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Pes Planus correction with FDL transfer , Calcaneal osteotomy and Wright Bioarch arthroresis screw

    Overview

    Learn the Pes Planus correction with FDL transfer , Calcaneal osteotomy and Wright Bioarch arthroresis screw surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Pes Planus correction with FDL transfer , Calcaneal osteotomy and Wright Bioarch arthroresis screw surgical procedure.
    Reports of flat foot deformity in association with tibialis posterior pathology appeared in the literature in the 1960’s, in 1989 Johnson and Strom developed a classification for Tibialis Posterior dysfunction, based on the progression of deformity and its treatment.
    Stability, flexibility and motor control of the hindfoot are very important components of the normally functioning foot. Movement of the hindfoot from eversion to inversion , alters the alignment of the chopart articulation and converts the flexible foot, useful for balance and shock absorption, into a closed pack, rigid configuration, which allows the foot to function as a mechanically effective lever. Normal hindfoot mechanics are reliant upon static (ligamentous), dynamic (musculo-tendinous) restraints, it’s function will also be affected by proximal (e.g valgus knee) and distal (e.g. elevated 1st ray) deformity. There are multiple interlinked static restraints of the hindfoot including the Deltoid ligament, Plantar Fascia, Spring Ligament, Interosseous Ligaments, cervical ligament, the inferior extensor retinaculum.
    Dynamic stabilisers include the Tibialis Posterior, Tibialis Anterior, the Achilles, Peroneals, Intrinsic foot muscles and to a lesser degree the long to flexors. The Tibialis Posterior tendon is the primary muscle motor, acting to invert the hindfoot converting its function to allow the calf muscles to generate force through the foot more efficiently, and to prevent excessive eversion. Failure of either the ligamentous restraints, the joints or the muscle motors lead to dysfunction of the foot, often in association with pain.
    The Tibialis Posterior muscle originates from the posterior border of the Tibia, the Interosseous Membrane and the fibula. the tendon forms in the lower third of the leg and passes within a thick retinaculum in a groove over the posterior and inferior margin of the medial malleolus. The tendon develops a major insertion onto the plantar medial aspect of the navicular tuberosity before passing plantarly with insertions into the cuneiforms, the 2-4th metatarsals and the cuboid.
    The most common cause of adult acquired flat foot is a failure of the Tibialis Posterior tendon, this can fail in the midsubstance or at the insertion, where it develops tendinopathy with midsubstance splits, tears and stretching, which may ultimately result in a complete rupture or more often an elongated, dysfunctional tendon.
    There is debate as to whether, the ultimate failure of the Tibialis Posterior tendon is the primary pathology, or whether this is the common end point of progressive failure of the static ligamentous constraints, leading to abnormal kinematics of the hindfoot which results to abnormal strain on the Tibialis Posterior tendon. Dyal found that 70% of patients with tibialis posterior insufficiency had a contralateral flat foot, suggesting a pre-existing tendency to over-pronation is a significant risk factor. Age hormonal and genetic factors are also likely to play a role on the condition, Kohls-Gatzoulis 2009 reported this to be more common in the over 40 population with a ratio 3:1 female: male. Various authors have shown median age ranges of between 45 and 60.

    Indications

    INDICATIONS:
    Adult acquired flat foot, failed non-operative management. Pain, restriction of function with reduced walking distance and speed.
    SYMPTOMS & EXAMINATION:
    Adult acquired flat foot is a progressive condition, as the deformity progresses, the symptoms tend to change and as such it presents with a multitude of complaints.
    Patients will usually with unilateral symptoms which in the main progress along the same lines though with a variable timeline. The causes are various and include recurrent overuse such as seen in a runner, a history of previous injury to the hindfoot ligaments, as part of an an acute inflammatory arthropathy or due to chronic degenerative change of the tendon. Initially, pain is felt fairly precisely behind the medial malleolus and on occasion radiating down to the tendons’ insertion into the Navicular. Pain is felt on weight bearing , possibly just on exercise, but will progress sometimes to pain at rest. As deformity progresses patients begin to develop lateral hindfoot pain classically occurs with pain at the tip of the Fibula and in the sinus tarsi, due to the valgus heel abutting the soft tissues at the Fibula tip and impingement at the angle of Gissane. Whilst the deformity remains flexible these symptoms may be reduced by mechanically offloading the tendon (with orthotics and intelligent shoewear choices, and stretching of the tight gastrocnemius-soleus complex). If progression to arthritic change occurs in the subtalar (and ultimately the ankle) joints, symptoms from these joints may dominate the clinical picture.
    On examination in mild cases there will be little to find. The tendon is in most cases discreetly tender but if swelling (of the tendon and associated subcutaneous oedema) is particularly severe then it may be difficult to identify the tendon itself. The degree of medial longitudinal arch reduction will vary from none to a severe planovalgus collapse. Until a fixed deformity ensues the planovalgus foot may not be obvious unless the patient is weight-bearing. It should be appreciated that the deformity is multi-planar and comprises a reduction of the height of the medial longitudinal arch ,hindfoot valgus and abduction of the forefoot due to midfoot pronation.
    A key test to do in assessing the plano-valgus foot and ankle is the single heel rise test , observing the patient from behind and noting whether the hindfoot moves appropriately into varus or remains in valgus. This differentiates a grade 1 tendinopathy in the Johnson and Strom classification (see below) which will likely respond to non-operative offloading or a more minor surgical intervention if this becomes required. The Tibialis posterior can be isolated by plantar flexing and everting the foot, power is then tested from this position against manual resistance in order to test MRC strength. The tendon is tested in an plantar flexed everted position in order to remove the effect of tibialis anterior as an inverter by reducing its lever arm.
    It is imperative that achilles or Gastrocnemius tightness is assessed. This is demonstrated with the foot aligned in its “anatomical position” ( The Talar-neutral position: the position in which the talar head is maximally covered by the navicular) with the knee both flexed and extended. It should be noted whether it is it possible to dorsiflex the ankle easily beyond neutral in the sagittal plane or not. If not then a tight Gastrocnemius or Achilles tendon is diagnosed which may be a contributing factor in the deformity and may also require correction at the time of surgery. The foot sitting in a plano-valgus position will allow the Achilles to shorten and become tight over time, however in some cases the Achilles tightness may be part of the primary problem rather than a secondary effect.
    It should be remembered that there are many causes of a unilateral planovalgus foot (including Lisfranc arthritis , Charcot midfoot collapse, late presentation of tarsal coalition, arthritis of the triple complex and previous Calcaneal fracture ) and other diagnoses must always be considered.
    The grading system of Johnson & Strom is most often used in describing the extent of the deformity and also is used in decision making on which intervention may be used most appropriately. Stage 1 is defined by tenosynovitis of the tendon with minimal deformity or weakness of the tendon and the single heel raise test is largely normal. This is likely to respond to conservative measures or a tendon sparing procedure ( debridement). A stage 2 tendon produces the classic pes planus deformity due to its elongation and reduction in power. A single heel rise will not be possible but the subtalar joint is mobile. This is the type of tendon requiring the reconstruction described in this section if conservative management fails. In stage 3 arthritis has occurred and the valgus deformity is fixed .Surgical treatment now requires a triple fusion. In stage 4 the ankle is also involved and if surgical treatment is required this is likely to involve a true pantalar fusion.
    INVESTIGATION.
    Plain X-Ray: Weight-bearing films can be used to document the structural deformity if one exists but are not required to make the diagnosis. Assessment of the degree of talar un-coverage is useful for surgical decision making.
    MRI:The investigation of choice for Tibialis posterior tendinosis which most objectively defines both the extent of the disease process and also the existence of intercurrent arthritic change.
    Ultrasound:In patients with paratenon inflammation only this can be used very effectively to both diagnose and infiltrate local anaesthetic and steroid into the appropriate layer.
    Weight bearing CT scan: A useful modality for assessing the alignment of the hindfoot, forefoot and any deformity in the medial column.
    NON-OPERATIVE ALTERNATIVES.
    The first line management of most patients is initially non-operative with activity modification and non steroidal anti-infammatory medications.
    An off the shelf semi-rigid functional foot orthotic or custom made rigid orthotic device with a medial arch, medial hindfoot posting and a heel counter, together with activity modification is a starting point. Physiotherapy modalities including therapeutic ultrasound and a graded rehab program are appropriate. Occasionally a few weeks immobilisation and strict non-weight bearing in a cast will be of benefit especially for the acutely swollen and painful tendon.
    A tall and appropriately designed post-operative boot is helpful for a number of weeks and beyond this the use of a more normal pair of boots that sit well above the ankle(for example hiking boots) , controlling hindfoot movement , help.
    OPERATIVE ALTERNATIVES (or adjuncts).
    Cobb (Split Tibialis anterior) tendon transfer.
    Flexor Hallucis Longus tendon transfer
    Cotton (medial column osteotomy )or similar
    Lateral column lengthening.
    Triple Fusion :Should be given consideration in the more elderly as an alternative to tendon transfer even in the absence of arthritic change.
    CONTRAINDICATIONS.
    The usual contra-indications of poor vascularity, poor soft tissue quality, smoking and immunosuppressive treatments that would need optimising pre surgery.

    Setup

    The procedure can be performed under a general or spinal anaesthetic.
    A popliteal nerve block is performed prior to the procedure.
    The patient is positioned supine on the table with a bolster under the ipsilateral buttock.
    A thigh tourniquet is applied and inflated to 300 mmHg prior to skin preparation.

    Operation – 1

    Silfverskiold test: To assess gastrocnemius and achilles tightness, and the need for its surgical release

    Silfverskiold test, reveals a degree of gastrocnemius contracture, as the foot is in equinus with the knee straight and dorsiflexes to 10 degrees with the knee bent.

    The Skin incision for the calcaneal osteotomy should be marked. We recommend and extended lateral incision which utilises the Posterior Peroneal Artery angiosome and is posterior to the sural nerve. The plantar limb of the incision runs along the junction of the plantar and dorsal skin, the vertical limb aims to the lateral border of the Achilles 3-4 cm above the superior border of the calcaneum.

    The incision should be developed to bone in order to maintain a tick vascularised skin flap, avoiding the temptation to undermine the subcutaneous tissues or develop layers.

    Gently retract the superior flap using a Kilner, cats paw retractor taking care not to traumatise the skin edge.

    Proceed with sub-periosteal dissection to elevate the flap from the calcaneal tuberosity, with sharp dissection using a knife and a sharp periosteal elevator.

    Once the superior and inferior margin of the calcaneum are exposed, a Trethowan, ring-handled spike is passed superiorly and inferiorly, make sure that there is no interposed soft tissue and that these are applied adjacent to the bone.

    Once sufficient tuberosity is exposed the saw can be applied to the lateral calcaneal surface in an oblique (Dorsal-proximal to Plantar-distal) fashion, and the saw cut contemplated. The blade here is possibly just beyond perpendicular to the calcaneum; a saw cut in this direction will make shifting the osteotomy quite difficult as the plantar structures will be tightened with medial displacement.

    Here the saw blade is angled slightly distally which prevents tensioning of the plantar structures and assists displacement of the tuberosity.
    The saw cut is made in a methodical fashion, taking particular care with the dorsal and plantar cortical margins. The saw should not penetrate through the medial cortex into the soft tissues in order to avoid injury to the branches of the tibial nerve which are at risk here. The medial cortical cut should therefore be completed with a broad osteotome.

    The Medial cortical cut is completed with a broad osteotome. if the osteotomy isn’t freed, its often either a dorsal or plantar cortical bridges that needs to be seperated.

    A dorsal cortical bridge remains the osteotome is used to complete the osteotomy.

    Once complete, the osteotomy is distracted using a laminar spreader, this should be placed in the harder tricortical dorsal and plantar bone to prevent compression of the cancellous central bone.

    With the osteotomy site distracted, the medial periosteum is freed using a periosteal elevator, in order to prevent tethering and to create space into which the tuberosity can be displaced.

    The tuberosity is displaced medially by gripping the heel in the palm of the hand and applying medially directed force with the ankle in plantar flexion, once adequate displacement (usually 1cm) is achieved, the displacement is locked in place by the assistant dorsiflexing the ankle, which tightens the plantar fascia and achilles, and compresses the osteotomy site.

    A “door-stop” wire can be driven along the lateral edge of the tuberosity into the osteotomy, in order to maintain the reduction and prevent any loss of displacement when the fixation screws are tightened.

    A longitudinal 1cm incision is made above the weight bearing border of the calcaneum,

    Blunt dissect to bone using a pair of dissection scissors, to ensure that the drill and screw can pass freely with minimal soft tissue trauma.

    A 2.5mm guidewire is passed into the anterior process of the calcaneum, roughly towards the angle of Gissane. The screw needs to pass through the overlapping bone at the osteotomy site, therefore the entry point in the tuberosity needs to be situated in the lateral half of the bone, and passed more laterally than medially.

    The position should be checked using image intensifier, with both lateral and axial views.
    Once wire position is satisfactory, screw length is determined using a depth gauge.

    The Cannulated drill is passed over the wire, and the calcaneum is drilled to the appropriate depth. It is helpful to mark the measured depth on the drill using a surgical pen.

    For the variable pitch screw, the proximal cortex is countersunk by hand in order to ensure that the screw head is flush or slightly buried.

    Pass the appropriate length screw over the guidewire and insert, the assistant should maintain the ankle in a dorsiflexed position to prevent displacement or rotation of the tuberosity fragment. The skin should be protected from damage from the wider portion of the proximal screw, here using a spread artery forceps.

    The position of the screw is checked on image intensifier, ensure that the tip of the screw is buried in bone and not breaching either the sinus tarsi or subtalar joint, and that the head of the screw is flush or slightly buried, and finally that the leading screw threads have all passed beyond the osteotomy site.

    The distal cut edge of the osteotomy site is often prominent, contouring this can help with wound closure and potentially, prevent persistent sub-fibular impingement. Cancellous bone graft can be taken here for use in planned associated procedures, such as a cotton osteotomy. Rongeurs are then used to gently breach the cortical bone.

    The softened cortical bone is then tamped down using a broad bone punch.

    Operation – 2

    The aim is to leave a relatively seamless contour.

    The flap should be closed in 3 layers if possible, again, gentle dorsiflexion during closure helps align the skin edges, which should be handled gently.

    The deep layers are closed with vicryl sutures.

    The skin is closed with interrupted mattress sutures. For ease of access, the authors close the lateral wound before addressing the medial side, at this stage the ipsilateral sand bag can be removed, the leg can then externally rotate, and the surgeon isn’t left struggling with access to the wound at the end of the procedure.

    The medial incision is planned, and traced with a surgical marker, landmarks are the posterior aspect of the medial malleolus, the navicular tuberosity and the plantar border of the medial cuneiform, the saphenous nerve and vein are located superior to the incision.

    The skin is incised down to the tibialis posterior tendon sheath, which is a definite thick capsular structure.

    There are multiple superficial veins that traverse the wound that should be carefully quarterized using a diathermy.

    The tibialis posterior tendon sheath is incised, it is not unusual to see a flush synovitic fluid at this stage. The tibialis posterior tendon is often present, but if ruptured the sheath is empty. Careful inspection of the tendon may reveal thickening, splits and a loss of the normal striated appearance of the tendon.

    Adhesions and adherent ,diseased capsule are excised from the distal tendon to allow its full inspection.

    The diseased tibialis posterior tendon can continue to be a pain generator, and a segment of the diseased tendon can be excised, leaving the distal 2cm to aid anchorage of the tendon transfer.

    At the bed of the tibialis posterior tendon sheath lies the talonavicular joint capsule and spring ligament. The spring ligament should be inspected for delamination, splits and tears. The ligament often appears lax. Eversion and inversion of the talonavicular joint helps to identify the joint line as well as the tension and integrity of the ligament.

    In the majority of longstanding and higher grade type 2 tendinosis, the spring ligament is lax and incompetent and should be repaired.

    Along the plantar-lateral margin of the tibialis posterior sheath runs the Flexor Digitorum Longus(FDL) tendon, in order to expose it, the FDL sheath is carefully divided longitudinally, being careful not to damage the tendon which lies immediately deep to it.

    Once a window is made in the FDL sheath a Macdonalds is passed into the sheath superficial to the tendon, and the sheath can be incised whilst the tendon is protected.

    dissection of the sheath is developed distally with McIndoes dissection scissors, protecting the FDL tendon.

    As the FDL passes distally into the plantar aspect of the medial foot, and superficial to the capsulo-ligamentous structures there is a rich venous plexus, deep, firm, retraction of the plantar flap and FDB reveals an adventitial plane between the capsular and venous structures, which is carefully developed, with a combination of blunt and sharp dissection and the assistance of diathermy where necessary.

    The FDL passes in its sheath deep to the navicular tuberosity, and it is traced distally towards the Knot of Henry (decussation of FDL and FHL). The level of the knot is usually plantar to the proximal 1st metatarsal, the FHL is identified approaching this more laterally.

    Once the Knot of henry is exposed, the FDL is tractioned with a tendon hook and divided proximal to the knot using McIndoes dissection scissors, whilst the ankle is held in plantar flexion, the hindfoot inverted and the lesser toes flexed. In most cases division proximal to the the knot provides enough length for the transfer. Usually there are adequate decussations between FDL(1.) and FHL(2.), so that a tenodesis is not necessary, but occasionally, if there is a paucity of connections, a side to side FDL to FHL tenodesis is performed.

    The cut end of the FDL is bought into the medial wound and a locking Whip-stitch is applied to the distal 2 cm, the authors prefer size 2 fibre wire.
    The distal end of the tendon is easily traumatised, the initial stitch should be passed with the help of a fine forceps, avoid crushing the end with artery clips.
    It is helpful for the assistant to apply longitudinal traction through this stabilising stitch, whilst the surgeon applies traction at a 90 degree angle on the leading stitch. By maintaining this tension suture passage is more straightforward.

    The whipstitch should be fashioned in such a way that the distal tendon is of a uniform diameter, and ensuring that the tip of the tendon is not excessively bulky, in order to allow the tendon to pass freely through the navicular drill tunnel.

    A dorsal to plantar incision is made along the medial talonavicular joint, taking care to ensure that the is sufficient cuff of ligament distally to accept the sutures. Excising a 3-4mm slip of tissue will help restore the tension in the tendon. The cut ends gently excoriated with a sharp blade to encourage bleeding.

    The divided spring ligament is repaired using 3-4 strong interrupted sutures, the authors use 3-4 rows of locked 2 ethibond.

    The interrupted capsular sutures are seen here with the talar head visible between the cut edges.

    The spring ligament is sutured, with the hindfoot held in an inverted position, to achieve a well tensioned repair.

    In more severe deformity, grade 2b, a medial displacement calcaneal osteotomy may be insufficient to correct the abduction deformity of the foot by itself. In these circumstances a lateral column lengthening or an arthroereisis screw can be used.
    Using an arthroereisis screw the sinus tarsi is identified anterior to the tip of the fibula, inferior to the neck of the talus.

    Operation – 3

    The sinus tarsi is identified 1-2 cm distal to the tip of the lateral malleolus and marked with a surgical pen.

    A 1cm incision is made over the sinus tarsi and a guidewire passed into the canalis tarsi. The wire is felt to emerge from the medial subtalar joint.

    Prior to sizing , abduction around the talo-navicular joint should be assessed by holding the neck of the talus and everting the foot. Trial sizers are then passed over the guidewire into the sinus tarsi. Select the size that resists excessive abduction beyond the physiological range, with a firm ‘rubbery’ end point. With the trial in situ assess foot position, the anterior border of the tibia should approximately align with the 2nd metatarsal if the foot has been corrected adequately.

    Position of the trial should be checked on Image intensifier, to confirm position in the sinus tarsi on the lateral view, and on the AP view the base of the screw should be just visible on the lateral side of the talar neck. The depth of the insertion is then taken from the numerical scale on the shaft of the introducer, usually between size 2 and 3.

    The appropriate sized arthroereisis screw, here a bioarch (Wright medical) is introduced into the sinus tarsi, to the same depth as the trial, again hindfoot movement should be assessed and alignment relative to the tibia re-checked.

    Confirm the position of the implant within the sinus tarsi once more using image intensifier. Again, the screw, on the AP view should not extend beyond the medial border of the calcaneum, should sit within the overlapping talus and calcaneum, and can extend slightly beyond the lateral border of the talar neck. On the lateral view should lie within the sinus and not impinge on the posterior facet.

    Test that the edges of the spring ligament are opposable by tensioning the sutures.

    A tunnel for passage of the FDL tendon is made in the navicular, a guidewire is passed, ensuring that this has adequate clearance from the medial navicular, the talo-navicular and the naviculo-cuneiform joints so as to maintain a strong bone bridge. By aiming the guidewire slightly laterally, this allows the FDL tendon to run plantar to the navicular tuberosity, thus augmenting the soft tissue repair. Once the position of the guidewire is checked and appears satisfactory, an appropriate diameter cannulated drill (often 5.5mm-6 mm) is passed over the guidewire through both dorsal and plantar cortices, whilst the assistant retracts the plantar flap.

    Once the Navicular tunnel is drilled, the spring ligament is repaired. The suture can be tensioned using a Mcindoes scissors, which are laid on top of the first throw of the suture, the second knot is then tied over the tip of the forceps and held tight whilst the assistant opens and closes the tips 2-3 times. As the scissors are then slipped out the knot snaps tight, with the repair strongly tensioned.

    The second throw of the suture is passe over the tips of the closed Mccindoes scissors and held firmly. The scissors are opened and closed 3-4 times which tensions the suture, whilst holding it snug, the scissors are removed and the knot snaps tight.

    The tension in the spring ligament has been restored after the repair.

    A suture passer is introduced into the tunnel from dorsal to plantar and the loop is opened plantar to the navicular, the tissues need to be retracted plantarly to create a working space in order to pass the whipstitch into the loop.

    A suture passer is passed from dorsal to plantar to retrieve the whipstitch, the whip-stitch is passed through the loop with the assistance of an artery clip. The FDL and whipstitch should be passed plantarly to all of the spring ligament sutures, so that it doesn’t get tethered in the repair.

    The Whipstitch is retrieved using a suture passer and passed dorsally through the tunnel, the tendon is then pulled through using firm traction and gentle circular movements, this is made easier by aligning the tendon with the tunnel, using a tendon hook (1.) to pull the FDL distally so that it is orientated in the same direction as the tunnel.

    The tendon is then tensioned with firm traction, holding the foot in an inverted position, it is most important to ensure that the tendon slides relatively freely into the tunnel and doesn’t get stuck in order to avoid laxity in the repair.

    A biotenodesis screw is used to lock the tendon with an interference fix, the screw should be larger than the drill hole, most frequently we use a 5.5mm biotenodesis screw in a 5mm drill hole, but occasionally in larger individuals a larger drill and screw is required. The tip of the screwdriver is passed into the tunnel, the flat paddle is held firmly whilst the screw is introduce.

    The biotenodesis screw is advanced until it is fully seated in the tunnel and it meets resistance, which is often produces a ‘squeeking’ sound.

    The fixation of the FDL transfer is augmented with interrupted absorbable sutures to the periosteum and the distal stump of the tibialis posterior tendon. The preserved distal plantar expansion of the tibialis posterior is then sutured to the FDL before it enters the tunnel.

    The wounds are closed in deep and superficial subcutaneous layers, with interrupted sutures to she skin, the wounds are dressed. Finally, ankle dorsiflexion is tested, using a Silverskiold test. If there is significant contracture of the gastroc or soleus, a gastrocnemius or achilles lengthening should be considered as appropriate.

    Post Operative

    1-2 night stay
    2 weeks in back-slab, during which elevation is encouraged for 50-55 minutes per hour.
    Anticoagulation with low molecular weight heparin should be considered.
    dressing changes at 1 & 2 weeks
    Complete cast between weeks 2 to 6 & non-weight bearing.The cast is changed at 2 and 4 weeks as the foot is sequentially bought from its inverted post-operative position to plantigrade
    Check X-ray at 6 weeks.
    The patient is transferred into a long post-operative boot and gradual increase in weight-bearing. Patients will often complain of an increase in pain and swelling from 6-8 weeks, and should be reassured that this is a likely consequence of beginning to weight bear and increased activity, they should be advised to take analgesia where necessary, regularly ice and elevate the foot and in a gradual, incremental fashion increase activity.
    Add an “off the shelf” supportive , semi-rigid 3/4 length orthotic with medial hindfoot posting , for the next 3 months.
    Physio to work on ankle range, gastroc stretching, intrinsic foot exercises, ankle and subtalar balance, isolating the transferred FDL muscle and strengthening regime including gluteals and core from 6 weeks.
    May be comfortable enough to make transition into stiff soled walking boot or structured running shoe by 12 weeks.
    Remain in this for all weight bearing for a further 6 weeks as a minimum.
    The Arthroereisis screw can be associated with sinus tarsi discomfort, also it can occasionally become displaced from the sinus tarsi, and consideration should be given to removing this at 6 months post operatively. The authors plan removal at 6 months post-op with the patient from the outset, if the implant remains asymptomatic, it can always be left in situ. Removal is achieved through the sinus tarsi incision and is reasonably straight-forward.
    Orthotics may be required in some cases, over the longer term . A good functional recovery will not unusually take 6 months, and it is likely to take 12 months for full recovery, even after this patients report ongoing strengthening of the transferred muscle.

    Recommended Reading

    Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot
    J Bone Joint Surg. 81-A. 1999 :11; 1545-1560
    B C Toolan , B J Sangeorzan , S T Hansen.
    Retrospective study assessing radiographic and clinical outcome of 30 control calcaneal osteotomies, spring ligament repairs and tendon transfers, with 15 study patients who underwent the same baseline procedure with the addition of an arthroereisis screw.
    The study group with the arthroereisis screw showed a significant improvement in the radiographic and clinical parameters when compared to the control group. The group conclude that the arthroereisis procedure is a useful adjunct to flat foot correction with little increased risk.
    Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot
    J Bone Joint Surg. 81-A. 1999 :11; 1545-1560
    B C Toolan , B J Sangeorzan , S T Hansen.
    All patients had grade 2 Tibialis posterior tendinosis.
    All patients underwent a tri-cortical bone block distraction fusion of the calcaneo-cuboid joint . All underwent an FDL transfer through the distal Tibialis posterior tendon from plantar to dorsal. All underwent a triple cut of the Achilles tendon. No spring ligament work was undertaken but 27 patients also required 1st TMT joint fusion , 4 naviculo-cuneiform fusion and 2 underwent both .
    36 patients (& 41 operations) were treated of which 88% were painfree or less painful than pre-op.
    There was high patient satisfaction rates with the outcome 33 of the 36 willing to undergoe the operation again if the same circumstances presented.
    That said 20% non-union at Calcaneo-cuboid joint ,32% sural nerve complications and 71% required secondary surgery.
    Correction of moderate and severe acquired flexible flatfoot with medialising calcaneal osteotomy and flexor diditorum longus transfer.
    J Bone Joint Surg ,2006 .88A:1726-1734
    A.M.Vora ,T.R.Tudor , B.G.Parks ,L.C.Schon
    Cadaveric study, 7 pairs of limbs. Different levels of deformity created. Severe deformity may require additional operative procedures.
    Dysfunction of the tendon of Tibialis Posterior.
    J Bone Joint Surg (br) 2004;86-B:939-46
    H.J.Trnka
    A good Review Article
    Arthrodesis techniques in the management of stage 2 and 3 acquired adult flatfoot deformity.
    J Bone Joint Surg 2005.87-A; 8:1866-1876.
    J.E.Johnson , J.r.Yu.
    An excellent and well illustrated and referenced review article on the role of fusions (and osteotomies) in flat foot reconstructions after Tibialis posterior failure.
    Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage 2 dysfunction of Tibialis posterior.
    J Bone Joint Surg 2002.84-B;54-58.
    J.T.Wacker ,M.S.Hennessy, T.S.Saxby.
    51 patients with grade 2 dysfunction prospectively enrolled.
    44 reviewed at a mean 51 months follow up. 43 Excellent or good outcome regarding pain & function using AOFAS score. Only 36 scored in the same categories for deformity correction. 2 Failures resulting in Calcaneo-cuboid fusion.
    The objective alignment assessed clinically was only “Fair” in 25% of patients.
    On technical points the transfer of FDL described was from plantar to dorsal navicular , then suturing the tendon back onto itself. The Tibialis posterior was radically excised and not tenodesed . The spring ligament was not tightened/plicated.
    No orthotics were proscribed in the post-operative period.
    Short- to mid-term outcomes following the use of an arthroereisis implant as an adjunct for correction of flexible, acquired flat foot deformity in adults.
    Foot Ankle Spec 2018 Apr
    Walley, Green, Hallam, Juliano, Aynardi.

    Reference

    • orthoracle.com

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