Pes planus correction : Calcaneal osteotomy(Wright DARCO calcaneal plate), spring ligament reconstruction and Flexor digitorum longus transfer
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There are a number of common causes of the acquired adult flat foot and a number of different surgical reconstruction options, tailored to these different pathological causes.
One of the commonest causes is the degenerate and functionally lengthened tibialis posterior tendon, usually associated with stretching and insufficiency of the spring ligament.
The mainstay for surgical reconstruction of the flexible and non-arthritic foot with stage 2 tibialis posterior insufficiency remains a medialising calcaneal osteotomy, combined with a tendon transfer (either a FDL or FHL) and plication of the spring ligament. Additional adjunct procedures may be used, including lateral column lengthening, medial column fusion and subtalar arthroereisis.
For the patient population with this deformity I use the flexor digitorum longus transfer with calcaneal osteotomy and spring ligament reconstruction in those adult patients who do not have evidence of ligamentous hyper-laxity, do not have profound collapse through the medial column and who are not over challenged by their BMI.
My surgical objective is to preserve as much useful tibialis posterior tendon as possible, whilst shortening it back to a functional length. Innervated but atrophied muscle with an associated debrided tendon of the correct length can be expected to return to useful pre-pathological function. The transferred Flexor Digitorum Longus tendon is routed through the stump of the tibialis posterior insertion where possible which obviates the need for using commercial anchors or interference screws into the navicular, a step which I personally find not infrequently difficult to get an appropriate tension with for the tendon transfer.
A robust and corrective Spring ligament reconstruction is also an important aspect of this technique, and my own practice is to use a simple but effective “pants over vest” shortening of the ligament, secured with locked mattress sutures.
The advent of step plates for fixation of calcaneal osteotomy has been a significant move forward from the practice of using parallel screw fixation. Plates resist tendency of the soft tissue envelope to work against the displaced calcaneal osteotomy, allow clear objective evidence to the surgeon on-table of the amount of displacement that has been achieved (with knowledge that this will be securely maintained until bony union) and do not routinely require the routine use of image intensification if careful technique is followed. There are a number of such locking step plates which perform similar function, though the plates demonstrated in this technique are the DARCO calcaneal displacement plate by Wright Medical.
OrthOracle readers will also find the following associated instructional surgical techniques of interest:
Pes Planus correction with FDL transfer , Calcaneal osteotomy and Wright Bioarch arthroresis screw
Tibialis Posterior reconstruction for pes planus, using FDL transfer and Arthrex Biotenodesis screw.
Calcaneal osteotomy with OrthoSolutions FRS Locking Plate
Calcaneal osteotomy (open technique using Atkins approach)
Tibialis posterior tendon debridement
Triple fusion: For calcaneal fracture malunion
Author: Mark Herron FRCS
Institution: OrthOracle, London, UK.
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