eMedicine Specialties > Orthopedic Surgery > Foot & Ankle
Acquired Flatfoot: Treatment
Updated: Apr 23, 2009
Treatment
Medical Therapy
Medical or nonoperative therapy for posterior tibial tendon dysfunction involves rest, immobilization, nonsteroidal anti-inflammatory medication, physical therapy, orthotics, and bracing.15 This treatment is especially attractive for patients who are elderly, who place low demands on the tendon, and who may have underlying medical problems that preclude operative intervention.
During stage 1 posterior tibial tendon dysfunction, pain, rather than deformity, predominates. Cast immobilization is indicated for acute tenosynovitis of the posterior tibial tendon or for patients whose main presenting feature is chronic pain along the tendon sheath. A well-molded short leg walking cast or removable cast boot should be used for 6-8 weeks.
Weight bearing is permitted if the patient is able to ambulate without pain. If improvement is noted, the patient then may be placed in custom full-length semirigid orthotics. The patient may then be referred to physical therapy for stretching of the Achilles tendon and strengthening of the posterior tibial tendon. Steroid injection into the posterior tibial tendon sheath is not recommended due to the possibility of causing a tendon rupture.
In stage 2 dysfunction, a painful flexible deformity develops, and more control of hindfoot motion is required. In these cases, a rigid University of California at Berkley (UCBL) orthosis or short articulated ankle-foot orthosis (AFO) is indicated.
Once a rigid flatfoot deformity develops, as in stage 3 or 4, bracing is extended above the ankle with a molded AFO, double upright brace, or patellar-tendon-bearing brace. The goals of this treatment are to accommodate the deformity, prevent or slow further collapse, and improve walking ability by transferring load to the proximal leg away from the collapsed medial midfoot and heel.
Nonoperative therapy for posterior tibial tendon dysfunction has been shown to yield 67% good-to-excellent results in 49 patients with stage 2 and 3 deformities.16 A rigid UCBL orthosis with a medial forefoot post was used in nonobese patients with flexible heel deformities correctible to neutral and less than 10° of forefoot varus. A molded ankle foot orthosis was used in obese patients with fixed deformity and forefoot varus greater than 10°. Average length of orthotic use was 15 months. Four patients ultimately elected to have surgery. The authors concluded that orthotic management is successful in older low-demand patients and that surgical treatment can be reserved for those patients who fail nonoperative treatment.
The following is a summary of conservative treatments for acquired flatfoot:
- Stage 1 - NSAIDs and short-leg walking cast or walker boot for 6-8 weeks; full-length semirigid custom molded orthosis, physical therapy
- Stage 2 - UCBL orthosis or short articulated ankle orthosis
- Stage 3 - Molded AFO, double-upright brace, or patellar tendon–bearing brace
- Stage 4 - Molded AFO, double-upright brace, or patellar tendon–bearing brace
Surgical Therapy
Surgical treatment depends on stage of dysfunction.
Surgical treatment of stage 1 dysfunction
If initial conservative therapy of posterior tibial tendon insufficiency fails, surgical treatment is considered. Operative treatment of stage 1 disease involves release of the tendon sheath, tenosynovectomy, debridement of the tendon with excision of flap tears, and repair of longitudinal tears. A short-leg walking cast is worn for 3 weeks postoperatively. Teasdall and Johnson reported complete relief of pain in 74% of 14 patients undergoing this treatment regimen for stage 1 disease.17 Surgical debridement of tenosynovitis in early stages is believed to possibly prevent progression of disease to later stages of dysfunction.
Surgical treatment of stage 2 dysfunction
Treatment of the flexible deformity of stage 2 posterior tibial tendon dysfunction is controversial. Direct repair of the torn tendon, tendon transfer or tenodesis by using the flexor digitorum longus (FDL) or flexor hallucis longus (FHL), spring ligament repair, medial displacement calcaneal osteotomy, lateral column lengthening, and limited arthrodeses of the hindfoot or midfoot have all been reported to yield satisfactory outcomes. Achilles tendon lengthening is recommended if ankle dorsiflexion is limited to 10° or less. The difficulty in obtaining an excellent surgical result is evidenced by the multitude of surgical procedures proposed for stage 2 dysfunction.
Direct repair
The torn tendon may be directly repaired by suturing the ends of an acute rupture. If the tendon is avulsed distally, it can be repaired to the navicular, or the portion of the tendon that is attenuated can be excised and the proximal and distal tendon stumps repaired end to end.
Proximal Z-lengthening of the posterior tibial tendon may be needed to achieve direct repair. The distal half of the anterior tibial tendon can be detached proximally and left attached to its insertion into the base of the first metatarsal and used to reinforce the directly repaired tendon.
Tendon transfer with FDL or FHL
The posterior tibial tendon often has an irreparable gap or is attenuated and scarred to the tendon sheath. The posterior tibial muscle may function poorly, even if the tendon can be directly repaired. This has led several authors to recommend tendon transfer to substitute for the dysfunctional or irreparable posterior tibial tendon. Jahss reported side-to-side tenodesis of the proximal and distal stumps of the posterior tibial tendon to the intact FDL tendon in 5 patients, reporting short-term satisfactory results, although all patients had residual heel valgus.4
Transfer of the FDL tendon to the distal stump of the posterior tibial tendon or directly into the navicular tuberosity through a vertically oriented tunnel has been advocated by several authors with good short-term subjective results. The procedure uniformly failed to correct the flatfoot deformity but functioned well in relieving pain and improving inversion strength.
Some authors have emphasized the importance of spring ligament (calcaneonavicular ligament) repair or reconstruction in conjunction with FDL transfer. A retrospective study of spring ligament repair/reconstruction and FDL transfer demonstrated excellent functional results in 14 of 18 patients, although arch correction on radiographs was inconsistent.
Goldner et al reported using the FHL for transfer into the distal stump of the posterior tibial tendon in 2 patients, 1 had a previous laceration of the tendon and the other had a chronic tear.3 The younger patient had a full and complete recovery, and the outcome in the other patient was not reported.
Calcaneal osteotomy18
Follow-up examination of patients who have undergone FDL tenodesis or transfer alone has not shown consistent correction of deformity. Because of a concern of deteriorating clinical results over time with soft-tissue procedures alone, some surgeons added bony procedures to the soft-tissue reconstruction. They theorized that the restoration of arch height and heel position might produce more durable and improved clinical results. The ideal bony procedure to treat acquired pes planovalgus corrects the foot deformity, decreases strain on the spring and deltoid ligaments, and protects the soft-tissue reconstruction.
Gleich first described a medial and inferior displacement osteotomy of the posterior third of the calcaneus in 1893.19 Koutsogiannis first described the medial displacement calcaneal osteotomy as a treatment of valgus hindfoot deformity.20 The addition of a medial displacement osteotomy through the posterior portion of the calcaneus moves the valgus heel under the weightbearing axis of the leg. The osteotomy also decreases the heel valgus producing deforming force of the Achilles tendon by shifting the Achilles insertion medially. In vitro studies have shown that a 1-cm medializing osteotomy of the calcaneal tuberosity decreases strain on the spring ligament and deltoid ligament. A 1-cm translational calcaneal osteotomy actually moves the center of pressure in the ankle joint 1.58 mm medially.
A retrospective study of 32 patients undergoing FDL transfer and calcaneal osteotomy with an average of 20 months follow-up showed 94% pain relief, improved function, and significant improvement in radiographic arch measurements. Sammarco and Hockenbury reported satisfactory results in 19 patients undergoing FHL transfer and medial displacement calcaneal osteotomy.21 Despite the fact that the FHL is stronger than the FDL, postoperative radiographs did not show significant arch correction, indicating that a medial soft-tissue procedure in conjunction with calcaneal osteotomy may not result in arch correction.
Lateral column lengthening
The Evans anterior calcaneal lengthening osteotomy lengthens the lateral column of the foot by inserting a 10- to 15-mm bone graft 10-15 mm proximal to the calcaneocuboid joint. This lateral column-lengthening procedure radiographically improves forefoot abduction and hindfoot valgus and restores the medial longitudinal arch. Cadaveric studies show that lateral column lengthening protects the calcaneonavicular (spring) ligament form overload during weight bearing. A retrospective study of 19 patients undergoing Evans calcaneal osteotomy in conjunction with posterior tibial tendon repair or shortening and deltoid ligament repair or reconstruction reported 6 excellent, 11 good, and 2 fair results. Significant radiographic arch correction was noted at 23-month follow-up.
A cadaver study of Evans calcaneal lateral column lengthening in normal feet showed elevated calcaneocuboid joint pressures following the procedure, raising questions about potential long-term degenerative arthritis of the calcaneocuboid joint following the procedure. This concern has led to the recommendation of lengthening the lateral column through distraction arthrodesis of the calcaneocuboid joint. However, results of another cadaver study failed to confirm elevation of calcaneocuboid joint pressure following calcaneal Evans osteotomy in preexisting flatfeet and, in some cases, actually showed lowering of calcaneocuboid pressure after lateral column lengthening.
A retrospective study of 41 feet undergoing lateral column lengthening through distraction arthrodesis of the calcaneocuboid joint in conjunction with FDL transfer and selective medial midfoot arthrodesis found satisfactory outcomes in 85% of cases and a uniform radiographic correction of flatfoot, but a calcaneocuboid nonunion rate of 20% was found. Note that this series included several patients who also had fusions of the naviculocuneiform or first metatarsocuneiform joints and that distraction arthrodesis of the calcaneocuboid joint was not the only bony procedure performed.
Thomas et al reported on 25 patients who underwent FDL transfer to the navicular and lateral column lengthening using 2 different methods.22 Postoperative American Orthopedic Foot and Ankle Society (AOFAS) scores were 87.9 for the osteotomy group and 80.9 for the calcaneocuboid distraction arthrodesis group, but the difference was not statistically significant. Significant improvement in radiographic parameters was seen in both groups. Complication rates were high in both groups, with an especially high rate of nonunion and delayed union in the calcaneocuboid distraction group.
A combination of FDL transfer to medial cuneiform, medial displacement calcaneal osteotomy, and Evans lateral column lengthening has produced good short-term results in a retrospective study of 17 patients with stage 2 posterior tibial tendon dysfunction. Significant improvement in the AOFAS hindfoot score was seen, and radiographs showed significant improvement in arch measurements at 17.5-month follow-up.
Fusion23
The difficulty with achieving consistent lasting correction of the flatfoot deformity with soft-tissue procedures alone or in conjunction with osteotomies has led some surgeons to recommend fusion as a treatment of stage 2 deformity. Some surgeons feel that soft-tissue procedures are less successful in patients who are obese and that obesity is an indication for joint fusion.
Kitaoka et al compared subtalar arthrodesis versus FDL transfer in an in vitro study of flatfooted specimens and found a more consistent correction of deformity following subtalar arthrodesis.24 A retrospective study of 21 feet treated with subtalar arthrodesis for posterior tibial tendon dysfunction yielded good-to-excellent results in 16 of 21 feet and significant correction of flatfoot deformity based on radiographic measurements. Stephens et al emphasize the need for reducing the subtalar joint prior to fusion and for differentiating a subtalar repositional arthrodesis from a subtalar fusion in situ.25
Another in vitro study compared subtalar fusion alone, calcaneocuboid fusion alone, talonavicular fusion alone, double (talonavicular and calcaneocuboid) arthrodesis, and triple arthrodesis in their abilities to correct an experimentally corrected flatfoot deformity. The study found that talonavicular or double arthrodesis resulted in better correction of flatfoot deformity than did subtalar fusion alone. A retrospective study of 29 patients with posterior tibial tendon dysfunction treated with isolated talonavicular fusion found good-to-excellent results in 86% of patients at an average follow-up of 26 months.
Combination treatments
Johnson et al used subtalar fusion, FDL transfer, and spring ligament repair in 17 feet with stage 2 dysfunction.26 At an average follow-up of 27 months, they reported excellent radiographic correction of pes planus deformity and improvement in AOFAS hindfoot score.
Chi et al reported on 65 feet that underwent FDL transfer with lateral column lengthening and/or medial column fusion.27 Lateral column fusion was performed for calcaneovalgus deformity with a flat calcaneal pitch angle. If the naviculocuneiform or first metatarsocuneiform joint showed sag on lateral radiographs, they also were fused. At 1- to 4-year follow-up, 88% of the feet that underwent lateral column lengthening, 80% of the feet that had medial column stabilization, and 88% that had medial and lateral procedures had decreased pain or were pain-free. Significant radiographic correction of the pes planus deformity was seen in all groups. The authors concluded that fusion of these unessential joints effectively corrected deformity and relieved pain.
Surgical treatment of stage 3 dysfunction
Surgical treatment of stage 3 posterior tibial tendon dysfunction requires realignment and arthrodesis of rigidly malaligned joints. The principle of fusing the fewest number of joints possible should be followed. Over time, the subtalar joint becomes fixed in valgus, and a subtalar arthrodesis is indicated to realign the hindfoot. If the forefoot is fixed in varus at the transverse tarsal (Chopart) joint or degenerative changes are present in the talonavicular and calcaneocuboid joints, fusion of these joints should be added. Stage 3 posterior tibial tendon dysfunction with fixed forefoot varus is treated with triple arthrodesis.28
Surgical treatment of stage 4 dysfunction
The valgus ankle in stage 4 dysfunction develops because of deltoid ligament instability. The deltoid ligament is difficult to reconstruct with a tendon transfer. Arthritic valgus ankle deformities secondary to deltoid ligament insufficiency have not been treated successfully with a total ankle arthroplasty because of the inability to achieve ligamentous balance. Treatment of a fixed subtalar deformity and degenerative ankle valgus requires tibiotalocalcaneal fusion. If fixed forefoot varus is also present, pantalar fusion may be necessary to realign the foot adequately. Either tibiotalocalcaneal or pantalar fusion results in a stiff foot, which results in an altered gait. Shoe modifications and bracing are often required after surgery.
The following is a summary of surgical treatments for acquired flatfoot:
- Stage 1 - Tenosynovectomy, tendon debridement, and tendon repair of partial tears
- Stage 2 (add Achilles tendon lengthening or gastrocnemius recession in cases of equinus contracture)
- PTT repair
- FDL or FHL transfer alone
- FDL or FHL transfer and calcaneal osteotomy
- FDL transfer and lateral column lengthening
- FDL transfer, lateral column lengthening, and medial column fusion
- FDL transfer, lateral column lengthening, and calcaneal osteotomy
- Subtalar fusion
- Talonavicular fusion
- Stage 3
- Subtalar fusion
- Triple arthrodesis
- Stage 4
- Tibiotalocalcaneal fusion
- Pantalar fusion
Preoperative Details
The stage of the disease, the overall medical condition of the patient, and the patient's expectations determine the recommended treatment. If the patient has low physical demands or has serious underlying medical problems, he or she should be treated nonoperatively. Patients should be advised about the prolonged length of recovery following surgical reconstruction of the foot. Generally, 6 weeks of no weight bearing is required for soft-tissue procedures and osteotomies, and up to 3 months of no weight bearing is required for fusions. Swelling of the foot should be expected for 4-10 months after surgery. Finally, although high rates of good-to-excellent results are reported for most surgical procedures, many patients continue to have some foot discomfort with prolonged standing or walking.
Intraoperative Details
FHL transfer
An 8-cm incision is made along the course of the posterior tibial tendon from a point just proximal and posterior to the medial malleolus to the navicular tuberosity. The posterior tibial tendon sheath is opened and a tenosynovectomy is performed. Partial tears of the tendon are repaired with 2-0 nonabsorbable Dacron sutures. If the tendon is attenuated and irreparable, it is excised, leaving a 1-cm stump attached to the navicular tuberosity. If the spring ligament is torn or attenuated, it is repaired and imbricated with 2-0 nonabsorbable sutures. The FDL tendon is identified in its sheath just deep to the posterior tibial tendon sheath. The FHL tendon is identified deep to the sustentaculum tali. The FHL tendon is sutured to the FDL tendon distally with 2-0 nonabsorbable sutures and then divided proximal to the anastomosis (see Image 6).
The flexor hallucis longus (FHL) tendon is identified under the sustentaculum tali and is pulled proximally. The FHL and flexor digitorum longus (FDL) tendons then are sutured to each other with 2-0 nonabsorbable suture prior to division of the FHL tendon.
The flexor hallucis longus (FHL) tendon is rerouted anterior to the posterior tibial tendon (PTT) and sutured to the navicular tuberosity using a suture anchor. Multiple number 2 nonabsorbable sutures also are used to suture the FHL tendon to the PTT stump and navicular tuberosity periosteum.
A suture anchor is placed in the navicular tuberosity, and the transferred FHL tendon is sutured to the navicular and to the distal stump of the posterior tibial tendon with number 2 nonabsorbable sutures (see Image 7). Tension on the FHL tendon is adjusted with the foot in inversion and plantarflexion. The tendon sheath, subcutaneous tissue, and skin are closed in layers. Percutaneous triple-cut Achilles tendon-lengthening or gastrocnemius recession is performed if the foot cannot be easily dorsiflexed past neutral.
After surgery, the foot is placed in a posterior splint in a position of equinus and inversion. A short-leg non–weightbearing cast is applied 3 days after surgery to maintain the position of equinus and inversion, and is worn for 4 weeks. The foot then is placed in a short-leg walking cast in a neutral position, which is worn for an additional 2 weeks. A Cam walker boot is worn beginning 6 weeks postoperatively and is removed for range of motion and strengthening exercise. Immobilization is discontinued 10 weeks postoperatively.
FDL tendon transfer
A similar approach is used for the FDL tendon transfer. In this case, the distal FDL is sutured into the FHL, and the FDL is released just proximal to the suture to give adequate length to the tendon. A vertical hole then is drilled into the navicular bone. The surgeon should be careful to leave an adequate bridge of bone in place medially. The plantar hole is rounded smooth proximally to take any sharp edge away that may damage the tendon. With the aid of a suture passer, the FDL tendon is routed from plantar to dorsal and sutured to itself (if enough tendon length is available) and to the surrounding tissue. The foot is held in an inverted position during this maneuver to place appropriate tension on the FDL tendon. Closure and postoperative care are similar to those for FHL transfer.
Calcaneal osteotomy
Calcaneal osteotomy is used in conjunction with FDL or FHL transfer. The calcaneal osteotomy is performed prior to the tendon transfer. A 5-cm oblique incision is made along the lateral heel from posterosuperior to anteroinferior. The incision is made posterior to the peroneal tendon sheath and sural nerve (see Image 8). Sharp dissection is used to proceed directly down to bone. Skin flaps are kept thick. The lateral wall of the calcaneus is exposed subperiosteally using a Key elevator. Small Hohmann retractors are placed over the superior aspect of the calcaneus anterior to the Achilles tendon and at the plantar aspect of the calcaneus anterior to the plantar fascial attachment.
The incision for calcaneal osteotomy is made posterior to the peroneal tendon sheath and sural nerve. The incision is made at a 45° angle to the plantar aspect of the foot.
The calcaneal osteotomy is distracted with a laminar spreader to spread the medial soft tissues. This permits easy medial displacement of the calcaneal tuberosity.
Lateral radiograph of the fixated calcaneal osteotomy. After the tuberosity is displaced medially 1 cm, 2 screws are inserted perpendicular to the osteotomy site under fluoroscopic control.
Intraoperative axial view of the fixated calcaneus documents satisfactory medial translation of the tuberosity and satisfactory screw position.
A straight, wide power osteotome (Micro-Aire, Inc) or sagittal saw is used to make a cut across the calcaneus in line with the incision at a 45° angle to the plantar surface of the foot and perpendicular to the surface of the calcaneus. C-arm fluoroscopy is used to document proper osteotomy position prior to making the bone cut. The medial aspect of the heel is palpated to gauge the depth of the osteotomy and to avoid overpenetration of the osteotome, which could cause injury to the tibial nerve and vessels. The depth of the osteotome cut also can be judged with a freer elevator during completion of the cut. After completion of the osteotomy, the medial soft tissues are spread by inserting a large Key elevator into the osteotomy site and levering the calcaneal tuberosity downward. A laminar spreader also can be placed into the osteotomy site and used to spread the medial soft tissues (see Image 9).
The tuberosity should be easily translated medially 1 cm if the medial soft tissues are adequately mobilized. It is important to ensure that the plantar surface of the osteotomy has been adequately mobilized. Otherwise, the posterior calcaneal fragment rotates internally rather than slide medially. The calcaneal tuberosity then is translated 1 cm medially, while avoiding superior translation of the fragment. A surgical assistant then holds the osteotomy in a corrected position while it is fixated with 2 4.0-mm diameter partially threaded cancellous screws placed perpendicular to the osteotomy cut (see Image 10). Typically, no washers are used.
Avoid placement of the screws into the subtalar joint and keep the screw heads off of the weightbearing surface of the heel. Screws are placed in a parallel fashion. Because the tuberosity has been shifted medially, the screws should be aimed slightly laterally in order to hit the main calcaneal body or the screw(s) may miss the anterior calcaneus. Screw position is documented with intraoperative fluoroscopy (see Image 11).
The wound is closed in layers. Postoperative care is the same as for FDL transfer, except weight bearing is not allowed until radiographs indicate that the osteotomy has healed, usually 6-8 weeks postoperatively.
Lateral column lengthening by distraction arthrodesis of the calcaneocuboid joint
Lateral column lengthening by distraction arthrodesis of the calcaneocuboid joint is also performed in conjunction with FDL or FHL transfer. A 5-cm dorsolateral incision is made over the calcaneocuboid joint. The sural nerve and peroneal tendons are retracted plantarly. The joint is exposed, and the articular cartilage is removed with osteotomes and curettes. The joint then is distracted using a smooth laminar spreader. An alternative technique is to use a small joint external fixator (EBI) to distract the lateral column, placing pins in the cuboid and calcaneus. Correction of the medial longitudinal arch and correction of heel valgus to neutral or slight valgus serve as the endpoint for distraction. The forefoot also should be rotated into neutral position prior to graft insertion.
Preoperative anteroposterior view of foot prior to lateral column lengthening. Note forefoot abduction and increased talonavicular coverage angle.
Distraction arthrodesis of the calcaneocuboid joint with tricortical iliac crest graft results in lengthening of the lateral column. The osteotomy is fixated with a laterally placed cervical plate. Note correction of forefoot abduction and correction of the talonavicular coverage angle.
A trapezoidal tricortical iliac crest graft then is fashioned to fit the distracted joint. The bone graft should be wider both dorsally and laterally, and tapering towards the plantar and medial aspects, respectively. A graft width of 8-12 mm usually suffices (see Images 12-13). A cervical plate placed laterally with 2 screws in the calcaneus and 2 screws in the cuboid is used for fixation. The remainder of the calcaneocuboid joint is filled with cancellous graft. The postoperative course is the same as for the calcaneal osteotomy, except weight bearing is delayed until fusion is confirmed radiographically.
Follow-up
For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Ankle Sprain and Sprains and Strains.
Complications
The major concern with any foot reconstructive procedure is to achieve a painless plantigrade foot that fits into a shoe. Undercorrection or overcorrection of a deformity can easily occur. Soft-tissue procedures alone do not correct the pes planus deformity of posterior tibial tendon insufficiency. Use caution intraoperatively to ensure that the heel is in slight valgus and that the forefoot is plantigrade and not left in varus. An ankle equinus contracture should not be left untreated.29
As with any medial midfoot procedure, take care to avoid neurovascular injury during posterior tibial tendon debridement or tendon transfer. Many surgical techniques involve suturing the distal stump of the transferred FDL tendon to the adjacent FHL tendon at the knot of Henry. The neurovascular bundle is at significant risk due to its close proximity during this anastomosis. Medial skin flaps should be kept thick to avoid wound dehiscence.
During medial displacement calcaneal osteotomy, the sural nerve is at risk if the lateral incision is made too anteriorly. The calcaneal osteotomy is made at a 45° angle to the long axis of the calcaneus through the calcaneal tuberosity. If the osteotomy is made too anteriorly, the posterior facet of the subtalar joint could be damaged. If the osteotomy is made too posteriorly, the Achilles insertion could be disrupted. If the osteotome overpenetrates the medial calcaneal wall, the neurovascular bundle could be damaged.
Avoid superior translation of the tuberosity during medial translation of the posterior calcaneal tuberosity, or the calcaneal pitch could be decreased and the arch flattened further. Two screws are recommended for fixation of the calcaneal osteotomy to avoid rotation of the calcaneal fragment and to enhance fixation, although single large cancellous screws have been used successfully. The screws should be inserted perpendicular to the osteotomy plane, and the subtalar joint should not be penetrated.
The lateral column-lengthening procedure achieves arch correction both clinically and radiographically. Overlengthening of the lateral column is possible, with creation of painful lateral forefoot overload. The Evans calcaneal osteotomy places the sural nerve, peroneal tendons, and anterior and middle subtalar facets at risk. The optimal position of the calcaneal osteotomy is 10 mm proximal to the calcaneocuboid joint to avoid damage to the anterior and middle facets. The high rate of calcaneocuboid joint nonunion during calcaneocuboid distraction arthrodesis also is a concern.
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| Workup: Acquired Flatfoot |
 Treatment: Acquired Flatfoot |
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Keywords
flat foot, flatfoot, pes planus, acquired adult flatfoot, posterior tibial tendon dysfunction, PTT dysfunction, posterior tibial tendon insufficiency, PTT insufficiency, Chopart joint, too-many-toes sign, too many toes sign, Evans calcaneal osteotomy, Evans' calcaneal osteotomy
