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Marie Williams: My name is Marie Williams, if you werenât here for the introduction the other night, and I actually am a Residency Director at Aventura Hospital and Medical Center in Florida, and Iâm going to talk to you about a topic called Flatfoot, but it should have said Flatfoot: Soft Tissue in Osseous Procedures. But in reality, really, when you talk about flatfoot, you donât so much talk about the surgery, but the biomechanical surgery or surgery itself.
Dr. Marc Bernard always gives such a great lecture on this. Itâs not an easy subject to think with. But guess what? We see it everyday in our practice. Many times, people will come in with an ingrown toenail, so to speak, and they donât know why it keeps coming back, even after their fenos and things like that and really, a lot of it is the rotation of the great toe against the ground that cause of that problem.
So if you think of things mechanically in the foot, a lot of pathology comes from that. The other thing that I wanted to mention to you is that orthopedics I donât think really understands biomechanics or biomechanics of the foot. The foot and ankle orthopedists, I see them doing work. Theyâre technicians more than they are artists of the feet. I think we have more of the art to this -- to the procedures as opposed to the cut-and-dry, âOh, this is the arthritic condition. This is where Iâm going to fuse it.â And thatâs the basic thing of the lower extremity or the foot. Some are excellent surgeons. Iâm not putting down foot and ankle orthopedists because some of them are really incredibly good at what they do and -- but I think that weâve taken so much time and attention on the biomechanical aspects of things that I think we have a better grasp. Just my opinion.
So I have no financial disclosures. I really do want you to understand the biomechanics of the flatfoot because you canât really talk about procedures unless you understand what is a flatfoot and the different types of procedures that you need to correct the different types of abnormalities, how do you decide what youâre going to do, and then know the different types of procedures that weâre going to do for osseous and soft tissue.
When you actually look at the foot, you look at the weight-bearing tensile forces in the plantar fascia. And you notice here that when you see someone hit, you look at three phases of gait; the contact phase, the midstance phase, and the propulsion phase of the gait. When that happens, the plantar fascia is very important because what it does is it separates the ends of the medial and lateral arches and the arch height changes and is provided by the windlass mechanism. So if you donât pay attention to the windlass mechanism, you may miss a lot of the pathology.
Spring ligament complex has received much attention as an important stabilizer of the medial arch and it has become a two-function action and it acts as the support for the head of the talus and provides stability to the TN joint and also, it has -- maintains the medial and longitudinal arch, but acting as a static support.
This is just a picture of a general concept of an acquired adult -- acquired flatfoot and basically, to the pathology. You know that the posterior tibial tendon or the posterior tibial tendon dysfunction is a very progressive deformity and disorder and it causes a ligament to stretch or attenuation over the medial and longitudinal arch. Actually, much of the stuff that we see in adult flatfoot is based on the pathology of the posterior tibial tendon or the posterior tibial tendon dysfunction and much of the treatment is addressed through that tendonâs structure.
So take a minute and letâs look at the function of the posterior tibial tendon or tibialis posterior. Itâs the main inverter of the foot. By inverting the foot, it locks the midtarsal joint and the Achilles tendon plantar flexes at the level of the tarsals with the result in supination.
Thatâs how it functions. What antagonizes it, the peroneus brevis which everts the foot and also decelerates the internal rotation of the tibia and limits pronation of the foot following heel strike. Donât forget the peroneus longus. That also is very important because it stabilizes the first rate to the ground. So when you lose function of the peroneus longus, you also have a supinatus, forefoot supinatus, and you can also have a flatfoot or an acquired flatfoot because of that.
So those -- that should be added in here. But what antagonizes the posterior tibial tendon is the peroneus brevis. Itâs always a question on biomechanical tests and thatâs the answer. But the longus is very, very important. I test that with my residents all the time. What is the peroneus longus doing? And they go, âI thought it was the brevis.â No, itâs both.
The posterior tibial tendon plays a critical role in the function of the foot. The posterior tibial tendon dysfunction leads to adult flatfoot. Itâs pretty much a simple statement, but thereâs so much going on. Weakness in the posterior tibial tendon unlocks the midtarsal joint, leading to collapse of the medial longitudinal arch. Thatâs the pathophysiology of whatâs happening.
The pathomechanics of posterior tibial tendon dysfunction leads to flatfoot by the loss of inversion of the posterior tibial, loss of inversion by the posterior tibial tendon which prevents the locking in the midtarsal joints. So the Achillesâ tendon function at the TN joint, causes flattening of the medial and longitudinal arch that I -- Iâll say that many, many times. The peroneus brevis functions unopposed causing, AB, abduction and eversion of the forefoot and valgus of the calcaneus. So thatâs the pathomechanics.
These are a list of etiologies. I donât need to go over all of them. But, you know, some of the common things are the some types of dislocations, Lisfranc injuries, arthritis, neuro.
You see a Charcot joint. One of the things that goes first is the posterior tibial tendon function which causes the collapse of the midtarsal joint and I know weâre doing and people are doing rings, and things, and fusions, but the posterior tibial tendon is the first thing that goes. Neurologic dysfunction can cause a lot of this as well as congenital deformities.
You canât speak about a flatfoot or procedures unless you really understand planal dominance. I go over -- when I naturally look at an x-ray, Iâm looking at what plane am I going to fix, or what planes do I have to fix, or why do I fix one thing and then now, they come back and something else is a problematic situation and maybe I missed the planal dominance or whether -- is it a triplane problem? So is it a front -- transverse plane, a frontal plane, a sagittal plane, or is it triplanar, or all of them?
So this is just a quick reference, really, in a transverse plane abnormality. Talocalcaneal angle is decreased. Calcaneocuboid angle is, AB, abducted. So increased. And the talar head is uncovered. So the normal -- you have 75% covered in the normal talus with a normal 0 to 5 degrees of calcaneocuboid abduction. Remember, thatâs going to increase in the normal degrees of the talocalcaneal angle of Kite. Itâs normally 25 to 40 and then itâs decreased. So what would you do? You could consider doing a posterior tib tendon advancement along with maybe an Evans Procedure or a flexor digitorum longus transfer. Transverse plane purely, you want to look at the abduction of the midfoot -- forefoot and midfoot and address it at that point. You may have to address it with that lengthening on the lateral column, the Evans osteotomy.
The more vertical the subtalar axis, the more transverse plane compensation.
Most identifiable by abduction between the midfoot and the rearfoot, the calcaneus is relatively vertical with minimal disruption at the TN joint. So thatâs one of the things you want to see. Youâll see the foot really, abducted, but the actual TN joint is almost normal.
So just as an example, here are the angles. I mean, we look at these angles. You can see the cuboid abduction angle that will increase, but the talonavicular joint is not uncovered.
On the frontal plane deformity, it actually is the alignment of the talus and the calcaneus relative to the long axis of the tibia. The position of the calcaneal tuber is relative to the extension of the long axis of the tibia. So if you donât look at the calcaneal axial picture, you might miss a little bit of this frontal plane problem. Now, these are where you do those medial calcaneal slides, a calceal jaundice or something like that or subtalar joint arthroereisis or a combination.
Remember that usually just an isolated frontal plane is not always â itâs not always present, but definitely, if you have frontal plane deformity, youâre definitely going to have to get the calcaneus back under the leg.
So itâs marked by eversion of the calcaneus subluxation at the TN joint and the naviculocuneiform sag. So when you look at that type of compensation, you want to correct the eversion with the calcaneal slide. You may want to deal with the compensation at the subluxation at the TN joint by possible fusion and navicular-cuneiform fusion or medial column fusion depending.
So this is a really good example of a very deformed foot in the calcaneal axial. You can see how much eversion that heel is on the right side. And this one â this â you know, that no matter what you do, unless you get the calcaneus back under the tibia, youâre not going to get a good result.
So the sagittal plane deformity, you know, you have your talar declination angle that you consider, your calcaneal inclination angle and the lateral talo-first metatarsal angle, which is Meary's angle. And the Meary â and Meary's angle needs to be parallel in relation to the talus to the first, it should be parallel. The calcaneal inclination angle is decreased and the talar declination angle is increased. So youâre going to be looking at those three types of problems radiographically and youâll see that in these types of procedures, youâre going to have to address the equinus which is significant in the sagittal plane problem.
Achillesâ tendon lengthening with maybe â or gastroc recession depending on your actual examination. How much equinus is there and then where is the deformity of the equinus? Is it in just the gastrocnemius-soleus complex or is it above the knee, below the knee, knee flexed? Youâll do all those types of maneuvers to see whether youâre going to do a TAL or a gastroc recession.
And then the con â medial caneal for osteotomy has also been popularized for this. I donât usually do the cotton much. I will look at the deformities and may end up doing a fusion of the first met cuneiform joint or lapidus, depending on the deformity, and or a naviculocuneiform fusion, if what I think is needed.
Remember that there can be a situation where itâs triplanar. So just remember youâre trying to correct these â all these planar dominance deformities and sometimes you canât really tell. Youâre going to have to look through your radiograph and decide where is the true apex of the deformity.
This is a good example. Itâs best seen on a lateral x-ray. Youâll see â I always call it, you know, youâll see that you have a calcaneal inclination angle decrease. Youâre going to see how much declination â talar declination angle you have and Meary's angle is definitely not parallel.
So this is a good example of a sagittal plane deformity where you may be correcting the equinus, and doing something to the forefoot, and getting the talus back in line with the navicular, and so that the first ray is actually aligned.
Triplanar deformities are what we see most commonly because by the time we get to these deformities, there has been compensation after compensation. So most commonly, with a flat foot, the subtalar joint, talonavicular joint, calcaneocuboid joint are all involved. These joints may be fused individually or as a unit, known as a triple arthrodesis of course. Itâs a 9-stage flatfoot procedure. We usually want you to do that. Thereâs no going back, I mean, youâre not going to do something else. On many times these people had so much pain, triple arthrodesis is the best answer.
When you look at a flatfoot, you also look at what soft tissue procedures and what assay procedures are available. Soft tissue procedures, youâre going to look at the Kidner type procedure of flexor transfer. In osseous the type procedures, youâll look at all the calcaneal lengthening, both the slide and the lateral Evans. Youâre also thinking about arthroereisis, that is a good alternative to a flexible flatfoot and a combination of all the procedures.
When Iâm looking at a flatfoot, I tend to do a combination of many of the procedures. I always address my posterior tibial tendon because I do believe thatâs the one with the primary deforming forces. And I think youâll miss if you donât deal with that.
So, Iâm going to give you the stages of the Posterior Tibial Tendon Dysfunction because, as Iâve said, I think itâs one of the most important things. So youâre looking at planar dominance from a true radiographic biomechanical point of view. You look at them in gait and now youâre watching that foot function. So weâll talk a little bit about that.
With staging of the Posterior Tibial Tendon Dysfunction, you have a stage 1, where thereâs pain and edema along the course of the tendon.
Thereâs mild weakness with â on heel raise, and thereâs a relief with rest, and thereâs really no true radiographic signs, just mainly a soft tissue tendon dysfunction. So you know, stage 1 tenonsynovitis on an MRI, Strom â Johnson and Strom actually states this very well. And I really like â I always review this because I feel that even though itâs an older, classic article, it is something that we still use today. And you look at a tenosynovitis only, no deformity and thereâs definite preservation of the posterior tibial tendon itself in strength.
But this might be someone who â if you put an orthotic, an orthotic in their shoe, this may just be the treatment for that flatfoot and that would be the end of the story. I donât know anyone who takes someone to surgery for a stage 1 PT dysfunction. But not uncommon, if you do it, remember what youâre trying to do. But orthotics might be the best thing for this situation.
In stage 1, you have cast immobilization, you have anti-inflammatories, an arch support with made to be a medial wedge orthotic. If this synovitis is so bad, that no matter what you do â then thereâs where that may, you may need to go and want to do just a synovectomy or something, decompress the inflammation in the posterior tibial tendon complex.
And youâll see that sometimes when you open it up, and you cut through the sheet and what do you get? You get a ton of this heavy synovial fluid and sometimes brown in color. You might even see striations in the tendon itself. Not a complete rupture, not even a partial rupture, but an inflammatory process in the tendon. So be aware of that if all your conservative treatment fails.
I donât know why that slideâs there but this is a multiplane disease and weâll go over that. Letâs see.
Okay. Iâm going to do this real quick but itâs kind of at a sequence. So, in a multiplane disease, it probably should have been in the slide before the posterior tibial dysfunction, but you can track with me.
Sometimes youâll get a foot deformity where you have a lot of different things going on. And this gentleman had mostly arthritic changes in the midfoot and severe pain. He also had, although this is not in line to collapsing in the medial arch when he walked, and he had significant pain in the sinus tarsi that just didnât go away.
So, because of that medial column, although it doesnât look collapse, he does have some â not a high cuboid abduction angle but the deformity is through here, where the foot is going in that direction when you look at them clinically.
So what I did is I just took and fixed, I did the TAL, and then I just want you to see here, I fixed the midfoot arthritic by fusing the medial column. And I did a little Subtalar Arthroereisis to help bring that talars up. Well, thatâs a lot of bringing up. But this is a very powerful procedure that we donât probably think is as powerful as it is as a Subtalar Arthroereisis procedure.
Iâm thinking that in an elderly adult patient, if you put it too big of an implant, itâs too much for them and they usually, you know, usually end up â Iâve taken them out because of that. So thatâs just a pre-imposed picture of a triplanar problem. And theyâre â again, itâs the way it looks post-operatively. And we just did a whole medial column fusion with a long plate.
And this another triplanar problem, basically where â itâs an interesting problem because the patient comes in for, what do you think? My bunion hurts, right? So thatâs good. So you go and you do your little lapidus procedure and fix the bunion.
But if you donât address that flatfoot, look at the talar declination angle, and no calcaneal inclination angle, youâre doing a disservice to the patient. So although you might want to get away with a lapidus and say thatâs it, if you donât address the rest of the flatfoot problem, then youâre not really correcting the bunion. And maybe thatâs one of the causes or reasons why we have return of painful bunions without -- and you look on the table, oh my god the bunion looks straight, everything looks great. But in reality, you havenât fixed this part of the foot.
So my plan is to do the lapidus fusion, possibly an arthroereisis, definitelty a TAL because it is -- it has a lot of sagittal plane problems as well as some frontal plane. Not a lot of transverse plane. So if you did an Evans here, which by the way, by literature, Evans is one of the most commonly used and well-known procedures for flatfoot, itâs being done for most all flatfoot, may not be the right answer for this patient. So just -- but it is -- itâs all a lengthening of a lateral column, so maybe thatâs not right but it was designed for the high cuboid abduction transfer plane problem. This is not that problem, but it has two primary planes of deformity, the sagittal and the frontal.
Okay. So, now Iâm bringing you back to the posterior tibial tendon problem where the tendon in the stage 1, posterior tibial tendon, you get dysfunction because -- and maybe attenuation of the tendon with inflammation. So weâre going on narratives, repair of the attenuation. Youâll do a synovectomy. You may wrap it with a graft, depending on your plan. But basically, once you actually let the fluid out, the patientsâ feel incredible just with that alone. So youâre releasing the synovitis and youâre doing a synovectomy. Not just to repair.
Okay. Now weâre back on track with stages. Now weâre going to back to stage 2 in the Posterior Tibial Tendon Dysfunction. You have increased pain, a minimal relief of pain with rest, flattening of the medial longitudinal arch, radiographic changes, you have 4-foot abduction, subluxation at the TN joint with a decrease medial longitudinal arch.
And hereâs a picture of the stage -- type stage 2, Iâm going to try to show you some pictures where youâre going to start to see where you get cuboid abduction angle. In the MRI for the tendon of that suprastituated axial view, you have abnormal -- small abnormalities in the posterior tibial tendon. You can see where the arrow is, youâre starting to get inflammation of fluid within the tendon itself.
And also, thereâs a planovalgus deformities. Sometimes a rupture of the posterior tibial tendon, hindfoot is flexible. In a stage 2A you have minimal abduction, 30% of the talus is uncovered, where you have peritalar subluxation on standing, from the anterior posterior, AP foot radiograph youâll see that. And stage 2B, you get the uncovering of the talus greater than 30%, these are things that have to be addressed mechanically. Sometimes you can put a very strong UCB type orthotic with -- maybe an AFO depending on, like, a Richie type brace for the elderly people do pretty well. Maybe a flexor transfer with a medial displacement calcaneal osteotomy or a lateral calcaneal lengthening depending on we got with radiographic findings, and how much eversion you have in the heel.
This is a stage 2, I donât know if you can see it as well. Come a little light but you can see where youâre getting the sag of the naviculocuneiform sag here.
This is in a child. You have uncovering -- beginning to get uncovering of the talus. And these are -- clinically, youâll see itâs interesting because what you do see in this type of a problem which is interesting and gets missed a lot. You see these little adductovarus toes because theyâre trying to compensate from the lateral evertors when the foot becomes flattened. So just be aware of that. And then you can see here the heel is mostly vertical and we get some medial bulging.
So the Kidner procedure I think is one of the best adjunctive procedures in flat foot and where youâre actually transferring the tendon into the planar service of the navicular after you actually shave the navicular and you tighten up the medial column with soft tissue. I have done Kidner procedures as an isolated procedure. I have -- unfortunately, I canât find the x-ray but I had a 20 year follow up on a young girl who came to my office. I did her when she was about 9 years old, 10 years old. She came to me at 30 and I was like I got to take pictures of you and her foot was completely straight and normal without pain. And I was like, well the Kidner procedures is a little bit stronger or better than even I thought. So isolated Kidner is a possibility but in this day and age, thatâs not the only procedure you should do. Really, you should address every part of the planal problem. But thatâs just a just a simple procedure that we attached right into the planar surface of the navicular. So also in stage two youâll start to see how you may be getting a little bit more of a valgus heel, some more subluxation on the medial longitudinal arch, uncovering of the talus is what youâre really seeing there. And when you see them clinically.
And this is before and after just with the subtalar arthroereising procedure in this young girl who was 14 and she had severe painful flat foot and just with arthroereisis procedure, sheâs clinically stable. I call it the internal orthodic because weâre just holding up, putting the talus back into the normal alignment to the navicular and they seem to do quite well. Sometime, itâs just really know your patient and know your deformity but this patient had a flexible flat foot. It was easy, easy to fix from that point of view and as I said, long term, sheâs doing very well. Has very little to no pain and as she grows, her foot is becoming more and more normal.
You can see here young guy. He had a -- again, a little bit of a sag, a lot of pain in the mid foot and we did a subtalar arthroereisis with the Kidner type procedure.
So calcaneal displacement just real quick, stage two, posterior tibial tendon dysfunction with a flexible hind foot valgus which is key. All you can do adjunctive procedures. Like I said, the flexor digitorum longus tendon transfer, tendon -- Achilles tendon lengthening. But do not do this type of procedure if you have a very rigid of rigid flat foot deformity or degenerative arthritis.
This is a great picture that one of my residents showed me that that has the safe zones. You know, we always talk about safe zones and this is an easy procedure. I always say, if youâre going to do an easy procedure, believe it or not, the Kusi-Janus or sort the medial slide is very easy because, A, you can avoid almost all the anatomical structures. Youâre down to bone in about two minutes and now you just have to make your osteotomy. As long as you get your appropriate fixation and thereâs a lot of new plates out there for this and a lot of new step off procedures.
The thing you have to worry about is visceral nerve and the peroneal tendons. If you see them, youâre a little bit off in your dissection because you should really stay in that safe zone. And this is just a good example of a medial displacement osteotomy. Incision is made and thereâs a step off played in there on to move that heel from a lateral to medial displacing it, so that itâs under the tibia. Youâre always trying to get a vertical to the tibia, so when they stand post-operatively, that heel is actually vertical to the tibia.
And this is just an example of that. You can see where that wire is. Youâre probably wondering what the heck that is, right? The result, not only did I slide it, but I plantar flexed it here because we wanted to get length from the Achilles and we really wanted to move it. So sometimes I use that like a little Steinmann pin or -- and Iâll pull it down before and move it over before I fixated. And then Iâll take that out so the bend is how much pull we were doing on that heel to get it in alignment.
This is just an example you can do TALs many ways percutaneously, three step incision. This is an anteroposterior approach, two small incisions on the most distal one we go anterior which means youâre going down toward the foot and in the proximal one we go a posterior which is coming out of the leg. Oh, so this is a example of calcaneal slide type procedure and what youâre correcting and youâre not only correcting the calcaneal inclination angle which seems like there is none. The declination of the angle and your correct [Indecipherable] [27:43] now interestingly enough, this patient also had a heavy implant because some of the compensations in her flat foot was actually jammed at the first metatarsals or so much first met elevates because thereâs no function in the perineal as long as and/or the posterior tibial tendon wasnât functioning either, so we corrected that as well with just the heavy implant, which is just as an adjunctive note.
And thatâs just an example of another one where youâre doing a medial slide that youâre doing a fusion of the on the navicular cuneiform sag and a TAL. Stage three, you have a long standing deformity, forefoot abduction, increased heel valgus, minimal change on heel raise and a pain lateral foot and radiographic signs, youâll see the forefoot abduction. Youâll see a very collapse in the longitudinal arch and arthritic changes in the TN joint. And MRI is just helpful in showing whatâs happening with the posterior tibial tendon. Usually youâll have a fluid in the sheath with a diminished changes and your regular changes in the tendon itself which shows how much power the posterior tibeal tendon has and how much it is functions when itâs -- when you have a forefoot. And stage 3 by Johnson and Strom shows that thereâs a fixed planar flexed forefoot with a fixed valgus in the hind foot, forefoot abduction. You have talar -- subtalar and medial foot degenerative changes.
And stage three triple arthrodesis may be necessary. I want to show you just a picture of that where you know -- I donât care what kind of fixation you use, Iâm not -- it doesnât matter to me as long as youâre actually realigning the subtalar joint. Youâre not putting in them in varus. You really -- that would be a crime, make sure you realign the foot. You can make [Indecipherable] [39:33] to change the foot so that youâre aligning your subtalar joint, your calcaneal cuboid joint and talonavicular joint in proper alignment. Mild valgus would be acceptable but do not varus that foot.
Achilles tendon lengthening may be indicated for contractures, youâre going to be evaluating that always. The subtalar fusion, it may be utilized as an isolated procedure when thereâs a fixed deformity of the subtalar joint but supple and easily correctable with a transverse tarsal joint when they have a supple transverse tarsal joint non-abnormality and no fixed forefoot deformity, so isolated subtalar joint problems.
And stage four is just the end stage progressive problem and youâre going to -- youâre looking at in a stage four, usually thereâs deltoid ligament incompetence, thereâs also severe deformity of the mid foot, forefoot and rear foot and triple arthrodesis is your answer for that. And similar to stage three, I think that once you had a stage four and youâre trying to correct it any other way, you will fail. I have done that, Iâve tried to correct it other ways and then Iâve always kick myself thatâs completely a collapse medial longitudinal arch with the calcaneal eversion and you can see here a little ducto varus in the toe because of compensation and if I just keep going through, you can see the whole medial side of the foot is on the ground, this is a very painful problem. You have increased Helming sign. You have a subtalar joint subluxation. And everything is -- itâs actually a tri-planar, multi-planar problem with us -- within an arthritic joint stage four.
Triple arthrodesis is necessary when thereâs a fix valgus deformity of the subtalar joint, fixed abduction of the transverse tarsal joints and a fixed varus deformity of the forefoot. So, this is where we want to use that procedure and youâll get a very good result if you follow these little algorithms in the flat foot. I donât need to tell you or go over the sequence but you know you just going to reduce these -- everyone does a little bit different, but always corrected deformity and mobilizing and prepare all three joints before you do fixation, thatâs one of my little paroles is that you want to get all the bones prepped before fusion and make sure that your anatomically correct in your wedging and are the reductions sequences usually the calcaneus the TN and then the CC last.
Just a quick picture that. And we reviewed that already. So thatâs just a quick overview of osse0us and soft tissue procedures of flat foot. I can tell you that that subject alone is a day of lecture in my opinion. With gait analysis, evaluation, thatâs how we should really do it appropriate. And you should be looking at feet, go to the mall, sit down. When I was in school and my biomechanics class I had an incredible biomechanical instructor and he said, âGo to the mall and sit down and watch people walk.â In your head, determine what their deformities and 99% of the time after youâre done looking at them for a long time, youâre going to know everything about their feet without them ever taking off their shoes.â And you know the guy was right, so that was Dr. Spencer in the day. So anyway, thank you very much.
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