Per Residency Insight 3 - Case Study: Collapsing Pes Planovalgus--considering the history, radiographic data, clinical exam, and now the follow-up and conclusion as presented in RI 4--share your thoughts on the treatment of Collapsing Pes Planovalgus.

I believe Dr. Botte is right on the mark. An alternative to the Lapidus medial column stabilization might be the consideration of a Cotton procedure of the medial cuneiform. This would also create a more pronounced arch and assist the PT tendon in supporting the medial column. Again, caution must be exercised in determining the need for a medial column procedure by quantifying the amount of correction you obtain with the Evans lateral column lengthening. If you obtain acceptable arch height by bringing the forefoot out of an abductory position with the Evans, then you could possibly work on the PT tendon and re-route it, decreasing the obvious attenuattion that is present. If you have a "green light" to work on the medial column, then a Cotton can be a definite alternative procedure. A gastroc recession or TAL should definitely be part of the procedure plan as it considerably adds to the sagittal plane deformity.

     I know there has been ongoing controversy in the area of arthroeresis and whether or not it should be utilized on anyone OTHER THAN kids/adolescents, but I am sure some Physicians out there might opt for a STJ implant for some type of correction of the arch. Although I WOULD NOT proceed with an STJ implant on this patient, some might consider it an option for addressing the medial column. I am definitely anxious to hear  how this patient was actually treated--very interesting. Thanks for sharing this case.

i  would  get  the  mri any  unilateral flatfoot  makes  me  think PT but i  would  get  more  test  then  think  of  how  to  repair  the problem

I agree with Dr Botte with his reconstructive  plan, i would also agree with a cotton to correct the medial column.  My worry would be the length of the first ray and after correting all planes  further jamming at the 1st mtpj will likely occur.  In this case a Lapidus would be a better choice( correcting the length as well).  As far as a stj stent,  they are typically not a good idea once transverse/ sagital plane compensation has been present for years.  Once the implant is in place the forefoot will  not be able to move into a valgus position to purchace the ground.  Hence needing osseous procedure.  If you placed a STJ stent and this patient was able to derotate the forefoot and purchase the ground, the long first ray would not allow them to completely get the first ray to purchase. I typically will only combine a cotton/first ray procedure/TAl/gastroc recession with my stj stents.  If the patient requires anything more to correct the deformity(such as this patient) you asking too much from your implant and it is doomed to fail.

great case thanks for sharing

All that has been proposed for far sound good. I also noted an Os Trigonum.

To start either a Kinder to address the Prominent navicular or an Evans will correct the transverse plane deformity.  The Apex of the sagittal deformity appears to be at the navicular cuneiforn joint therefore either a Lowman, Cotton, Miller and what about a Young (the keyhole). Finish it off with a TAL.

I have had experience with the (Evans, Lapidus and TAL) to correct a flatfoot deformity this is possible under 2 hours,  but I would like to hear which Sagittal plane correction is the most commonly preformed and has the best results

This is a great discussion.  I will take a slightly different approach, however.  Since the patient's left calcaneus does not reduce, this is a rigid deformity.  There is also noticeable arthritic changes present in the rearfoot and midfoot based on the radiographs.  I would propose completing a triple arthodesis to better align the rearfoot and prevent painful motion of these arthritic joints, along with a medial column fusion (Miller procedure) to address the apex of deformity at the NC joint and better align the first metatarsal (reduce its elevatus).  I would also inspect the PTT and debride any degenerative changes noted. There is no mention of equinus in this particular case, but if it were present, I would complete either a TAL or gastrocnemius resession depending on where the deformity lies based on the Silfverskiold test.

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These are all very good thoughts about correcting this problem. I am wondering why Dr. Fitzgerald does a vertical calcaneal osteotomy cut rather than making the cut at 45 degrees or more parallel to the peroneal tendons. I surmise that a vertical cut facilitates placement of the fixation screw. What other advantages or disadvantages does this approach offer?

Also, the FDL weave through the PTT starts with passing it through the PTT then does it just wrap around the tendon as it appears in the photo? Was the PTT advanced therefore by tenodesis of the FDL to the navicular? What type of anchor was used?  I like the idea of using bioregenerative tissue techniques like Graftjacket. Used it for Achilles tendon repair and it worked well. It tends to add some bulk to the repair but then incorporates in the repair and dissipates after a a couple of months.

We generally utilize a vertical or slightly oblique osteotomy cut for the MDCO.  The risk on increasing obliquity is that your osteotomy will extend proximal-posteriorly into the area of the dorsal achilles insertion, or plantar-distally into the plantar fascia insertion.  The benefit of a more oblique osteotomy is increased surface area for healing.

The FDL tendon is woven throughout the PTT to the level of the insertion on the navicular, where the PTT is advanced in its insertion, and the FDL is tenodesed utilizing arthrex tendon anchors.

I agree with your assessment regarding the use of bioengineered tissues in the augmentation of tendon repairs.  We chose to utilize Tenoglide to provide a collagen scaffold to surround the tendon to reduce the development of adhesions and to allow for gliding motion to develop at the repair site.

Modifying this case a bit, if this patient had a high degree of tibial varum would the medial displacement calcaneal osteotomy (or STJ arthrororesis) not be as effective or even contraindicated? Generally, aren't patients with high degree of tbial varum more difficult to control biomechanically as well as surgically? And, considering a high degree of genu valgum doesn't this mitigate against a successful surgical outcome and lean more favorably toward biomechanical control?

Both tibial varum and genu valgum can be difficult to manage.  In this instance, if there was a tibial varum component, the patients valgus rearfoot would appear less significant with weight bearing.....essentially the PTTD would be compensating, to some degree.   It can be difficult to control patients with tibial varum biomechanically largely due to increased supination instability of the STJ which can be difficult to manage (see imagine below), with various sequellae (cavus foot deformity, lateral ankle instability, etc).... 

Depending on the degree of the varus deformity it in the tibia, a MDCO may be less effective (essentially reducing the compensation for the tibial deformity).  Arthroresis can provide some potential control of the STJ, however the instability in this instance is likely to be in both pronation and supination.

I would suspect that a patient with concomitant RF Valgus deformity as well as a tibial varum would have less overall complaint due to essential structural compensation.  If one was to consider surgical correction, it might be well to address the tibial component with osteotomies which re-align the tibial to the foot.  There are numerous was to secure such an osteotomy (valgus or neutral producing).

Genu valgum, or "knock-knee deformity" posses a significant challenge as well.  Commonly this deformity secondary to knee position --often this presents in pediatric patients --and poses a problem because this deformity alters the mechanical axis through the lower extremity.  In the image below, the shaded image demonstrates how the mechanical axis falls outside of the knee in genu valgum. 

A patient with a significant RF valgus AND genu valgum is going to have a "global" valgus deformity that is going to be difficult to correct.  I agree with your assessment, this would be a patient that i would attempt to control biomechanically initially with orthotics or functional bracing, as well as lifestyle modification, NSAIDS, and physical therapy.  Those cases which remain recalcitrant to conservative therapy may ultimately require surgical correction, however this is likely to require proximal tibial osteotomies or epiphysiodesis (in pediatric patients) in addition to whatever foot/ankle surgery may be indicated.  The goal of genu valgum reconstruction is to realign the limb such that the mechanical axis falls within the knee joint.

In those cases were surgery is to be attempted, i would address the genu valgum 1st, so as to have a better idea of the final functional relationship between the leg and the foot prior to any reconstructive foot and ankle surgery