Guest Editorial: Adult Acquired Flatfoot Deformity (AAFD): To the Infinity and Beyond! No abstract available

Using the Scope in the Treatment of Flatfoot? Are You Kidding? Flatfoot surgery is evolving. As in other areas, less invasive techniques result in fewer wound complications, less postoperative pain, less bleeding, shorter hospital stays, and potentially shorter recovery times. In this article, we outline how the arthroscope can be used in flatfoot surgery to reduce the invasiveness of surgery. The article outlines how to perform a percutaneous gastrocnemius slide for the associated tight heel cord, and how to perform tibialis posterior tendoscopy. A percutaneous medializing calcaneal osteotomy can be performed as an arthroscopic guided procedure to confirm the placement of the saw, and ensure a safe cut. Arthroscopic ankle fusion, triple arthrodesis, subtalar fusion, and navicular cuneiform fusion can be used in select cases to correct the deformity. The methods and techniques are outlined.

The Flatfoot Through a Pinhole: Do It Percutaneously! Surgical treatment of adult-acquired flatfoot deformity typically requires multiple soft tissue and bony procedures, many of which can be effectively performed with minimally invasive surgery techniques. Use of minimal skin incisions helps limit the morbidity of surgery, reducing postoperative pain and the incidence of wound complications. This chapter will focus primarily on the bony procedures which can be accomplished through minimally invasive surgery, including the medializing calcaneal osteotomy and the first tarsometatarsal fusion. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

The Role of Biologics in the Treatment of Flatfoot Symptomatic adult-acquired flatfoot deformity (AAFD) is traditionally treated by realignment osteotomy and a tendon transfer. Despite high success rates for this procedure, prolonged recovery time and associated morbidities may lead many patients to shy away from having this type of surgery performed on them. Over the past decade, the use of biologics such as platelet-rich plasma and concentrated bone marrow aspirate concentrate has been gaining much popularity. The efficacy of these biologics to treat tendon pathologies is currently well supported in the literature. Therefore, when treating early AAFD with a functioning posterior tibial tendon, biological agents have the potential to enhance tendon healing and functional recovery. In this review we will be discussing the treatment algorithm which we currently use in our practice to manage AAFD. This will include the use of biologics with minimally invasive procedures, such as posterior tibial tendon tendoscopy and subtalar arthroereisis screws, which have the potential to address the biological and mechanical aspects of this common pathology. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Should it Stay or Should it Go? Thinking Critically About Posterior Tibial Tendon Excision in Flatfoot Correction Stage II adult acquired flatfoot deformity is characterized by painful, progressive collapse long thought to be driven by posterior tibialis tendon (PTT) deficiency or insufficiency. In this article, we discuss the history of our understanding the role of the PTT in the development of adult acquired flatfoot deformity, and considerations in tendon excision in flatfoot correction. We argue that routine excision of the PTT should be rethought and instead the tendon should be critically assessed in each case and debridement with repair should be attempted when appropriate. Technique for flexor digitorum longus transfer is detailed as well as preoperative evaluation, imaging, nonoperative treatment, and adjuvants including biologics.

The Collapsing Foot: It’s All About the Ligaments! There are many surgical techniques described for the deltoid ligament and spring ligament reconstruction in the treatment of a collapsing flatfoot. In some cases, addressing these ligaments may offer a way to treat a collapsing flatfoot that preserves the talonavicular and subtalar joints. Preservation of these joints may lead to better outcomes for patients, as their functionality is not limited by hindfoot fusions. Preliminary evidence suggests that patients, when properly selected for, show good long-term outcomes after undergoing surgical reconstruction of those ligaments. The technique for spring ligament and deltoid ligament reconstruction in cases of collapsing flatfoot deformity is described in this article. Level of Evidence: Diagnostic Level V—Expert Opinion. See Instructions for Authors for a complete description of levels of evidence.

The Collapsing Flatfoot: Bone Alignment, Bone Alignment, Bone Alignment! Stage II adult acquired flatfoot deformity involves a loss of the medial longitudinal arch and an increase in hindfoot valgus due to both soft tissue dysfunction and attenuation with subsequent collapse of the foot’s inherent bony architecture. Although there is an important role for soft tissue reconstruction in the majority of cases of adult acquired flatfoot deformity, any soft tissue procedure in the absence of correction of the underlying bony alignment will be prone to failure so these soft tissue procedures should only be performed after maximal bony realignment has been obtained. In this article, we discuss our approach to bony realignment of for stage II flatfoot through use of a medializing calcaneal osteotomy and lateral column lengthening procedures such as the Evan’s osteotomy and the stepcut lengthening calcaneal osteotomy to correct hindfoot valgus and forefoot abduction respectively. Rationale for treatment, indications, preoperative planning, surgical technique, and outcomes are discussed. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

The Flatfoot in Collapse Needs Stability and That is Why I Fuse It The pathophysiology and treatment of the adult-acquired flatfoot is still quite controversial. Soft tissue reconstruction and tendon transfer surgery combined with corrective osteotomy for flexible deformities are well established in the literature. However, patients with signs of hindfoot osteoarthritis, rheumatological or neurological diseases, and obesity can benefit from surgical correction with arthrodesis because of greater outcome predictability. Various types of arthrodesis, including isolated, triple, double, or segmental procedures, have been described to treat this deformity. We will discuss the events leading to the progressive collapse of the medial arch and distinguish between patients who could benefit from reconstruction with arthrodesis from those who cannot, as well as the indications for these technical options. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Deltoid Insufficiency and Flatfoot—Oh Gosh, I’m Losing the Ankle! What Now? Adult acquired flatfoot deformity is a severe condition in which the ankle is markedly affected by medial instability and valgus deformity. Unbalanced forces pose high stress on the tibiotalar joint, and different levels of arthritis may develop. Correcting valgus tilt in the ankle, at the time of flatfoot reconstruction, is imperative to prevent future collapse and the need for ankle arthrodesis or arthroplasty. Unfortunately, there has been no universal procedure adapted by foot and ankle surgeons for repair or augmentation of the deltoid ligament. We recommend a technique of reconstruction of the superficial and deep deltoid ligaments using suture tapes and, eventually, the combination with autograft tendon, in conjunction with spring complex reconstruction. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

It All Fell Apart … Now How Do I Reconstruct My End-stage Flatfoot? Plantigrade mechanical alignment is the hallmark of a successful extra-articular flatfoot reconstruction. When executed appropriately, joint-preserving flatfoot realignment surgery often results in good functional outcomes and acceptable patient satisfaction. However, flatfoot reconstruction can fail for multiple reasons including progressive arthritis at adjacent joints, soft-tissue hyperlaxity, nonunion of an osteotomy, and under or overcorrection of the deformity. The reasons for failure must be identified and adequately addressed to achieve a successful outcome following revision surgery. We frequently perform a triple arthrodesis, with an extended medial column fusion (as necessary), after recurrent medial column collapse. We present our diagnostic algorithm, surgical techniques, and pearls for the treatment of the failed extra-articular flatfoot reconstruction.