67/68: Flatfoot Pronation - Dayton

Question 1

what is pathologic pronation?

Answer 1

• Joints, tendons, and ligaments are forced to function beyond their physiologic limits
• Net Result: Subluxation, dislocation, degeneration, symptoms
• may be primary (marfan’s etc, )
• or secondary to compensation for static deformity or kinematic abnormality

Question 2

over pronation leads to:

Answer 2

• medial stretching
• lateral jamming
• excess energy expenditure
• joint degeneration
• secondary deformities
• increased demands on leg m., knee, hip and back

Question 3

indications for flat foot correction

Answer 3

• Restore proper biomechanics to the foot and the lower extremity
• Improve stability and function
• Halt progression
• Treat painful symptoms
• To alleviate or prevent structural and non-structural associated conditions

Question 4

options for flat foot correction

Answer 4

• Posterior Muscle/Tendon Lengthening
  
  • Reduces the pronatory force on the foot
  • The foot pronates (dorsilexes at the midfoot) to compensate for the lack of ankle dorsiflexion
• Calcaneal Osteotomy
  
  • Realigns the subtalar and midtarsal axis
  • Increases the supination force medial to the STJ axis
  • Permanently reduces pronation and subluxation
• Medial arch reconstruction required if secondary degeneration or tendon rupture has occurred
• Correction of secondary deformities

Question 5

primary vs. secondary correction

Answer 5

• Primary correction
• Changes the axis alignment of the STJ / MTJ complex which results in improved stability and reduces secondary changes
• Removes compensatory forces
• Secondary correction
• Repairs structures damaged by the pathologic pronation

Question 6

“flat foot” shows up in your office. what are the first important considerations?

Answer 6

rigid or flexible?

equinus?

Question 7

patella internally rotated. what is foot type?

Answer 7

pronated

Question 8

anatomy review

Answer 8

• Gastrocnemius and Plantaris are 3 joint muscles
  
  • Cross the knee, ankle and subtalar joints
• Soleus is a 2 joint muscle
  
  • Crosses only the ankle and subtalar joints
• Gastrocnemius aponeurosis lies on the anterior surface of the muscle
• Soleus aponeurosis lies on the posterior surface of the muscle
• Sural nerve and small saphenous vein are vulnerable

Question 9

most accurate way to test for equinus

Answer 9

• Holding the foot Slightly SUPINATED is the most accurate way to measure
  
  • pronation will give false
• Knee Extended & Flexed
  
  • Testing gastroc and soleus

Question 10

options for gastroc lengthening

Answer 10

Question 11

indications for evans anterior calcaneal osteotomy (opening wedge)

Answer 11

• flexible pes valgus
  
  • progressive
  • painful
• No DJD
• Younger pts

Question 12

static anatomic changes accomplished by evans calcaneal osteotomy

Answer 12

• Lengthens the lateral column
• Relocates TN joint
• Preloads the plantar fascia
• Improves Peroneus longus function
• rotational equilibrium results

Question 13

technique evans calcaneal osteotomy

Answer 13

• Longitudinal incision from the cuboid to the lateral malleolus just dorsal and parallel to the peroneal tendons.
• Full thickness sub-periosteal flap raised with the peroneal tendons.
• Osteotomy vertical 1.5-2 cm (floor of sinus tarsi) from cc, parallel to joint
• Graft placed and fixated with locking plate

Question 14

dorsal oepning wedge cuneiform osteotomy

Answer 14

cotton

used to reduce elvated first ray

adj procedure to calcaneal osteotomy

Question 15

why do a triple arthrodesis?

Answer 15

• Salvage for chronic pain with DJD
• ALWAYS correct the deformity
• Mobilize and prepare all three joints before fixation
• Congruous anatomic joint surfaces are preferable to planar or wedge fusion of surfaces
• Reduction Sequence
  
  • Calcaneous – TN - CC