Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine, Harrisonburg, Virginia

Case Presentation Conclusion:
Collapsing Pes Planovalgus
in a 58 y/o Patient

We received many great responses regarding the management of this complex patient per last week's issue of RI. You can view these responses by following the e-talk thread on this topic.

TREATMENT PLAN:

The various conservative and surgical options were discussed with the patient, and the various risks and benefits we each discussed.  Citing long standing difficult and frustration with this problem the patient opted to pursue a more definitive course of action and to undergo surgery.

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

To address the patient’s attenuated PT tendon, a debridement with flexor digitorum longus transfer was performed.  The repair was augmented with the use of TenoGlideä (Integra Life Science, Plainsboro NJ) to reduce the risk for the development of tissue adhesions.  An absorbable bioBLOCK™ (Integra Life Science, Plainsboro NJ) was placed to provide temporary offloading of the PT repair with FDL transfer site.  Additional medical displacement calcaneal osteotomy was performed to medially direct the forces through the reafoot.  Please see below images from the case:

Figure 1:  The lateral malleolus, fifth metatarsal base, and lateral margin of the Achilles tendon are marked prior to incision. The MCDO incision was oriented vertically approximately halfway between the lateral margin of the Achilles and the posterior margin of the lateral malleolus.

Figure 2:  In this instance, the calcaneal osteotomy is oriented vertically, and approximately 1cm of medial displacement was obtained.

Figure 3:  Percutaneous fixation was obtained, and a 6.5mm cancellous screw was driving across the MDCO site.

Figure 4:  The medial malleolus is marked, and the insertion of the PT tendon is marked at the navicular tuberosity.

Figure 5: At the level of the insertion, the PT tendon was noted to be thickened with longitudinal lesions noted.

Figure 6: The posterior tibial tendon was reflected dorsally, and the dissection was continued to the level of the FDL.

Figure 7: Tension on the FDL tendon demonstrated flexion of the lessor digits, confirming that the visualized tendon was indeed the FDL.

Figure 8: The incision was extended and the FDL tendon was freed at its distal attachment. All juncturae between the FDL and the FHL were transected.

Figure 9A: The posterior tendon was debrided, and all inflammatory tissue was removed. The FDL tendon was then woven through the posterior tibial tendon to augment the repair.

Figure 9B: The FDL tendon was fully woven through the posterior tibial, and with tenodesis at the navicular tuberosity.

Figure 10A: TenoGlide was then placed to augment the tendon transfer.

Figure 10B:  The Tenoglide was secured utilizing a running suture.

Figure 11: The medial incision was closed utilizing 3-0 nylon. Upon completion of the procedure, the patient will be placed into a Jone’s compression dressing, which will be converted to a short-leg non-weight bearing cast at the first office visit.

Figure 12: A wire was placed to mark the sinus tarsi for the bioBlock™ arthroresis placement.

Figure 13A: The bioBLOCK™ arthroresis from Integra Life Sciences, which is resorbable, and thus provides temporary protection while the posterior tibial reconstruction/FDL transfer site heals.

Figure 13B:  Placement of the bioBLOCK™ in the sinus tarsi allows for limitation in eversion, thus limiting the stress across the tendon reconstruction site.

CONCLUSION:

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, and when attempting surgical reconstruction, each must be addressed.  In the case presented, the patient was placed in a jones’ compression dressing postoperatively and was transitioned to a short leg cast at the first office visit. The patient was then casted for approximately 8 weeks and then transitioned to a removable cam-walker (RCW) and allowed to weight bear in the RCW.  At this point the patient was sent to physical therapy to initiate passive range-of-motion exercises.  At 12 weeks the patient was returned to normal shoe-gear with further physical therapy to strengthen the medial arch suspension.

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