Approach and treatment of the adult acquired flatfoot deformity

Abstract

Adult acquired flatfoot deformity (AAFD), embraces a wide spectrum of deformities. AAFD is a complex pathology consisting both of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. Each patient presents with characteristic deformities across the involved joints, requiring individualized treatment. Early stages may respond well to aggressive conservative management, yet more severe AAFD necessitates prompt surgical therapy to halt the progression of the disease to stages requiring more complex procedures. We present the most current diagnostic and therapeutic approaches to AAFD, based on the most pertinent literature and our own experience and investigations.

Figures

Fig. 1

This weight-bearing, AP radiograph of the foot demonstrates a patient with flatfoot deformity associated with minimal forefoot abduction as evidenced by less than 30 % talo-navicular uncoverage (arrow)

Fig. 2

This weight-bearing, AP radiograph of the foot demonstrates a patient with a more severe flatfoot deformity associated with a large amount of forefoot abduction as evidenced by more than 30 % talo-navicular uncoverage (arrow)

Fig. 3

A weight-bearing, mortise radiograph of the ankle demonstrates valgus talar tilt and opening at the medial edge of the ankle joint line suggestive of early deltoid ligament insufficiency in the setting of flatfoot deformity

Fig. 4

This clinical photograph demonstrates the finding of the “too many toes sign.” When looking at the heel from the back of the patient, only the fifth toe and part of the fourth toe are seen in a normal foot. In a flatfoot, more toes are seen (arrow). In this case, the patient has bilateral hindfoot valgus and flatfoot. However, the left is more severe

Fig. 5

A weight-bearing, hindfoot alignment view of both feet demonstrates bilateral hindfoot valgus deformity as evidenced by the lateral and valgus position of the calcaneus with respect to the axis of the tibia. The left (labeled “L”) is much more severe than the right (labeled “R”)

Fig. 6

A weight-bearing, lateral radiograph of the foot shows the position of the plate used to fix (large arrow) the osteotomy of the medial cuneiform (ie, “Cotton osteotomy”). The radiograph also demonstrates fixation of a lateral column lengthening (small arrow) and a calcaneal heel slide (asterisk)

Fig. 7

Weight-bearing, AP (a) and lateral (b) radiographs of the foot demonstrate a first tarsometatarsal fusion fixed with 2 cross screws (large arrow) and an Evans lateral column lengthening fixed with a claw plate (small arrow). A medializing calcaneal heel slide was also performed and stabilized with 2 screws (asterisk)