Pes Planus correction: Lateral column lengthening and medial column fusion ( over-corrected club foot deformity)
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The management of clubfoot has changed immensely over the last decade with largely as a result of the widespread uptake of the Ponsetti technique.
Despite advances in management of the paediatric club foot, the condition still results in significant morbidity beyond adolescence and into the adult population.The spectrum of problems range from the under-corrected (or residual) club foot to the over-corrected club foot.
The overcorrected club foot is variably characterised by a valgus heel, and abducted foot, subfibular impingement, and a disrupted medial column which may be abducted, elevated or both. A dorsal bunion is commonly encountered. The action of the tibialis anterior inserting into the medial cuneiform and 1st metatarsal will often act as an elevating, deforming force.
Classically, in an acquired flat foot, increased foot abduction is associated with increasing levels of talar uncoverage, in these situations, a lateral column lengthening has the effect of rotating the foot around the talar head, addressing the abduction deformity and restoring a more normal talar coverage.
In the over-corrected club foot, the centre of rotation of angulation may not be at the talo-navicular joint. In the case illustrated here the abduction deformity is in fact centred over the naviculo-cuneiform joints, with a normally covered talonavicular joint. In such circumstances, a lateral column lengthening in isolation would lead to adduction and the talonavicular joint and over-coverage.
By releasing the talonavicular joints and preparing the naviculo-cuneiform joint surfaces, the aim is to allow the lateral column lengthening to rotate the foot around the naviculocuneiform joints, thus reducing them whilst not affecting the normal talar coverage.
The lateral column lengthening both immediately alters the alignment of the foot but also possibly increases the passive tension in the plantar soft tissues in particular the plantar fascia and also the peroneus longus tendon, which aids the level of correction.
The main techniques used in correction of the acquired flat foot are the Achilles release, spring ligament reconstruction, medial column stabilisation by corrective fusion, augmentation of the tibialis posterior tendon and procedures to the lateral aspect of the hindfoot, including medialising calcaneum osteotomy, lateral column lengthening (either extraarticular through lengthening of the anterior process of the calcaneous or intraarticular through bone block fusion of the calcaneocuboid joint or sinus tarsi correction with an arthroresis implant.
The case detailed here is a very good case in point as to why one needs to clearly identify the level at which the deformity occurs.
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Author: Nick Cullen & Mark Herron
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.