pes planus

sagittal transverse, and frontal planes (occurs simultaneously, but typically a dominant plane)

42* from the frontal and transverse planes and 16* from the sagittal plane

greater motion will now occur along the frontal plane (more inversion-eversion) ie a frontal plane dominant flat foot condition

greater motion will occur in the transverse plane (more abduction-adduction)

the motion will occur in the frontal plane

the primary plane of motion will be in the sagittal plane

frontal plane compensation

transverse plane compensation

when axis is more medial to laterally directed

adult acquired flatfoot.

originates in the deep posterior leg compartment from the proximal tibia, tibiofibular syndesmosis and the medial edge of the proximal fibular shaft

onto the medial and plantar navicular and smaller slips that attach to the plantar 2nd, 3rd, and 4th metatarsal bases and plantar aspects of the cuneiforms

primarily as an adductor of the midtarsal joint, directly opposing the peroneus brevis

deltoid, medial portion of the calcaneocuboid, long and short plantar, interosseous talocalcaneal ligaments and plantar fascia

supporting structures of the medial hindfoot, the ligaments, must become weakened

women, pts over 50 years old. diabetes, obesity and HTN can also be factors

> 50, female, any general or metabolic condition that predisposes toward tendon degeneration like diabetes, obesity, and rheumatic diseases

pts will complain of variable unilateral pain starting from the medial malleolar area extending to the medial arch at the PT tendon insertion on the navicular tuberosity or plantar to the tuberosity

medial talar head prominence, calcaneal eversion, and forefoot abduction ("too many toe sign")

Hubscher maneuver and single limb heel raise (considered abnormal if the calcaneus does not invert)

Johnson and Strom Classification of PTTD with Myerson modification (pg. 10/11)

Peritendonitis and/or tendonsosi

Tendon elongated

Elongated

Nonfunctional, loss of deltoid ligament causes ankle valgus

X-ray and MRI

rest, ice, NSAIDS, and weightbearing immobilization with a below knee cast or cast boot/cam walker for 6-8 weeks.

rigid ankle foot orthotic

soft tissue, joint sparing bone procedures and joint destructive bone procedures (fusion)

triple arthrodesis

pantalar fusion

• - Posterior tibial tendon debridement and synovectomy
• - FDL tendon transfer
• - Tendoachilles lengthening
• - Gastrocnemius recession
• - Kidner
• - Young Tenosuspension
• - Peroneus Brevis to longus transger
• - Cobb Procedure for PT tendon repair

PT tendon is debrided of all degenerative tissue through a standard incision. Hypertrophic synovial tissue is excised. The incision may be brought proximally if the tendon is degenerated proximally. Normally done with other procedures.

through incision, the flexor digitorum longus tendon is harvested deep to the PT tendon and transected just proximal tot he knot of Henry (connection between FDL and FHL at navicular tuberosity). Harvested tendon is sutured directly tot he TP tendon or anchored to navicular medially for increased inversion strength

2 converging elliptical incisions are made into the spring ligament, removing a section of the ligament. Gap is then brought together and sutured to reinforce the ligament, thus providing greater support to the medial longitudinal arch

ex the Hoke triple (Achilles tendon lengthening) with incisions made at 2, 5 and 8 cm then the foot is DF. Indicated in flatfoot for combined gastrocnemius-soleus equinus and severe equinus deformity

can be open or endoscopically. cutting only the deep crural fascia overlying the gastrocnemius muscle. the plantaris tendon may also be incised. Gastrocnemius recession in indicated for gastrocnemius equinus in nonspastic disease

slot is made in the navicular medially and the TA tendon is rerouted into the created slot. A tendoachilles lengthening is also performed. Performed more commonly for non-PTTD flexible flatfoot deformities

lateral foot incision overlying the peroneal tendons the P. brevis tendon is transected at its most distal aspect and sutured to the P. longus tendon. Advantages are that it removes the eversion force of the P. brevis and increasing the 1st ray platarflex power of the P. longus

performed for either a midsubstance PT tendon rupture or when elongation and weakening of the tendon is seen. Incision made along length of the PT tendon. In a new incision proximal to the ankle the TA tendon is exposed. A second distal incision is made and the TA tendon is split into medial and lateral halves. Medial half is transferred through a drill hole in the medial cuneiform and out the proximal side and then sutured to the PT tendon.

• - Evans osteotomy
• - MCDO
• - Calcaneal 'L' osteotomy
• - Dwyer
• - Silver
• - Cotton
• - Medial Cuneiform
• - Cuboid
• - Gliech
• - STJ Arthroesis

osteotomy of the calcaneus performed from the lateral aspect, 1 cm proximal to the calcaneocuboid joint. designed to lengthen the lateral column. primary procedure to correct a transverse plane dominant flat foot

lateral slightly oblique incision is made just posterior to the peroneal tendons. through this incision a linear osteotomy is made completely across the calcaneus in line with the skin incision. posterior fragment of the calcaneus is translated medially until the calcaneus is situated under the sustentaculum tali

modified MDCO, in which 2 converging bone cuts are made into the calcaneus. Advantage over MDCO is the ability to invert the calcaneus as well as trnaslating the calcaneus medially, which prevents dorsal elevation of posterior calcaneus caused by pull of Achilles tendon

removes a medial pie-shaped wedge of bone from the calcaneus. indicated for frontal dominant flat foot, but is rarely performed, more commonly used in pes cavus surgery

created obliquely from just posterior to the posterior calcaneal facet extending to just posterior to the calcaneocuboid joint. this osteotomy is opened and a wedge bone graft is placed into the space, corrects frontal plane dominant flatfoot

placing a pie-shaped wedge of bone int the medial cuneiform. done through dorsal incision over the medial cuneiform. the central portion of the medial cuneiform is osteotomized and the first ray distal to this area is plantarflexed, a bone graft is placed into the space, this corrects sagittal dominant condition and is often used to correct FF varus

similar to Cotton, involves placing a bone graft into the medial cuneiform, in this case the wedge-shaped graft is placed medially to treat a transverse plane dominant flatfoot

correct transverse plane compensated deformity. done by inserting a wedge of bone with a wider lateral side into the cuboid, adducting an abducted forefoot, or cutting a wedge of bone with the wedge medially out of the cuboid, which also adducts the forefoot

straight osteotomy of the calcaneus in an oblique direction. obliquity of the osteotomy is usually parallel to the long axis of the tibia. the inferior calcaneal segment may then be shifted distally to increase the calcaneal inclination angle and medially, additionally the medial wedge can be removed to bring the heel into a more varus position

"arthroereisis" means limiting joint motion. involves placing an external device into the tarsal canal through a small incision over the sinus tarsi laterally. indicated for frontal plane flatfoot compensation and contraindicated in transverse plane dominance

• - Hoke procedure
• - Lapidus
• - Miller
• - Lowman
• - CC distraction arthrodesis
• - Isolated subtalar arthrodesis
• - Triple Arthrodesis
• - Pantalar fusion

isolated fusion of the naviculocuneiform joint is performed along with Achilles tendon lengthening. The 3 naviculocuneiform joints are prepared with either a joint curettage technique (removing only cartilage down the subchondral bone plate) or joint resection method in which a saw is used to remove the desired areas of bone

isolated fusion of the medial cuneiform-first met. joint corrects sagittal plane compensation by removing a wedge plantarly

Arthrodesis of the naviculocuneiform and the medial cuneiform-first met. joint corrects a sagittal plane dominant flatfoot. will leave the medial arch rigid postoperatively

frown-shaped incision along the medial arch of the talonavicular joint removing a plantar wedge, thus increasing arch height in a sagittal plane dominant flatfoot. Achilles is also lengthened and TA tendon is transposed medially and sutured into its new position.

isolated talonavicular arthrodesis

corrects transverse plane deformity flatfoot. isolated fusion of the calcaneocuboid joint via a lateral incision with distraction of the joint, cartilage debridment and insertion of a bone graft. is joint destructive and controversial b/c it can lead to lateral foot pain

the subtalar joint may be fused to provide stability

fusion of the talocalcaneal, talonavicular and calcaneocuboid joints. for Stage 3 and 4 PTTD along with deltoid ligament reconstruction. performed for many conditions

arthrodesis of the tibiotalar (ankle), subtalar, talonavicular and clancaneocuboid joints. for Stage 4 pts due to ankle involvement. Alternative may be a Triple with deltoid ligament repair. Considered a "salvage" operation