When A Patient Presents With Collapsing Pes Planovalgus

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Ryan H. Fitzgerald, DPM, AACFAS

Upon the physical exam, the patient demonstrates a significant collapsing pes planovalgus foot type (left > right). (See photo 1.) Pedal pulses are palpable and graded +2/4 bilaterally with capillary fill time < 3 seconds. There is hair growth on the leg to the distal one-third of the tibia bilaterally. The patient demonstrates bowstringing of the tibialis anterior tendon. Muscle strength is graded +5/5 in dorsiflexion/plantarflexion. However, there is muscle weakness with resisted inversion that is more pronounced on the left.

   The patient demonstrates pain with palpation along the course of the posterior tibial tendon on the left side with the point of maximum tenderness located approximately 3 cm from the insertion on the navicular. In resting calcaneal stance position, the patient demonstrates a significant rearfoot valgus, which does not reduce with toe raise. (See photos 2 and 3.)

   Plain film radiographs of bilateral feet demonstrate increased talar declination on the lateral X-ray with collapse of the midfoot and an increase in Meary’s angle (see photo 4.) On the AP view, there is a decrease in talonavicular coverage (see photo 5).

Keys To Surgical Correction And Post-Op Management

I discussed the various conservative and surgical options with the patient, as well as the various risks and benefits. Citing longstanding difficulties with ambulation and frustration with the failure of conservative modalities, the patient opted to pursue a more definitive course of action and undergo surgical correction of this deformity.

   Considering the clinical picture, I determined that the patient had late stage II posterior tibial tendon dysfunction (PTTD). While his rearfoot valgus did not reduce with a single leg, toe raise, it was passively reducible to neutral while the patient was non-weightbearing. Considering the degree of deformity, I booked the patient for posterior tibial tendon repair with flatfoot reconstruction.

   To address the patient’s attenuated posterior tibial tendon, I performed a debridement and repair of the posterior tibial tendon with a flexor digitorum longus tendon transfer to provide increased strength and stability. I augmented the repair with the use of TenoGlide™ (Integra Life Sciences) to reduce the risk for the development of tissue adhesions (see photo 16). I placed a bioabsorbable bioBlock™ (Integra Life Sciences) subtalar arthroereisis to provide temporary offloading and reduction of pressures along the posterior tibial tendon repair and flexor digitorum longus transfer site (see photos 19 and 20).

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marvene blackmoresays: February 5, 2011 at 8:49 pm

Addressing the actual problems for the patient's benefit is always excellent practice. Strongly agree that calcaneal osteotomy be used rather than destruction of healthy bone, tissue, and function methods such as subtalar and metatarsal fusions.

Pre-planning is also essential. For example, why put a fusion rod in the subtalar ever, and especially when a later ankle arthroplasty is probable?

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