Children and adolescents with painful idiopathic rigid flatfeet without known causation can have significant, persistent, disability and do not uniformly respond well to traditionally-described nonoperative interventions.