Management of these deformities can be quite challenging. Accordingly, the author provides an illuminating case study.
The patient is a 58-year-old male who presents complaining of significant pain along the medial ankle and medial arch of his left foot. The patient states that he has noticed his arch collapsing “over the last couple of years” but that it has only become painful over the last four to six months.
The patient says he feels better with shoes that have high arches in them and relates that another podiatrist previously saw him and fitted him for orthotics. The patient believes the orthotics help somewhat although he still relates pain and loss of function. The patient denies any recent hospitalizations or changes to his medical history. He also denies nausea, vomiting, chest pain, shortness of breath, calf pain or any other symptoms.
His past medical history reveals hypertension and hypercholesterolemia. His past surgical history consists of a cholecystectomy and previous open reduction internal fixation for his left wrist. He denies using tobacco, relates occasional alcohol use and drinks caffeine daily. He has no known drug allergies. He is currently taking atorvastatin calcium (Lipitor, Pfizer), hydrocholorothiazide and lisinopril.
What The Physical Exam Reveals
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).
Additionally, I performed a medial displacement calcaneal osteotomy (MDCO) to medially direct the forces through the rearfoot (see photos 6-8).
The patient wore a Jones compression dressing postoperatively and transitioned to a short leg cast at the first office visit. The patient then wore a cast for approximately eight weeks and subsequently transitioned to a removable cam-walker (RCW). The patient was able to bear weight in the RCW. At this point, he went to physical therapy to initiate passive range of motion exercises. At 12 weeks, he returned to normal shoe gear with further physical therapy to strengthen the medial arch suspension.
The management of collapsing pes planovalgus deformities is complex and can pose a challenge to the foot and ankle surgeon. This condition is a multiplanar deformity. When attempting surgical reconstruction, one must determine planal dominance and address each component of the deformity.
Dr. Fitzgerald is in private practice at Hess Orthopaedics and Sports Medicine in Harrisonburg, Va. He is an Associate of the American College of Foot and Ankle Surgeons.