foot deformities overview illustrating evaluation, presentations and different methods to deal with

1. َّ‫ن‬ِ‫إ‬َّ‫ـه‬‫الل‬َُّ‫ر‬ُ‫م‬‫أ‬‫ي‬َِّ‫ل‬‫د‬‫الع‬ِ‫ب‬
َِّ‫حسان‬ِ‫اإل‬‫و‬َِّ‫إيتاء‬‫و‬َِّ‫ذ‬‫ي‬
‫ربى‬ُ‫ق‬‫ال‬‫نهى‬‫ي‬‫و‬َِّ‫ن‬‫ع‬َِّ‫حشاء‬‫الف‬
َِّ‫ر‬‫نك‬ُ‫م‬‫ال‬‫و‬َِّ‫ي‬‫غ‬‫الب‬‫و‬‫م‬ُ‫ك‬ُ‫ظ‬ِ‫ع‬‫ي‬
‫م‬ُ‫ك‬‫ل‬‫ع‬‫ل‬‫ر‬‫ك‬‫ذ‬‫ت‬َّ‫ون‬﴿٩٠﴾

2. Complex Foot &
Ankle Deformities,
Current
Practice
Dr Samir Zahed
Professor of Orthopedic Surgery,
Benha University
Monday Educational Program 2016, semester II
Foot Deformities,
Current Practice

3. Outline
 Anatomy & Biomechanics Grounds
 Deformity Assessment
 Equinus, Cavus, Varus, Equinocavovarus
 Toes Deformities
 Valgus, Planus, Hyper-pronation, planovalgus
 Diabetic Foot

4. Anatomy &
Biomechanics
Grounds

5. Anatomy & Biomechanics grounds
 Foot Construction &
shape
 26 bones (One-quarter of
bones in human body);
33 joints;
20 muscles.
 Foot loading
 Heel 50-60%
 Forefoot 40-50%
 Peak forefoot pressure under
2nd MT

6. Foot Functions
 Base of support/weight
distribution
The human foot combines mechanical
complexity and structural strength.
The foot can sustain enormous pressure
(several tons over the course of a one-
mile run) and provides flexibility and
resiliency.
 Conformity to changing terrain
Footwear helps to distribute pressures
more evenly
 Shock Absorption
 Propulsion
Foot acts as a rigid lever at push-off
The ankle serves as foundation, shock
Anatomy & Biomechanics grounds

7.  Three Arches
One Transverse
 Two Longitudinal
 Medial-shock
absorber
 Lateral-
transmits wt.
 Weight Support &
Conformity functions
need adequate &
pliable platform
 Propulsion Function
needs a strong
levers (2nd class)
Anatomy & Biomechanics grounds
Foot Functions

8. Foot Functions
 Muscle mainly active in
propulsion (dynamic)
 Tibialis posterior
 Triceps surae
 Ligaments active in
standing (static):
 2- Spring (calcaneo-
navicular ligament)
 3- Short plantar (calcaneo-
cuboid ligament)
 1- Long plantar (calcaneo-
cuniform- metarasal ligament)
4- Plantar aponeurosis
Anatomy & Biomechanics grounds

9. Dorsiflexion of proximal phalanx raises the
arch through traction on the plantar fascia &
mid foot locks in a rigid position to act as a
lever arm
Anatomy & Biomechanics grounds
Windlass Effect

10. Early Heel Strike
= Contact Made on the Lateral
Border of the Heel
= Foot is Supinated
= Foot is Rigid (locked)
Integrated Function
of Foot/Ankle Joints
Lateral
Side
Medial
Side
Anatomy & Biomechanics
grounds
Early to Mid- Stance
= Foot goes to poronation
= Foot is Mobile (unlocks)
= Shock absorption, increases
support on the ground, and
enhances balance
Late Stance to Toe-Off
= Foot goes again to supination
= Foot turns rigid (locks)
= Force transfer from Achilles
tendon to toes through contracted
planter fascia
= Enhances Propulsion
Left Foot

11.  Supination
 Calcaneal inversion (Varus)
 Dorsiflexion + External
Rotation of talar Head
 Compensatory Forefoot
Supination (Varus)
 Pronation
 Calcaneal Eversion (Valgus)
 Plantar Flexion + Internal
Rotation Of Talar Head
 Compensatory Forefoot
Pronation (Valgus)
 Heel Rise
 Shortening and tightness of
planter fascia
 Supinated inverted foot
 Locked transverse tarsal joint
 Hindfoot inversion
Integrated Function
of Foot/Ankle Joints
Anatomy & Biomechanics
grounds

12. Main Movers
of foot
Muscle
imbalance in
foot deformity
MuscleMain
Tib postAdductor
Peronus previsAbductor
Tib AntSupinator
Peronus longusPronator
Deformity Strong Muscle Weak Muscle
equinus Triceps sure Ankle dorsiflexors
cavus plantar fascia,
intrinsics
Ankle dorsiflexors
varus tib post & tib
ant
peroneal brevis
flatfoot peroneus brevis tibi post
supination Tibi ant peroneus longus
Anatomy & Biomechanics grounds

13. Deformity
Assessment

14. Deformity Assessment
 Classic foot & ankle
examination
 Specific for deformity
assessment
 look for the patient
walking (gait), then
examine the components
of the deformity while the
patient lying supine &
prone, then again look for
the patient putting weight
walking again and again
 Components of deformity in
hind mid, forefoot, & toes
 Flexibility (correctability)
 deformity changes on
weight bearing during
walking (dynamic elements)
 Special tests, block test &
its dynamic version

15. Equinus, Cavus,
Varus,
Equinocavovarus

16. Equinus, Cavus, Varus,
Equinocavovarus
 Commonly seen in
combinations
 Hind foot is varus, or
equinus or equinovarus
 Midfoot in cavus (high
arch)
 Lateral border may be long
 Forefoot may be inverted
 Dropping first ray
 Clawing of the toes +/-
 Flexibility (Block test)

17. Equinus, Cavus, Varus,
Equinocavovarus
Mostly seen in
 Congenital (since birth)
Clubfoot: persistent, neglected,
relapsed
 Developed in childhood,
adolescence or adulthood
idiopathic
Parlytic
 CP
 CMT (herditary somatosensory
neuropathy)
 Freidreich ataxia
 Muscular dystrophy
 Polio
 Spinal cord affections (eg. spinal
dysraphism or tumors)

18. Equinus, Cavus, Varus,
Equinocavovarus
Stages
1. Flexible cavus / Flexible 1st MT
- plantarflexion corrects with
pressure on 1st MT
2- Fixed 1st MT equinus /
hindfoot mobile varus
- hindfoot corrects with
Coleman block test
3. Fixed lesser MT's equinus /
fixed hindfoot varus
- hindfoot does not correct with
Coleman block test
4. Joint degenerative changes
X Ray
See through sinus tarsi, evident both talar
domes, calcaneal height ˃ 20-25˚, Maerys
angle ˃ 4˚ dorsal

19. Equinus, Cavus, Varus,
Equinocavovarus
Surgical principles
1. Flexible cavus / Flexible 1st MT
- semi-rigid insole orthotic with a depression
for first ray and a lateral wedge
2- Fixed 1st MT equinus /
hindfoot mobile varus
- Steindler release (plantar fascia release)
- Jones, 1st TMT fusion/ 1st MT osteotomy
- Shortening lateral border
- Tib post transfer if weak dorsiflexion
- PL to PB transfer if weak eversion
3- Fixed lesser MT's equinus /
fixed hindfoot varus
- Above +
- Lateral slide Calcaneal Osteotomy
- T Achilles lengthening
4. Joint degenerative changes
- Arthrodesis for salvage of rigid deformity
- Frame may be of help to maintain size of foot

20. A 32 year-old male complains of lateral foot pain
and a progressively awkward gait. He has a
family history of "foot problems" and reports
some minor burning and numbness in both feet.
Physical exam reveals bilateral cavus feet with
clawing of the toes and intrinsic muscle wasting
of the hands. A clinical photograph is shown in
Figure
Which of the following is responsible for the
patients initial symptoms and awkward gait?
1. Weak gastrocnemius-soleus complex
2. PB overpowering the tib post tendon
3. Tib ant overpowered by PL
4. Plantar flexion of the first ray
5. Clawing of the toes
Quiz

21. An 18-year-old male presents with recurrent ankle
sprains of the left ankle. During Coleman block
testing the hindfoot is positioned in 3˚of valgus.
The PB & tib ant have 4/5 strength compared to 5/5
strength in PL, gastrocsoleus complex, & tib post
Using a semi-ridged orthotic with a recess for the
head of the first ray and lateral hindfoot posting
has failed to improve symptoms.
Which of the following surgical interventions is
most appropriate?
1. PL to PB transfer + medial calcaneal slide
osteotomy
2. Triple arthrodesis
3. 1st ray dorsiflexion osteotomy + plantar fascia
release
4. Subtalar arthrodesis
5. First TMTjoint arthrodesis & MTP capsular
release
Quiz

22. A 14-year-old male child presents with the
increasing foot deformity shown in Figure
.
On physical exam, it is noted that he is
unable to walk on his heels and has
decreased Achilles reflexes bilaterally.
Coleman block testing reveals correctable
hindfoot deformity.
Which procedure is associated with
improved clinical outcomes in patients
with the above described condition?
1. Transfer of PB to PL
2. Split tib ant transfer to lateral column
3. Triple arthrodesis
4. Tib post transfer to dorsum of the foot
5. Lateral column lengthening calcaneal
osteotomy
Quiz

23. A 42-year-old woman with Charcot-Marie-Tooth disease
complains of longstanding foot pain. Orthotics, bracing, and
NSAIDs no longer provide relief.
She has cavovarus hindfoot deformity that does not correct
with Coleman block testing.
Radiographs are notable for degenerative changes within the
talocalcaneal and calcaneocuboid joints.
Which of the following is the most appropriate treatment?
1. Split tibialis posterior transfer
2. Triple arthrodesis
3. Lateral closing wedge calcaneal osteotomy with peroneus
longus to brevis transfer
4. First metatarsal dorsal closing wedge osteotomy
5. Achilles tendon lengthening
Quiz

24. What is the preferred orthotic device for a
symptomatic adult foot deformity that is
shown in Figure ?
He has no arthritis on radiographs, and
responds to Coleman block testing as
shown in Figure?
1. Short walker boot
2. Accommodative custom orthotics
3. Lace up soft ankle brace
4. Medial hindfoot posting with arch support
5. Lateral hindfoot posting with recessed
first ray
Quiz

25. Quiz
A 3-year-old boy has been treated in the past with Ponseti
casting now presents with dynamic supination during gait.
You're planning to perform an anterior tibialis transfer to the
lateral cuneiform.
All of the following are true except
1. This transfer is required in 10-20% of children who undergo
the Ponseti treatment
2. Weak peroneals are counteracted by overpull of the anterior
tibialis
3. Grade 4 or 5 strength of the anterior tibialis is needed prior
to transfer
4. Subtalar rigidity supplements the transfer
5. Dynamic supination includ

26. Quiz
A 4-year-old boy demonstrates excessive
supination occuring during the swing phase
of gait following Ponseti casting for an
isolated right clubfoot.
Which of the following sites identified in
Figure shows the correct destination for the
transferred tendon in order to balance the
foot and eliminate the supination?
1. A
2. B
3. C
4. D
5. E

27. Toes Deformities

28. Lesser Toes Deformities
 Claw toes
Flexible painful deformity (no contracture)
FDL flexor-to-extensor transfer (Girdlestone)
Fixed contracture
 Girdlestone (above), MTP capsulectomy, and PP head
resection
Fixed claw toe deformity of all four lesser toes
 Girdlestone and distal MT shortening osteotomy (Weil
lesser MT osteotomy)
 Hammer toes
EDL lengthening or tenotomy (flexible)
Excision of head of PP (most common
surgery)
 Mallet toes
 Percutanous tenotomy of FDL

29. A 34-year-old woman presents with right foot pain
and a callus over the 1st TMT joint. Accommodative
shoe wear has failed to relieve symptoms.
Images displaying key radiographic angles in the
evaluation of this disorder are shown in Figures. The
distal metatarsal articular angle (DMAA) is measured
at 15 degrees.
Which of the following operative procedures is most
appropriate for this deformity?
1. Closing wedge osteotomy of the proximal phalanx
(Akin)
2. Distal soft-tissue release
3. Distal metatarsal osteotomy
4. Medial eminence resection and exostectomy
(Silver)
5. Scarf osteotomy
Quiz

30. A 47-year-old woman that works as an attorney has a 3-year
history of bilateral painful forefeet that is exacerbated with the
dress shoes she wears for work.
Physical examination reveals bursal inflammation and calluses
at the medial eminence of the first metatarsal with a 1st MTP
joint deformity that passively corrects.
The hallux valgus angle (HVA) is measured at 25 degrees and the
intermetatarsal angle(IMA) is measured at 12 degrees.
Which of the following surgical interventions is most appropriate
for correction of her deformities?
1. Distal metatarsal osteotomy (Chevron)
2. Closing wedge osteotomy of the proximal phalanx (Akin)
combined with distal soft tissue release (Modified Mcbride)
3. Resection of medial eminence (Silver bunionectomy)
4. Proximal metatarsal osteotomy and first MTP arthrodesis
5. Metatarsal cuneiform fusion (Lapidus)
Quiz

31. Hallux Valgus
 Patho-anatomy
 Types
◦ Adult hallux valgus
◦ Juvenile and Adolescent
Hallux valgus
 factors that differentiate juvenile
/ adolescent hallux valgus from
adults
 often bilateral and familial
 pain usually not primary complaint
 varus of first MT with widened IMA
usually present
 DMAA usually increased
 often associated with flexible flatfoot
 complications
 recurrence is most common
complication (>50%), also
overcorrection and hallux varus

32. Hallux Valgus
Radiographic Measurements in
Hallux Valgus (weight bearing AP , lateral &
oblique views)
Hallux valgus (HVA) Long axis of 1st MT and prox. phalenx Identifies MTP
deformity
Normal
< 15°
Inter metatarsal (IMA) Between long axis of 1st and 2nd MT < 10°
Distal metatarsal
articular (DMAA)
Between 1st MT long. axis and line
through base of of distal articular cap
Identifies MTP
joint incongruity
< 15°
Hallux valgus
interphalangeus (HVI)
Between long. axis of distal phalanx
and proximal phalanx
< 10°

33. Hallux Valgus
Procedure Technique
1- Modified McBride Includes release of adductor from lateral sesamoid/proximal phalanx,
lateral capsulotomy, medial capsular imbrication (original McBride
included lateral sesamoidectomy)
2- Chevron /Biplanar
Chevron/ Mitchell
Distal 1st MT osteotomy (intra-articular).
Biplanar Chevron (corrects DMAA)
3- Scarf / Ludloff / Mau Metatarsal shaft osteotomies.
4- Proximal crescentric
osteotomy/ Broomstick
osteotomy
Proximal metatarsal osteotomies. (plus modified McBride)
5- Akin proximal phalanx medial closing wedge osteotomy

34. Hallux Valgus
Procedure Technique
6- Keller resection
arthroplasty
Include medial eminence removal and resection of base of proximal
phalanx
7- MTP arthrodesis
8- Lapidus procedure first TMT joint arthrodesis with distal soft tissue procedures
(Modified McBride)
9- First Cuneiform
Osteotomy
Opening wedge osteotomy (often requires autograft)

35. Hallux Valgus
Surgical Indications for Various Techniques
to treat Hallux Valgus
HVA IMA Modifier Procedure
Mild
< 25° < 13°
Distal osteotomy Chevron or Mitchell osteotomy.
usually with mod McBride
Moderate 26-40° 13-15° Shaft osteotomy or
Proximal osteotomy
Scarf/ Ludloff/ Mau or crescent/
Bromestick. + mod McBride
Severe
41-50° 16-20°
Double osteotomy Proximal osteotomy + biplanar
Chevron (if DMAA > 15°) + mod
McBride

36. Hallux Valgus
Surgical Indications for Specific Conditions
Juvenile/Adolescent with open
physis
First cuneiform open wedge
osteotomy
1- Hypermobile 1st MT
2- Recurrence with pain in 1st
TMT joint
Lapidus procedure
1- DJD, gout, RA
2- CP
3- Down's syndrome, Ehler-
Danlos
MTP Arthrodesis

37. Hallux Valgus
Procedure Indications Complications
Modified McBride - 30-50 y/o female with
- HVA 15-25
- IMA <13
- IPA < 15
- Recurrence
- Hallux varus
Chevron /
Mitchell
- mild to moderate deformities in adults
and children,
- biplanar chevron corrects increased
DMAA
- AVN of MT head
- recurrence
- dorsal malunion with transfer
metatarsalgia
Akin - combined with Chevron in moderate to
severe deformities
- hallux valgus interphalangeus
Scarf / Ludloff /
Mau
- IMA 14-18°
- DMAA is normal or increased
- dorsal malunion with transfer
metatarsalgia
- recurrence
Proximal
crescentric or
Broomstick
-Severe deformity
- IMA > 20
- HVA > 50
- hallux varus
- dorsal malunion with transfer
metatarsalgia
- recurrence

38. Hallux Valgus
Procedure Indications Complications
Keller resection
arthroplasty
- largerly abandoned due to
complications.
- indicated only in older patients with
reduced functional demands
- cock-up toe deformity
- poor potential for correction
of deformity
MTP arthrodesis - DJD of 1st MTP
- CP
- painful callosities beneath lesser MT
heads
Lapidus
procedure
- moderate or severe deformity
- hypermobility of first ray
- Nonunion (may or may not be
symptomatic)
- dorsiflexion of the 1st MT with
transfer metatarsalgia
First Cuneiform
Osteotomy
- children with ligamentous laxity, flatfoot,
and hypermobile first ray
- adolescent with an open physis
- Nonunion (may or may not be
symptomatic)

39. A 34-year-old woman presents with right foot pain
and a callus over the 1st TMT joint. Accommodative
shoe wear has failed to relieve symptoms.
Images displaying key radiographic angles in the
evaluation of this disorder are shown in Figures. The
distal metatarsal articular angle (DMAA) is measured
at 15 degrees.
Which of the following operative procedures is most
appropriate for this deformity?
1. Closing wedge osteotomy of the proximal phalanx
(Akin)
2. Distal soft-tissue release
3. Distal metatarsal osteotomy
4. Medial eminence resection and exostectomy
(Silver)
5. Scarf osteotomy
Quiz

40. A 47-year-old woman that works as an attorney has a 3-
year history of bilateral painful forefeet that is exacerbated
with the dress shoes she wears for work.
Physical examination reveals bursal inflammation and
calluses at the medial eminence of the first metatarsal
with a 1st MTP joint deformity that passively corrects.
The hallux valgus angle (HVA) is measured at 25 degrees
and the intermetatarsal angle(IMA) is measured at 12
degrees.
Which of the following surgical interventions is most
appropriate for correction of her deformities?
1. Distal metatarsal osteotomy (Chevron)
2. Closing wedge osteotomy of the proximal phalanx
(Akin)
combined with distal soft tissue release (Mod Mcbride)
3. Resection of medial eminence (Silver bunionectomy)
4. Proximal metatarsal osteotomy and first MTP
arthrodesis
Quiz

41. Which of the following clinical scenarios regarding hallux valgus could
be appropriately treated with a modified McBride procedure?
1. 35-year-old female with a 20 degree HVA, a 11 degree IMA, and an
incongruent 1st MTP joint
2. 40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a
congruent 1st MTP joint
3. 70-year-old female with a 35 degree HVA, and a 13 degree IMA with
a hypermobile 1st ray
4. 65-year-old female with a 25 degree HVA, a 14 degree IMA, and
severe hallux rigidus
5. 85-year old minimally ambulatory male with a 45 degree HVA, and
a 20 degree IMA
Quiz

42. A 67-year old female presents with the bilateral foot
deformity shown in Figures.
All of the following contribute to the risk of recurrence
after surgery EXCEPT:
1. Resection of the lateral sesamoid
2. Lack of lateral capsular release
3. Lack of medial metatarsophalangeal joint capsule
closure
4. Use of an Akin procedure alone for a moderate to
severe deformity
5. Under correction of the widened 1-2 intermetatarsal
(IMA) angle
Quiz

43. Complex Foot Deformities

44. ‫ا‬‫ي‬‫ا‬‫ه‬ُّ‫ي‬‫أ‬َّ‫ين‬ِ‫ذ‬‫ال‬‫آ‬‫وا‬ُ‫ن‬‫م‬‫وا‬ُ‫ق‬‫ات‬
َّ‫ـه‬‫الل‬َّْ‫ر‬ُ‫ظ‬‫ن‬‫ت‬ْ‫ل‬‫و‬َّ‫ن‬َّ‫س‬ْ‫ف‬‫ا‬‫م‬َّ‫د‬‫ق‬َّْ‫ت‬‫م‬
َّ‫د‬‫غ‬ِ‫ل‬‫وا‬ُ‫ق‬‫ات‬‫و‬َّ‫الل‬َّ‫ـه‬َّ‫ن‬ِ‫إ‬َّ‫ـه‬‫الل‬
َّ‫ير‬ِ‫ب‬‫خ‬‫ا‬‫م‬ِ‫ب‬َُّ‫ل‬‫م‬ْ‫ع‬‫ت‬َّ‫ون‬﴿١٨﴾
(‫الحشر‬)

45. Valgus, Planus, Hyper
pronation,
Planovalgus

46. Valgus, Planus, hyper
pronation, planovalgus;
Overview
 Presentation
 Evaluation
 Selected Types
Congenital Vertical Talus
Flexible Flat Foot
Tarsal Coalition
PTTD

47. Valgus, Planus, hyper
pronation, planovalgus;
Overview
Presentation
 Flexible
 Idiopathic,
 Neonatal calcaneovalgus of uterine packing
 Physiologic (morphologic),
 Infants & children
 Ligamentous hyper laxity
 Acquired (Secondary to)
 Tibialis posterior tendon affection as in PTTD & accessory navicular
 Faulty foot loading as in obesity, valgus external rotation tibia
 Paralytic problems as in spinal dysraphism, muscular dystrophy, CP
 Rigid
Congenital vertical talus
Tarsal coalition
Charcoat arthropathy
Externo Peroneal Spasm secondary to:
 Subtalar arthrosis; trauma, RA, non specific inflammation
 Subtalar arthritis as a late stage of PTTD, # calacaneus, ect
Functional

48. Valgus, Planus, hyper
pronation, planovalgus;
Overview
Evaluation
 Family and Clinical History
 Clinical Examination
Flexible vs rigid
Morphologic vs functional (if
flexible)
Tiptoe test
Toe raise (Jack test)
 Radiology
Severity (meary,s angle) &
talocalcaneal angle & calcaneal
height, talar uncoverage
Tarsal coalition
Subtalar arthritis
CT

49. Valgus, Planus, hyper
pronation, planovalgus;
Overview
Congenital Vertical Talus
Dates since birth
DD
Congenital oblique talus
Fibular hemimelia, absent fibula
&possible lateral rays
Idiopathic calcaneovalgus, flexible
TT
Early peroneal & extensors
lengthening
Prolonged splinting

50. A 12-year-old boy has 2 years of right foot pain that
prevent participation in athletic activities and is
symptomatic with walking. He has attempted UCBL
and custom made orthoses for 1 year with no relief
of symptoms.
His hindfoot is supple and he has full dorsiflexion.
Clinical images of the foot & a lateral radiograph are
shown.
A surgical plan to address the deformity would most
appropriately include which of the following?
1. Lateral calcaneal slide osteotomy
2. Transfer of the peroneus longus to the peroneus
brevis
3. 1st metatarsal dorsiflexion osteotomy
4. Calcaneal neck lengthening osteotomy
5. Posterior tibial tendon transfer to dorsum of the
foot
Quiz

51. Valgus, Planus, hyper
pronation, planovalgus;
Overview
Flexible Flat Foot
(Non PTTD)
Treatment Algorithm
Clinical picture
Diagnosis & initial treatment
Clinical response & final treatment
Shoes and Orthotics
Orthotics do not alter underlying
structural fault, moreover they may
negatively affect foot
Orthotics do not encourage
redevelopment of the arch
Running sports shoes have been found
to be as effective as medical shoes and
are more socially acceptable
 They reduce shoe wear and are said to
be more effective in treating shoes
rather than feet

52. Valgus, Planus, hyper
pronation, planovalgus;
Overview
Flexible Flat Foot (Non PTTD)
 Treatment Algorithm
 Clinical picture
 Diagnosis & initial treatment
 Clinical response & final treatment
 Shoes and Orthotics
 Surgeries
 Subtalar Arthroeresis
Not in subtalar arthritis, paralytic, or
severe ligamentous laxity
 Soft tissue procedures
Alone or in combinations with others
ETA +/- tib post advancement
 Osteotomy
 lateral calcaneal lengthening
Medial sliding calcaneal osteotomy
Combination of both
 Fusion
 Arthrodesis of the medial column, including
N-C joint &MT- C joint
 Distraction arthrodesis of C-C joint
 Subtalar or triple in degen. cases

53. Valgus, Planus, hyper
pronation, planovalgus;
Overview
Tarsal Coalition
Diagnosis
Canale & keley oblique view
Harris-Beath axillary view
CT
DD
Subtalar inflammation with
spasmodic valgus foot
TT
Resection with or without other
procedures
Realignment Osteotomies
Evans lateral calcaneal lengthening
Medial slide calcaneal osteotomy
Fusion
Subtalar
Trible
Controversial
except in cases
with degeneration
More in late
adolescence and
adults

54. Valgus, Planus, hyper
pronation, planovalgus;
Overview

55. Tibialis Posterior Tendon
Dysfunction
Deformity Radiographs
Stage I • Tenosynovitis
• No deformity
• Normal
Stage IIA • Flatfoot deformity
• Flexible hindfoot valgus
• Normal forefoot
• Arch collapse deformity
Stage IIB • Flatfoot deformity
• Flexible hindfoot valgus
• Forefoot abduction ("too many toes", >40%
talonavicular uncoverage)
Stage III • Flatfoot deformity
• Rigid hindfoot valgus
• Rigid forefoot abduction
• Arch collapse deformity
• Subtalar arthritis
Stage IV • Flatfoot deformity
• Rigid hindfoot valgus
• Rigid forefoot abduction
• Deltoid ligament compromise
• Arch collapse deformity
• Subtalar arthritis
• Talar tilt in ankle
mortise

56. Tibialis Posterior Tendon
Dysfunction
Nonoperative
 immobilization in walking cast/boot for 3-4
months
◦ Indications: first line of treatment in stage I disease
 custom-molded in-shoe orthosis
◦ Indications: stage I patients after a period of
immobilization, and stage II patients
◦ Technique: UCBL with medial posting
 ankle foot orthosis
◦ Indications: stage II, III, and IV patients who are not
operative candidates, and low demand (age > 60-
70)
◦ technique
 AFO found to be most effective
 want medial orthotic post to support valgus
collapse

57. Tibialis Posterior Tendon
Dysfunction
Operative
 Tenosynovectomy
Indications: in stage I disease if immobilization fails
 FDL transfer, calcaneal osteotomy, TAL, +/- forefoot correction
osteotomy [plantarflexion (dorsal opening-wedge) medial
cuneiform (Cotton) osteotomy], +/- lateral column lengthening, +/-
PTT debridement
◦ Indications: stage II disease
◦ Contraindications: hypermobility, neuromuscular conditions, severe subtalar
arthritis: obesity (relative), age >60-70 (relative)
 Triple arthrodesis and TAL
◦ Indications: stage III disease, and stage II disease with severe subtalar pain
 Triple arthrodesis and TAL + deltoid ligament reconstruction
◦ Indications: stage IV disease with passively correctable ankle valgus
 Tibiotalocalcaneal arthrodesis
◦ Indications: stage IV disease with a rigid hindfoot, valgus angulation of the
talus, and tibiotalar and subtalar arthritis

58. Tibialis Posterior Tendon
Dysfunction
Treatment
Stage I • Immobilization walking cast for 3-4 months, followed by
UCBL orthosis
• Tenosynovectomy if immobilization fails
Stage IIA • FDL transfer, calcaneal osteotomy, TAL, +/- lateral column
lengthening, +/- PTT debridement
Stage IIB • The same as IIA +/- forefoot correction osteotomy
Stage III • Triple arthrodesis and TAL
Stage IV • triple arthrodesis and TAL + deltoid ligament reconstruction
in correctable ankle valgus
• Tibiotalocalcaneal arthrodesis in non correctable ankle
valgus

59. An obese 65-year-old woman has a chronic painful
flatfoot with a rigid valgus hindfoot deformity.
Radiographs reveal subtalar joint degenerative changes
but no signs of ankle joint degenerative changes or
abnormal talar tilt. She is unable to single-leg heel raise
and has a "too many toes" sign.
What stage of posterior tibial tendon dysfunction is she
best classified as?
1. IIB
2. IV
3. III
4. IIA
5. I
Quiz

60. A 53-year-old female has a 20 month history of left
hindfoot pain that has failed to respond to AFO bracing
and physical therapy.
She has a unilateral planovalgus deformity, shown in
Figure which is flexible. She is unable to do a single
leg-heel rise.
Which of the following surgical options is most
appropriate?
1. Triple arthrodesis
2. Isolated FDL transfer to the navicular
3. Dorsiflexion osteotomy of the 1st ray with peroneus
longus-to-brevis transfer
4. Lateralizing calcaneal osteotomy with FDL to
navicular transfer
5. Lateral column lengthening, medializing calcaneal
osteotomy, and FDL transfer to the navicular
Quiz

61. A 70-year-old female complains of progressive
pain of the medial ankle and foot over the past
10 years. Orthotics no longer provide relief of
her pain. The hindfoot deformity is unable to
be passively corrected on physical exam.
Figure A is a posterior view of the patient's
foot upon standing and a current radiograph is
provided in Figure B.
Which of the following is the best treatment
option?
1. Posterior tibialis tendon debridement
2. FDL transfer to navicular and calcaneal
slide osteotomy
3. FDL transfer to navicular, calcaneal slide
osteotomy, and lateral column lengthening
through the cuboid
4. Talocalcaneal arthrodesis
5. Triple arthrodesis
Quiz

62. A 54-year-old female has a painful flatfoot that has not improved with
over 8 months of conservative management with orthotics.
Preoperatively, she was unable to perform a single-heel rise and her
hindfoot was passively correctable.
Figures A and B are radiographs of the affected left foot.
She undergoes FDL tendon transfer to the navicular, medial slide
calcaneal osteotomy, and tendoachilles lengthening procedures.
Following these procedures, the appearance of the foot is
demonstrated in Figure
What is the next most appropriate intraoperative procedure to be
performed during her foot reconstruction?
1. Dorsiflexion dorsal closing wedge medial cuneiform
osteotomy
2. In-situ 1st-3rd tarsometatarsal joint arthrodesis
3. Plantar flexion dorsal opening wedge medial cuneiform
osteotomy
4. Lateral column closing wedge shortening osteotomy
5. Subtalar arthrodesis
Quiz

63. A 50-year-old male with long-standing type 1
diabetes presents with redness, swelling and
crepitus in his foot two weeks after a
twisting injury. Elevation of the extremity
reduces the hyperemia.
A radiograph is shown in Figure .
What is the most likely diagnosis?
1. Osteomyelitis
2. Charcot-Marie-Tooth disease
3. Lisfranc fracture-dislocation
4. Charcot arthropathy
5. Freiberg's Disease
Quiz

64. Diabetic Foot

65. Diabetic Foot Charcot
Neuropathy
Brodsky Classification
Type 1 • Involves tarsometatarsal and naviculocuneiform joints
• Collapse leads to fixed rocker-bottom foot with valgus angulation
60%
Type 2 • Involves subtalar, talonavicular or calcaneocuboid joints
• Unstable, requires long periods of immobilization (up to 2 years)
10%
Type 3A • Involves tibiotalar joint
• Late varus or valgus deformity produces ulceration and osteomyelitis of
malleoli
20%
Type 3B • Follows fracture of calcaneal tuberosity
• Late deformity results in distal foot changes or proximal migration of the
tuberosity
<10%
Type 4 • Involves a combination of areas <10%
Type 5 • Occurs solely within forefoot <10%

66. Diabetic Foot Charcot
Neuropathy
Nonoperative Treatment
Indications: first line of treatment
Technique:
 Total contact casting
• casts changed every 2-4 weeks for 2-4 months in acute charcot
 Orthotics
• Patellar bearing brace in types II, III, & IV
• Charcot restraint orthotic walker (CROW) boot can be used after
contact casting especially in type II & III
 Shoe modifications: in type 1
• Wound care shoes (WCS) to relieve ulcerated areas
• Double rocker shoe modifications will best reduce risk for
ulceration at the plantar apex of the deformity
 Medications
• bisphosphonates
• neuropathic pain medications
• antidepressants
• topical anesthetics
Outcomes
• 75% success rate

67. Diabetic Foot Charcot Neuropathy
Operative Treatment
• Resection of bony prominences (exostectomy)
and TAL
• Indications: "braceable" foot with equinus
deformity and focal bony prominences causing
skin breakdown
• Goal is to achieve plantigrade foot that allows
ambulation without skin compromise
• Deformity correction, arthrodesis +/-
osteotomies
• indications
• severe deformity that is not "braceable"
• outcomes
• very high complication rate (up to 70%)
• Amputations
• indications
• failed previous surgery (unstable
arthrodesis)
• recurrent infection

68. A 50-year-old male with long-standing type 1
diabetes presents with redness, swelling and
crepitus in his foot two weeks after a twisting
injury. Elevation of the extremity reduces the
hyperemia.
A radiograph is shown in Figure .
What is the most likely diagnosis?
1. Osteomyelitis
2. Charcot-Marie-Tooth disease
3. Lisfranc fracture-dislocation
4. Charcot arthropathy
5. Freiberg's Disease
Quiz

69. A 56-year-old male with uncontrolled diabetes presents
for follow up of a recurrent midfoot ulceration. He has
been placed into a total contact cast for extended periods
without resolution of the ulcer.
On physical examination the patient is unable to feel a
5.07 gm monofilament on the plantar aspect of his foot.
He has an equinus contracture.
A clinical photo of the patient and lateral radiograph of
the foot are provided in Figures. Radiographs are
unchanged from prior evaluation.
What is the next best option at this point?
1. External fixation
2. Below the knee amputation
3. Continued observation
4. Exostectomy with placement into a protective brace
5. Exostectomy & achilles tendon lengthening with
placement into a protective brace
Quiz

70. A 62-year-old gentleman with a 10-year history of
Type II diabetes complains of warmth, swelling,
and pain in his right foot that has progressively
worsened over the past 6 weeks. He denies
fevers or chills, and states that the swelling and
warmth dissipates each night after he sleeps
with his foot elevated on pillows.
A clinical photograph of the foot is provided .
The midfoot is hot to touch and mildly tender
with palpation. A radiograph is provided in
Figure.
Which of the following is the most appropriate
management?
1. Custom orthotics with first ray recession and
lateral heel posting
2. Total contact cast and non-weight bearing
3. Intravenous antibiotics
4. Talonavicular and tarsometarsal arthrodeses
5. Transtibial amputation
Quiz

71. A 57-year-old woman with type 2 diabetes presents
with right foot pain resulting in gait disturbance for
the past 6 months. Medical comorbidities include
renal insufficiency and hypertension.
A radiograph is provided in Figure.
What initial management is most appropriate?
1. Carbon fiber shank insole
2. Custom orthotic with Jones bar and medial
posting
3. AFO (ankle foot orthosis) with posterior leaf
spring
4. Total contact casting
5. Accomodative plastizote insole with depression
cut into the midfoot and extra-depth shoes
Quiz