MEDIAL & LATERAL COLUMN PROCEDURES FOR ADULT ACQUIRED FLATFOOT
IS THERE AN IDEAL COMBINATION?
Sumer Patel DPM
Kaiser Santa Clara Medical Center
Chair, Foot & Surgery TPMG
Disclosures
Grants & Research
NONE
Other Financial Support
NONE
Sumer Patel DPM
Kaiser Santa Clara Medical Center
WESTERN FOOT AND ANKLE CONFERENCE
MEDIAL & LATERAL COLUMN PROCEDURES FOR ADULT ACQUIRED FLATFOOT
IS THERE AN IDEAL COMBINATION?
OBJECTIVES
• Review classification for AAFF
• Clinical and Radiographic Exam
• Lateral column procedures
• Lateral Column lengthening vs CCDA
• Medial column procedures
• Isolated fusions vs cotton procedures
• Medial displacement Calcaneal Osteotomy
Sumer Patel DPM
Kaiser Santa Clara Medical Center
NEED TO UNDERSTAND THE PATHOLOGY
CLASSIFICATION SYSTEMS FOR PTTD
Weinraub & Heilala 2000
acute medial inflammation, tendonitis
A- no planar deformity
B reducbile planar deformity
C - Rigid /arthritic deforimty
Haddad et al, 2011
1A: rutpure from a systemic inflmamatory disease
1B: partial PTT tear with normal hindfoot anatomy
1C: parital PTT tear with hindfoot deformity
STAGE II reducible hindfoot valgus
tendinosis with medial attenuation and insufficencity
A- no planar deformity
B reducbile planar deformity
C - Rigid /arthritic deforimty
IIA: hindfoot valgus
IIB: flexible forefoot supination
IIC: fixed forefoot supination
IID: forefoot abduction
IIE: Medial Ray instability
STAGE III Rigid hindfoot Valgus
advanced attenuation or rupture of PTT
A- no planar deformity
B reducbile planar deformity
C - Rigid /arthritic deforimty
IIIA:Rigid Hindfoot Valgus
IIIB: + rigid FF abduction and/or sagital plane instability
STAGE I
Johnson & Strom 89
PT tenosynoviits
no clinical foot deformity
STAGE IV Myerson added Ankle Valgus 97
Johnson K, Strom D. Tibialis Posterior Tendon Dysfunction. Clinical Orthopaedics and Related Research, Feb 1989. No. 239 p 196-206.
Weinbraub G, Saraiya M. Adult Flatfoot/Posterior Tibial Tendon Dysfunction: classification and treatment. Clinics in Podiatric Medicine and
Surgery 2002. Vol 19 p 345-370.
IVA: flexible
IVB: rigid
Lateral Column:
Lateral Column Lengthening
Calcaneal Cuboid Distraction Arthrodesis
Medial Column:
Medial Cuneiform Opening Wedge
TMTJ Arthrodesis
Navicular Cuneiform Arthrodesis
Place for Medial Displacement Calcaneal Osteotomy
Posterior tibial tendon
Equinus
Forefoot Varus
Medial Column evaluation
Too many toes sign
Amount of Rear foot Valgus
Forefoot Abduction
•
Talo-1st metatarsal angle
•
Talonavicular Coverage
Lateral
Calcaneal inclination
angle
Talo-metatarsal angle
20
13º
Medial Column
•
Fault
•
Medial ray insufficiency
Arthritis
Lateral Column:
Lateral Column Lengthening (Evans)
Calcaneal Cuboid Distraction Arthrodesis
Medial Column:
Medial Cuneiform Opening Wedge
TMTJ Arthrodesis
Navicular Cuneiform Arthrodesis
Place for Medial Displacement Calcaneal Osteotomy
lateral column lengthening (Evans) VS
Calcaneal Cuboid distraction arthrodesis
(CCDA)
Hansen et al.
1 cm of lengthening can improve
TN coverage by 26
Hansen S, Chi T, Toolan B, Sangeorazan B, The Lateral Column Lengthening and Medial Column Stabilzation Procedures. Clinical Orthopaedics
and Related Research 1999, Number 365 PP81.90.
lateral column lengthening (LLC) VS Calcaneal Cuboid distraction arthrodesis
(CCDA)
Calcaneal inclination angle
LCL
CCDA
Lateral Column Lengthening (Evans)
LONG TERM FOLLOW UP
Very good
13%
First described by Evans in 1975
Phillips Follow up study
23 pts.
17 good or very good (77%)
6 fair or poor (23%)
Good
Fair
Poor
9%
13%
65%
Phillips G. A Review of Elongation of Os Calcis for Flatfeet. JBJS , Jan 1983. Vol 65-B No. 1. p 15-18.
Lateral Column Lengthening (Evans)
Cooper et al ‘97
•
Rise in peak pressures to the
Calcaneal Cuboid joint with
loading
Cooper P, Nowak M, Shaer J, Calcaneocuboid Joint Pressures with Lateral Column Lengthening (Evans) Procedure, Foot & Ankle International,
April 2007, vol 18 No. 8, p 199-205.
Lateral Column Lengthening (Evans)
Let’s Compare Flatfoot pressures to
corrected pressures
Momberger et al showed no increase
pressure in a flatfoot
Momberger N, Morgan J, Bachus K, West J, Calcaneaocuboid Joint Pressure after Lateral Column Lengthening in a Cadaveric Plano valgus
Deformity Model, Foot & Ankle International, Sept 2000, vol 21 No. 9 730-765.
Lateral Column Lengthening (Evans)
Is there an Ideal size?
8mm
Healing Rates: Autograft vs Allograft
Autograft:
Faster healing?
Donor site morbidity
Allograft:
Slower healing?
no donor site morbidity
Evans Healing Rates: Autograft vs Allograft: NO SIGNIFICANT DIFFERENCE
Dolan et all. Randomized Prospective Study Comparing Tri-cortical Iliac Crest Auto graft to Allograft in the Lateral Column Lengthening
Component for Operative correction of Adult Acquired Flatfoot Deformity. Foot & Ankle International, January 2007/vol 28, No.1 p 8-12.
Lateral Column Lengthening (Evans)
NO SIGNIFICANT DIFFERENCE
Healing Rates: LCL Autograft vs Allograft
Vosseller et al 2013
126 feet: 20 failures, 13 allograft and 7 auto graft
Vosseller J et al. Auto graft and Allograft Unite Similarly in Lateral Column Lengthening for Adult Acquired Flatfoot Foot. Hospital for Special
Surgery (2013) 9: p6-11.
Calcaneal Cuboid Distraction
Arthrodesis
retained motion?
>70% STJ and 60% TN
eversion more then inversion
Astion D. et al, Motion of the Hindfoot after Simulated Arthrodesis. JBJS, Feb 1997 vol 79-A, No. 2. P 241-246.
LCL vs CCDA
CCDA BETTER AT IMPROVING CALCANEAL INCLINATION*
Thomas R, Wells B, Garrison R, Prada S, Preliminary Results Comparing Two Methods of Lateral Column Lengthening, Foot & Ankle
International Feb 2001, 107-119.
LCL vs CCDA
Thomas R, Wells B, Garrison R, Prada S, Preliminary Results Comparing Two Methods of Lateral Column Lengthening, Foot & Ankle
International Feb 2001, 107-119.
Both offer marked improvement in radiographic parameters
Calcaneal inclination angle, TN coverage and longitudinal arch
height
Lateral column lengthening
Possible increase in Calcaneal Cuboid stress but less with <8m graft sizes
loss of correction
Calcaneal Cuboid Distraction Arthrodesis
Higher rate of non union
loss of motion
Lateral Column:
Lateral Column Lengthening
Calcaneal Cuboid Distraction Arthrodesis
Medial Column:
Medial Cuneiform Opening Wedge (Cotton)
TMTJ Arthrodesis
Navicular Cuneiform Arthrodesis
Place for Medial Displacement Calcaneal Osteotomy
MEDIAL CUNEIFORM OPENING WEDGE OSTETOMY
TARSOMETATARSAL ARTHRODESIS
Instability of first ray
Union rates
NAVICULAR CUNEIFORM ARTHRODESIS
CAN CORRECT TRANSVERSE PLANE
Greisberg J, Assal M, Hansen S, Sangeorzan B. Isolated Medial Column Stabilization Improves Alignment in Adult-acquired Flatfoot. Clinical
Orthopaedics and Related Research, No. 345 2005. P 197-202.
10 DEGREES OF CORRECTION IN TN COVERAGE
Jordan T, Rush S, Ford L, Hamilton G, Radiographic Outcomes of Adult Acquired Flatfoot Corrected by Medial Column Arthrodesis with or
without a Medializing Calcaneal Osteotomy, The Journal of Foot & Ankle Surgery 2011, 50 176-181.
20
10
Correction of Equinus
Lateral column lengthening
Medial column procedure
Medial displacement calcaneal
osteotomy
Medial soft tissue repair
•
Transfer
•
Augmentation
Gastroc Equinus
Large transverse plane deformity
Reducible Forefoot Varus
Gastroc Recession
Lateral Column Lengthening
Gastroc Equinus
Large transverse plane deformity
Non reducible Forefoot Varus
No instability to medial column
18
28
Gastroc Equinus
Large transverse plane deformity
Non reducible Forefoot Varus but no instability to
medial column
Gastroc recession
Lateral Column lengthening
Cotton
12
38
23
14
Equinus
Forefoot Abduction
Navicular cuneiform instability
16
20
24
8
Equinus
Forefoot Abduction
Navicular cuneiform instability
26
16
Equinus
Forefoot Abduction
Fixed FF varus
8
18
0
18
Equinus
Forefoot Abduction
1st TMTJ hypermobility
17
24
27
1
MEDIAL & LATERAL COLUMN PROCEDURES FOR ADULT ACQUIRED FLATFOOT
References
• Myerson et al, Hypermobility of the First Ray. Foot and Ankle Clinics. Volume 5 (3) September 2000.
• Hansen S, Chi T, Toolan B, Sangeorazan B, The Lateral Column Lengthening and Medial Column Stabilzation
Procedures. Clinical Orthopaedics and Related Research 1999, Number 365 PP81.90.
• Jordan T, Rush S, Ford L, Hamilton G, Radiographic Outcomes of Adult Acquired Flatfoot Corrected by Medial
Column Arthrodesis with or without a Medializing Calcaneal Osteotomy, The Journal of Foot & Ankle Surgery
2011, 50 176-181.
• Thomas R, Wells B, Garrison R, Prada S, Preliminary Results Comparing Two Methods of Lateral Column
Lengthening, Foot & Ankle International Feb 2001, 107-119.
• Momberger N, Morgan J, Bachus K, West J, Calcaneal cuboid Joint Pressure after Lateral Column Lengthening in
a Cadaveric Plano valgus Deformity Model, Foot & Ankle International, Sept 2000, vol 21 No. 9 730-765.
• Cooper P, Nowak M, Shaer J, Calcaneocuboid Joint Pressures with Lateral Column Lengthening (Evans)
Procedure, Foot & Ankle International, April 2007, vol 18 No. 8, p 199-205.
MEDIAL & LATERAL COLUMN PROCEDURES FOR ADULT ACQUIRED FLATFOOT
References
• McCormick J, Johnson J. Medial Column Procedures in the Correction of Adult Acquired Flatfoot Deformity.
Foot Ankle Clinics. 2012 p 283-298.
• Haddad S, Myerson M, Younger A, Anderson R, Davis H. Adult Acquired Flatfoot Deformity. Foot & Ankle
International. January 2011 Vol 32. No. 1, p 95-111.
• Gould N. Graphing the Adult Foot and Ankle. Foot & Ankle. Vol 2, No. 4 1982. P 213-219.
• Bluman E, Title C, Myerson M. Posterior Tibial Tendon Rupture: A Refined Classification System. Foot and
Ankle Clinics. 2007 (12). P 233-249.
• Haeseker G, Mureau M, Faber F. Lateral Column Lengthening for Acquired Adult Flatfoot Deformity Caused by
Posterior Tibial Tendon Dysfunction Stage II: A Retrospective Comparison of Calcaneus Osteotomy with
Calcaneocuboid Distraction Arthrodesis. The Journal of Foot & Ankle Surgery 2010, vol 49 p 380-384.
• Johnson K, Strom D. Tibialis Posterior Tendon Dysfunction. Clinical Orthopaedics and Related Research, Feb
1989. No. 239 p 196-206.
• Myerson M, Badekas A, Schon L. Treatment of Stage II Posterior Tibial Tendon Deficiency with Flexor
Digitorum Longus Tendon Transfer and Calcaneal Osteotomy. Foot & Ankle International, July 2004. Vol 25 p
445-450.
• Sangeorzan B, Mosca V, Hansen S. Effect of Calcaneal Lengthening on Relationships among the Hind foot,
Midfoot and Forefoot. Foot & Ankle , April 1993. Vol 14, No. 3. P 136-142.
MEDIAL & LATERAL COLUMN PROCEDURES FOR ADULT ACQUIRED FLATFOOT
References
• Wood et al, Clinical Tip: The Reverse Coleman Block Test Radiograph, Foot & Ankle International July 2009,
vol 30 NO. 7, p 708-710.
• Weinbraub G, Saraiya M. Adult Flatfoot/Posterior Tibial Tendon Dysfunction: classification and treatment.
Clinics in Podiatric Medicine and Surgery 2002. Vol 19 p 345-370.
• Phillips G. A Review of Elongation of Os Calcis for Flatfeet. JBJS , Jan 1983. Vol 65-B No. 1. p 15-18.
• Ajis A, Geary N. Surgical Technique, Fusion Rates and Plano valgus Foot Deformity Correction with
Naviculocuneiform fusion. Foot & Ankle International 2014. Vol 35(3) p 232-237.
• Greisberg J, Assal M, Hansen S, Sangeorzan B. Isolated Medial Column Stabilization Improves Alignment in
Adult-acquired Flatfoot. Clinical Orthopaedics and Related Research, No. 345 2005. P 197-202.
• Myerson M, Lutz M. Radiographic Analysis of an Opening Wedge Osteotomy of the Medial Cuneiform. Foot
& Ankle International 2011. Vol 32, No. 3. P 278-287.
• Vosseller J et al. Auto graft and Allograft Unite Similarly in Lateral Column Lengthening for Adult Acquired
Flatfoot Foot. Hospital for Special Surgery (2013) 9: p6-11.
• Dolan et all. Randomized Prospective Study Comparing Tri-cortical Iliac Crest Auto graft to Allograft in the
Lateral Column Lengthening Component for Operative correction of Adult Acquired Flatfoot Deformity.
Foot & Ankle International, January 2007/vol 28, No.1 p 8-12.
MEDIAL & LATERAL COLUMN PROCEDURES FOR ADULT ACQUIRED FLATFOOT
References
• Astion D. et al, Motion of the Hind foot after Simulated Arthrodesis. JBJS, Feb 1997 vol 79-A, No. 2. P
241-246.