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Deltoid ligament reconstruction allows for joint preservation of the ankle in the setting of patients a triple arthrodesis due to a flat foot deformity. Although the increased forces that may occur in the ankle joint after a triple arthrodesis cannot be eliminated, reconstruction of the ligament will delay and may prevent the onset arthritis, allowing the patient to maintain mobility of the ankle joint. The anatomy, surgery, and risks and benefits are discussed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Rigid adult flatfoot deformity ranges in severity and is caused by a variety of conditions. Treatment is based on the etiology, the severity of symptoms, the stage of the deformity, and patient goals. Posterior tibial tendon pathology, osteoarthritis, posttraumatic arthritis/deformity, inflammatory arthropathy, and neuropathic arthropathy are all known causes of adult flatfoot deformity. Regardless of the cause, treatment goals are the same-restore a plantigrade foot, decrease symptoms, and increase function. When nonsurgical modalities have failed, many surgical reconstructive options are available to restore anatomy and function.

Background: The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture., Methods: Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery., Results: The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case., Conclusions: Early isolated talonavicular arthrodesis provides excellent pain relief and prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.

Background: Triple arthrodesis through a two-incision approach is the traditional surgical treatment of fixed flatfoot in adults. However, since it limits motion and forces the remaining joints to absorb more load, long-term studies report diminishing results over time from symptomatic breakdown of adjacent joints. In addition, wound-healing problems have been reported in up one-third of patients undergoing a major flatfoot reconstruction which are more commonly associated with the anterolateral approaches. Therefore, since 2003, we have been interested in selective arthrodesis of the subtalar and talonavicular joints sparing the uninvolved calcaneocuboid joint and the lateral skin., Materials and Method: We have performed this procedure in 11 patients (14 feet) who had deficient lateral skin and a fixed hindfoot valgus deformity where adequate correction may have led to lateral wound complication. They were followed in a prospective fashion and assessed at a minimum of 6 months followup., Results: Wound healing occurred without any complications in all cases. Evaluation was performed at an average of 21.5 (range, 6 to 50) months. Significant radiographic improvements were observed on each measurement: anteroposterior talonavicular coverage angle improved from 38.5 degrees to 7 degrees, lateral talo-first metatarsal angle improved from 21 degrees to 0 degrees, hindfoot frontal alignment angle improved from 18 degrees to 7.5 degrees. All patients had an asymptomatic calcaneocuboid joint., Conclusion: Arthrodesis of the subtalar and talonavicular joints through a medial approach combined with peroneal lengthening is a reliable procedure for the treatment of rigid flatfoot with deficient lateral skin without calcaneocuboid joint degeneration.

Stage IV PTTD is the most challenging of the posterior tibial tendon deficiencies. The combination of a flattened longitudinal arch and a tilted ankle make successful management unpredictable. Conservative management universally fails and surgical options have been limited to pantalar and tibiotalocalcaneal arthrodesis. Alternatives to surgical management included herein are unproven, but provide a potential solution beyond that of arthrodesis.

Arthrodesis of the subtalar joint is well recognized treatment option for moderate or severe flatfoot associated with adult acquired flatfoot secondary to posterior tibial tendon dysfunction. The success of the subtalar arthrodesis is dependent on restoration of normal bony relationships in the hindfoot and midfoot. For this reason, a distinction is made between a repositional arthrodesis and the traditional in situ type of arthrodesis. An in vitro study of the adult acquired flatfoot identifies an anteroposterior subluxation of the subtalar articulation that can be corrected durably and reliably through a repositional talocalcaneal arthrodesis. Intraoperative reduction techniques are useful in obtaining reduction of the peritalar subluxation. There are certain clinical features that help identify patients with flatfoot deformities who are good candidates for subtalar fusion. As the pathoanatomy of the flatfoot deformity is better elucidated, treatment techniques are modified to better address the key elements of the deformity. A repositional subtalar arthrodesis was shown to produce excellent correction in a moderate to severe in vitro flatfoot example in the authors' clinical series.

Twenty-one patients (21 feet in 18 women and three men) who were treated with subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus at an average age of 60 years (range, 44-75 years) were studied. Mean duration of symptoms was 3 years. All had realignment of the calcaneus in relation to the talus, and all had screw fixation without supplemental bone graft. Average followup was 3 years (range, 2-5 years). All patients had successful union. The tibiocalcaneal angle averaged 13 degrees +/- 3.1 degrees before operation and 6 degrees +/- 1.9 degrees after operation. The lateral talometatarsal, lateral talocalcaneal, and lateral tibiotalar angles all improved significantly. Arch height (navicular height) increase averaged 5 +/- 2.7 mm. Arch length (calcaneal-metatarsal) decrease averaged 4 +/- 3.2 mm. One complication occurred: delayed wound healing (excellent result). Clinical results were excellent in eight feet, good in eight, fair in four, and poor in one. Patients were satisfied with the operative result in 16 feet, satisfied with reservations in four, and dissatisfied with the operative results in one. Subtalar arthrodesis effectively corrects deformity, does not require bone graft, has a high union rate, and is associated with a low complication rate. However, 11 of the 21 patients continued to have some pain, and in patients with preexisting arthrosis of adjacent joints, symptoms may persist.