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Adult-Acquired Flatfoot Deformity

Etiology, Diagnosis, and Management

Mostafa M. Abousayed, MD Abstract

» Adult-acquired flatfoot deformity is a complex process attributed
Maxwell C. Alley, BA
mainly to posterior tibial tendon insufficiency.
Rachel Shakked, MD
» Thorough physical examination and radiographs of the foot and
Andrew J. Rosenbaum, MD ankle are usually adequate to achieve diagnosis.

» Nonoperative management is the first line of treatment and has a

Investigation performed at the Division reported success rate ranging from 67% to 90%.
of Orthopaedic Surgery, Albany
Medical College, Albany, New York » A multitude of surgical options are available, particularly for stage II,
with no consensus on the best options.

» Fusions are associated with poor outcomes; hence, there is a trend

toward earlier reconstruction before arthritis ensues.

A
dult-acquired flatfoot defor-
mity is a complex deformity
associated with the collapse
of the medial longitudinal
arch1. Several factors have been proposed
in the etiology of adult-acquired flatfoot
deformity including arthritic, neuromus-
cular, and traumatic conditions; however,
posterior tibial tendon dysfunction remains
the most common etiology1-6. A spectrum
of conditions affecting the posterior tibial
tendon has been identified, with tendinitis
occurring early in the disease process and
tendon rupture occurring at the more
advanced stages.
Although adult-acquired flatfoot de-
formity is traditionally attributed to dys-
function of the posterior tibial tendon,
other additional structures are now impli-
cated as well, including the spring, deltoid,
and interosseous talocalcaneal ligaments7.
Although several articles have sug-
gested that Kulowski8 reported on posterior
tibial tendinitis as early as 19361,3,5, the
classic picture of posterior tibial tendon
dysfunction was described later5,6,9. This
entailed hindfoot valgus and abduction
at the midfoot with forefoot supination.
From their work, the pathognomonic “too
many toes” sign and the heel-rise test were
described.
In 1989, Johnson and Strom de-
scribed their classification of posterior tibial
tendon dysfunction. This was the first
classification to describe the anatomical and
clinical features that characterize adult-
acquired flatfoot deformity and it also
proposed treatment strategies10. Advances
in research and technology led to a more
detailed understanding of the deformity.
This article will discuss the patho-
physiology, classification, diagnostic mo-
dalities, and treatment inventions for this
complex disorder.
Anatomy and Pathophysiology
The posterior tibial muscle, innervated by
the tibial nerve, originates in the deep
compartment of the leg from the proximal
third of the tibia and adjacent interosseous
membrane. Its tendon passes posterior to
the ankle’s axis of rotation, immediately
behind the medial malleolus in a groove
supported by the flexor retinaculum, and
medial to the subtalar axis, making it a
plantar flexor and inverter of the hindfoot.
It also produces supination of the forefoot
and supports the medial longitudinal

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JBJS REVIEWS 2017;5(8):e7 · http://dx.doi.org/10.2106/JBJS.RVW.16.00116 1

 | Adult-Acquired Flatfoot Deformity
arch11. At the level of the navicular tu-
berosity, the tendon divides into 3 parts:
(1) the anterior part, which is the largest
and inserts on the navicular tuberosity,
inferior capsule of the medial naviculo-
cuneiform joint, and inferior aspect of the
medial cuneiform; (2) the middle part,
which attaches to the middle and lateral
cuneiforms and cuboid and bases of the
second through fifth metatarsals; and (3)
the posterior part, which inserts on the
sustentaculum tali of the calcaneus12.
The posterior tibial tendon is crucial
for effective gait, as its contraction facili-
tates hindfoot inversion, in turn locking
the transverse tarsal joints and creating a
rigid platform for push-off13. This action
of the posterior tibial tendon is supple-
mented by other static structures, in-
cluding the foot’s osseous architecture,
spring ligament, deltoid ligament, plantar
fascia, and talonavicular capsule14,15. Of
those, the spring ligament, also known as
the plantar calcaneonavicular ligament,
has recently gained much interest. Testut
and Jacob described 2 distinct fascicles: an
anterior fascicle inserted in the plantar
surface of the navicular and a transverse
fascicle that blends with the deltoid liga-
ment16. Later, Sarrafian17 identified 2
different ligaments, superomedial and
inferior calcaneonavicular ligaments,
hence the term the spring ligament com-
plex used by many investigators18,19.
Insufficiency of the posterior tibial
tendon results in the collapse of the
medial arch and excessive valgus devia-
tion of the hindfoot. The midfoot be-
comes abducted at the transverse tarsal
joint, with uncovering of the talar head.
The vector of pull of the Achilles tendon
TABLE I Etiology of Adult-Acquired Flatfoot Deformity*
Intrinsic Factors
Congenital flatfoot
Posterior tibial tendon hypovascularity
Tight gastrocnemius-soleus complex
MMP polymorphism
*MMP 5 matrix metalloproteinase.
2 AUGUST 2017
subsequently becomes lateral to the axis
of the subtalar joint and accentuates
eversion. Progressive stretching of the
medial soft-tissue structures further ac-
centuates the hindfoot valgus deformity,
and equinus deformity may ensue be-
cause of an Achilles contracture.
Etiology
Multiple intrinsic and extrinsic factors
can lead to adult-acquired flatfoot defor-
mity (Table I). Trauma, inflammatory
arthropathies, corticosteroid injections,
various medical comorbidities, and ge-
netic abnormalities have been described
in its development5,20-28. Holmes and
Mann reported on the association of
obesity, hypertension, diabetes, trauma,
and corticosteroid injections with the
development of posterior tibial tendon
insufficiency, with 60% of their 67 pa-
tients having $1 of these comorbid-
ities22. An area of hypovascularity in the
posterior tibial tendon beginning 1.5 cm
inferior to the medial malleolus and
extending 1 cm distally is also thought to
contribute to the development of adult-
acquired flatfoot deformity, as this region
renders the posterior tibial tendon vul-
nerable to tendinosis and rupture11,23-25.
Myerson et al. found an association be-
tween seronegative arthropathy and pos-
terior tibial tendon insufficiency mainly
in younger patients with symptoms of
enthesopathy26. Matrix metal-
loproteinase (MMP) polymorphisms,
particularly of MMP-1 and MMP-8,
have also been related to posterior tibial
tendon tendinopathy27,28. Despite ef-
forts to identify underlying causative
factors in patients with adult-acquired
Extrinsic Factors
Trauma
Corticosteroid injections
Obesity
Diabetes mellitus
Hypertension
flatfoot deformity, some patients do not
demonstrate any known predisposing
factors.
Diagnosis
History
A comprehensive history and physical
examination are of paramount impor-
tance in the evaluation of adult-acquired
flatfoot deformity. Initial pain is nor-
mally located along the course of the
posterior tibial tendon and is activity and
standing-dependent. However, pain at
rest develops with increasing disease se-
verity. Worsening deformity leads to
impingement in the sinus tarsi and
subfibular regions, causing discomfort
laterally29. Many patients will describe a
history of a flat arch at baseline that has
progressively worsened with time.
Physical Examination
Clinicians must evaluate patients’ feet
with them bearing weight. From be-
hind, hindfoot valgus and forefoot ab-
duction may be present. The “too many
toes” sign is consistent with excessive
abduction20 (Fig. 1). Clinicians must
remember that although arthritic con-
ditions of the midfoot can also present
with arch collapse, hindfoot alignment
in such conditions is maintained.
Palpation along the course of the
posterior tibial tendon should be per-
formed to identify any tenderness,
swelling, or defects. DeOrio et al.
assessed the validity of the posterior
tibial edema sign in correlation with
magnetic resonance imaging (MRI)
findings of posterior tibial tendon ten-
dinitis, tendinosis, or tenosynovitis. The
authors found that the edema sign had
88% sensitivity and 100% specificity in
identifying tendon pathology30.
Muscle strength and motion about
the ankle and hindfoot must also be
assessed. The patient is asked to invert the
foot passively and against resistance to
evaluate for posterior tibial tendon weak-
ness. The foot is ideally placed into a
plantar flexed and inverted position before
evaluation to isolate the posterior tibial
tendon. Ankle range of motion, specifi-
cally dorsiflexion, is assessed to evaluate for
· VOLUME 5, ISSUE 8 · e7

Fig. 1
Photograph showing the posterior view
of a right foot with a hindfoot valgus
deformity with a concomitant abducted
forefoot deformity resulting in the “too
many toes” sign.
gastrocnemius-soleus complex tightness.
Thisis performed viatheclassicSilfverskiöld
test31 after passively correcting the
heel valgus to eliminate motion through
the transverse tarsal joint. Subtalar mo-
bility is then evaluated for the presence of a
fixed deformity, which has treatment im-
plications. The position of the forefoot is
evaluated while ensuring neutral position
of the heel. In advanced stages, a fixed
supination deformity of the forefoot may
be present and may affect the designated
treatment. Single and double-limb heel-
rise tests should be performed to evaluate
the strength of the posterior tibial tendon
(Fig. 2). Tendon dysfunction will manifest
Fig. 2
Photograph showing a positive heel-rise
test that demonstrated hindfoot valgus
on the right side with underlying flatfoot
deformity compared with the varus
alignment of a normal foot depicted on
the left side.
AUGUST 2017 · VOLUME 5, ISSUE 8 · e7
as inability either to invert the hindfoot or
to perform the test. Patients who are able
to perform the test may experience pain
with repetitive attempts, denoting early
tendon pathology. Finally, gait is assessed
to evaluate heel inversion during toe-off.
Radiographic Evaluation
Weight-bearing radiographs of the foot
and ankle remain the gold standard for
the diagnosis of adult-acquired flatfoot
deformity. Anteroposterior, lateral,
and hindfoot radiographs of the foot
should be obtained. The anteroposterior
view may demonstrate forefoot abduc-
tion and talar head uncoverage. Nu-
merous parameters have been described
to assess talar head uncoverage, includ-
ing the talonavicular coverage angle, ta-
lonavicular uncoverage percent, and
lateral incongruency angle32,33 (Fig. 3).
The lateral talar-first metatarsal angle
(Meary angle) is evaluated on lateral ra-
diographs (Fig. 4). This angle denotes
medial arch collapse and helps to localize
where the deformity occurs in respect to
the talonavicular, naviculocuneiform,
or medial cuneiform-first metatarsal
joints34. Ankle radiographs may dem-
onstrate valgus tilt consistent with del-
toid insufficiency or ankle arthritis. The
view of Saltzman and el-Khoury35 can
be used to evaluate hindfoot align-
ment36. With this view, the moment
arm between the tibial weight-bearing
Adult-Acquired Flatfoot Deformity |
axis and the most inferior point of the
calcaneus can be quantified (Fig. 5-A).
Williamson et al. described a new hind-
foot alignment angle that can also be used
to quantify hindfoot alignment (Fig.
5-B). They found that their new mea-
surement was reliable and correlated lin-
early with the hindfoot moment arm and
helped to differentiate normal patients
from those with flatfoot37. Other pa-
rameters commonly measured on routine
radiographs include the talocalcaneal an-
gle, calcaneal pitch, naviculocuneiform
angle, medial cuneiform height, and
peritalar subluxation (Figs. 3 and 4).
Haleem et al. reported on the use
of multiplanar weight-bearing imaging
to accurately localize the deformity in
respect to the talus38. Their novel mo-
dality has the advantage of attaining
weight-bearing computed tomography
(CT)-like images with 3-dimensional
views while patients assume an upright
posture allowing for full weight-bearing.
When compared with conventional CT
scans, they are faster to obtain and allow
less radiation exposure. Although stan-
dard weight-bearing radiographs are
considered the standard of care, they
only provide a 2-dimensional assess-
ment of a 3-dimensional complex de-
formity. Additionally, obtaining full
weight-bearing radiographs can be
cumbersome because of patients’ body
habitus or the equipment used.
3
 | Adult-Acquired Flatfoot Deformity
Although this technique carries the po-
tential to be a more accurate and reliable
tool for the evaluation of posterior tibial
tendon dysfunction, more studies are
required to assess its validity and cost-
effectiveness.
MRI Evaluation
MRI is not routinely needed for the di-
agnosis of adult-acquired flatfoot defor-
mity. However, it can be used to evaluate
the spring ligament and the degree of
damage to the posterior tibial tendon
and to identify sites of intraosseous
edema, which may be associated with
impingement. A preoperative diagnosis
of a spring ligament rupture on MRI
can help to guide surgical management
in patients with severe abduction de-
formity. In those patients, ligament re-
construction may help to achieve
correction of the deformity without the
need for excessive lateral calcaneal
4 AUGUST 2017
lengthening that can lead to adverse ef-
fects. Other values for MRI are assessing
the condition of the deltoid ligament
and peroneal tendons, which may affect
the surgical plan.
Ultrasound Evaluation
Ultrasonography can be considered an-
other helpful tool to evaluate the con-
dition of the posterior tibial tendon
and other soft-tissue structures includ-
ing the spring ligament. One study
compared high-resolution ultrasound
with 3.0-T MRI in the diagnosis of
posterior tibial tendon dysfunction in 23
patients with clinical examination find-
ings of posterior tibial tendon dysfunc-
tion and a mean age of 50 years39. Nine
patients underwent surgical interven-
tions. Ultrasound and MRI results were
found to be equivalent in 87% of the
cases. Of the 9 patients who underwent
a surgical procedure, 6 (67%) had
Fig. 3
Figs. 3-A through 3-D Radiographs
showing the anterior talus-first metatarsal
angle, the talonavicular coverage
angle, the talonavicular uncoverage per-
centage, and the lateral incongruency
angle. Fig. 3-A Anteroposterior view of
the anterior talus-first metatarsal angle,
which is the angle between the longitu-
dinal axes of the talus and first metatarsal
(normal, 0° to 20°). Fig. 3-B The talona-
vicular coverage angle, which is the angle
between 2 lines, 1 between the medial
and lateral articular margins of the talus
and 1 between the medial and lateral
articular margins of the navicular (normal,
,7°). Fig. 3-C The talonavicular unco-
verage percentage, in which small circles
represent the amount of talar head
uncovered by the navicular (normal, 10%
to 30%). Fig. 3-D The lateral incongru-
ency angle, which is the angle between
2 lines, 1 connecting the lateral articular
surface of the talus and navicular and
1 between the lateral articular surface of
the talus and the lateral talar neck at its
narrowest part (normal, 5° 6 26°).
findings similar to preoperative ultra-
sound results compared with 5 (56%)
in the MRI group. Another study by
Harish et al. compared the efficiency
of ultrasound with that of MRI in the
diagnosis of spring ligament rupture in
16 patients (18 feet) with symptomatic
posterior tibial tendon dysfunction40.
Similar results were obtained in 94% (17
of 18 feet), demonstrating the value of
ultrasound as a diagnostic tool in the
preoperative evaluation of patients with
symptomatic posterior tibial tendon
dysfunction.
Tendoscopic Evaluation
Tendoscopy is a minimally invasive
modality that can be utilized to evaluate
tendon pathology, particularly in pa-
tients with suggestive symptoms but
negative MRI findings. Although MRI
is considered the diagnostic tool of
choice for tendon assessment, Gianakos
· VOLUME 5, ISSUE 8 · e7
 Adult-Acquired Flatfoot Deformity |

Fig. 4
Figs. 4-A, 4-B, and 4-C Radiographs showing the lateral talus-first metatarsal angle, the lateral talocalcaneal angle, and the calcaneal pitch. Fig. 4-A
The lateral talus-first metatarsal (Meary) angle, which is the angle between the longitudinal axes of the talus and first metatarsal (normal, 0° 6 4°). Fig. 4-B
The lateral talocalcaneal angle, which is the angle between a line bisecting the talus and a line bisecting the calcaneus (normal, 25° to 45°). Fig. 4-C Calcaneal
pitch, which is the angle between a line drawn along the most inferior part of the calcaneus and the supporting surface or the transverse plane
(normal, 10° to 20°).

et al. showed that tendoscopy is superior,
finding an 87% correlation between
tendoscopy findings and preoperative
MRI findings41. In their 4 patients in
whom tendon pathology was missed on
MRI, tendoscopy was helpful not only
in diagnosis but also in treatment. They
reported short-term improvement in
Foot and Ankle Outcome Score (FAOS)
and Short Form-12 (SF-12) scores fol-
lowing tendoscopy for posterior tibial
tendon dysfunction that was mainly in
the early stages.
Classification
In 1989, Johnson and Strom created a
3-stage classification system for adult-
acquired flatfoot deformity. This was an
anatomical and clinical classification
based on the condition of the posterior
tibial tendon, hindfoot alignment, and
flexibility of the deformity10. In 1997,
Myerson added a fourth stage of disease
for describing deltoid ligament insuffi-
ciency with valgus collapse and degen-
eration of the ankle42 (Table II).
Although several authors have attemp-
ted to develop newer classification
systems, the Johnson and Strom classi-
fication with the Myerson modification
remains the most commonly
used system1,43,44.
Nonoperative
(Conservative) Management
Nonoperative management is consid-
ered the mainstay of treatment for pa-
tients with stage-I posterior tibial tendon
dysfunction. A trial of conservative
management is also warranted before
indicating a patient for a surgical pro-
cedure in the more advanced stages.
Nonoperative interventions include
immobilization, nonsteroidal anti-
inflammatory drugs (NSAIDs), braces,
orthotics, and physical therapy32,45,46.
An initial period of immobilization fol-
lowed by support can yield satisfactory
results in symptomatic patients with
success rates ranging from 67% to
90%45,47,48. This can be achieved
through a short leg cast or a boot for
a period of 6 to 8 weeks. Other types
of braces that can be used include the
lace-up brace, double upright ankle-foot
orthosis, and Arizona brace. Patients
can then be transferred to orthotic

AUGUST 2017 · VOLUME 5, ISSUE 8 · e7 5

 | Adult-Acquired Flatfoot Deformity

Fig. 5
Figs. 5-A and 5-B Radiographs showing
the hindfoot moment arm and the hind-
foot alignment angle. Fig. 5-A The hind-
foot moment arm, which is the shortest
distance between the longitudinal axis of
the tibia and the most inferior part of the
calcaneus (normal averages 3.2 mm in
varus). Fig. 5-B The hindfoot alignment
angle, which is the angle between the
longitudinal axis of the tibia and the axis
of the calcaneal tuberosity. The axis of the
calcaneal tuberosity is defined as the
bisector of 2 transverse lines connecting
the medial and lateral osseous contours
of the calcaneus (normal, 5.6° 6 5.4°).

support with a medial heelpost and
medial arch that can be fitted in stiff-
soled shoes. Failure to achieve substan-
tial improvement can occur in advanced
stages with pronounced deformities.
This may warrant extending the period
of immobilization or the use of a custom
brace45. Physical therapy might be ben-
eficial after the initial inflammatory phase
subsides. This includes gastrocnemius-
soleus complex stretching, posterior tibial
and peroneal strengthening, and propri-
oceptive modalities.
Lin et al. reported on 33 feet in 32
patients with stage-II posterior tibial
tendon dysfunction treated
nonoperatively with a double upright
ankle-foot orthosis. At a mean follow-up
of 8.6 years, 69.7% of patients had relief
of symptoms and were weaned off the
brace46.
Alvarez et al. reported an 89%
success rate in their cohort of 47 patients
with stage-I and II posterior tibial ten-
don dysfunction treated conservatively
with an orthosis and physical therapy45.
Operative Management
Operative intervention is warranted
when conservative modalities fail (Fig.
6). Patient-related factors including
tobacco use, functional ability, and
medical comorbidities must also be
considered when discussing elective
surgical intervention.
Stage I
Surgical options for stage-I adult-
acquired flatfoot deformity include pos-
terior tibial tendon tenosynovectomy,
debridement, and/or flexor digitorum
longus tendon transfer42. These can be
performed in combination with other
procedures, such as a medializing calca-
neal osteotomy or arthroereisis, to sup-
plement the tendon procedure.
Myerson et al. recommended debride-
ment as the sole treatment in younger

TABLE II Myerson Modification of Johnson and Strom Classification of Adult-Acquired Flatfoot

Deformity

Stage Description

I Mild medial pain and swelling with no deformity, can perform heel-rise test but demonstrates
weakness on repetition, tenosynovitis on pathology with normal tendon length
II Moderate pain with or without lateral pain, flexible deformity, unable to perform heel-rise
test, elongated tendon with longitudinal tears
IIA ,30% talar head uncoverage
IIB .30% talar head uncoverage
III Severe pain, fixed deformity, unable to perform heel-rise test, visible tears on pathology
IV Lateral talar tilt
IVA Flexible ankle valgus without severe arthritis
IVB Fixed ankle valgus with or without arthritis

6 AUGUST 2017 · VOLUME 5, ISSUE 8 · e7


Fig. 6
A flowchart representing management of adult-acquired flatfoot deformity. PTT 5 posterior tibial tendon, FDL 5 flexor digitorum longus, MCO 5
medializing calcaneal osteotomy, 1/- 5 with or without, LCL 5 lateral column lengthening, vs 5 versus, TMT 5 tarsometatarsal, and TAR 5 total
ankle replacement.
patients with seronegative inflammatory
arthropathy as the underlying etiology
of the disease26. However, in elderly
patients with more advanced tendinop-
athy, a concurrent calcaneal osteotomy
yielded superior results32.
Biological Adjuncts
Recently, there has been an increased
interest in the use of biological adjuncts
in treatment of tendinopathies of the
foot and ankle. Platelet-rich plasma
and bone marrow aspirate concentrates
are the most commonly used. Several
in vitro studies demonstrated their pos-
itive regulatory effect on tenocytes49,50.
This can be particularly helpful in early
stages of posterior tibial tendon dys-
function before tendon rupture occurs.
Nevertheless, randomized clinical trials
demonstrating their efficiency are
AUGUST 2017 · VOLUME 5, ISSUE 8 · e7
warranted before their use in posterior
tibial tendon dysfunction can be
established.
Stage II
Flexor Digitorum Longus Transfer
The flexor digitorum longus tendon and
posterior tibial tendon have a similar line
of pull, making the flexor digitorum
longus the tendon of choice for rein-
forcement or substitution of the poste-
rior tibial tendon when tendon
insufficiency is diagnosed5,20,51. Silver
et al. investigated the relative balance
and excursions of the muscles of the foot
and ankle and found the flexor dig-
itorum longus to be almost 3 times
weaker in strength when compared
with the posterior tibial tendon52. Al-
though it is postulated that the flexor
digitorum longus tendon may undergo
Adult-Acquired Flatfoot Deformity |
hypertrophy following transfer, it is
still unlikely to counteract the effect of
the peroneus brevis alone53. A medial-
izing calcaneal osteotomy is therefore
performed in combination with flexor
digitorum longus transfer to improve
the alignment and to protect the trans-
fer. Of note, it is postulated that exces-
sive tensioning to correct the deformity
can actually lead to a tenodesis effect
and worse outcomes54.
Chadwick et al. reported on 31
patients treated with combined flexor
digitorum longus transfer and medial-
izing calcaneal osteotomy for stage-II
adult-acquired flatfoot deformity with
a mean follow-up of 15.2 years55. Sub-
stantial improvements were noted in the
American Orthopaedic Foot & Ankle
Society (AOFAS), visual analog scale
(VAS), and SF-36 scores. Complete
7
 | Adult-Acquired Flatfoot Deformity
satisfaction was seen in 87% of subjects,
with 90% reporting that they would
have the same procedure again.
Although the flexor hallucis longus
tendon is substantially stronger than
the flexor digitorum longus, its use to
substitute for the posterior tibial tendon
is not preferred. A more pronounced
donor-site deficit and a higher potential
for neurovascular injury due to its
closer proximity to the neurovascular
bundle make it less favored for
transfer42.
Medializing Calcaneal Osteotomy
The medializing calcaneal osteotomy
corrects heel valgus via medial displace-
ment of the calcaneus. This shifts the
axis of pull of the gastrocnemius-soleus
complex medial to the subtalar joint,
producing an inversion moment56. In
addition to correcting the valgus angu-
lation of the hindfoot, it decreases the
strain on the medial ligamentous struc-
tures, namely the spring ligament and
posterior tibial tendon. Originally de-
scribed by Gleich in 189357, several
authors have reported encouraging re-
sults with this procedure alone58-60, al-
though it is mostly used in combination
with other procedures including flexor
digitorum longus transfer and lateral
column lengthening.
Lateral Column Lengthening
Lateral column lengthening is used to
correct forefoot abduction and to im-
prove talar head uncoverage61-64. It is
used for stage-IIB disease when .30%
talar head uncoverage is present. The
lateral column lengthening can be per-
formed with an osteotomy in the ante-
rior aspect of the calcaneus65 or via
distraction arthrodesis in the calcaneo-
cuboid joint, with the latter associated
with less ankle and subtalar joint range
of motion and less favorable out-
comes66. It has been postulated that to
achieve correction via lateral column
lengthening, an intact spring ligament
must be present to act as a hinge to allow
lengthening.
The lateral column lengthening
can cause excessive foot stiffness,
8 AUGUST 2017
decreased eversion, fifth metatarsal stress
fractures, and lateral-sided foot pain67-71.
In a study comparing the triad of
flexor digitorum longus to posterior
tibial tendon transfer, medializing cal-
caneal osteotomy, and lateral column
lengthening (26 patients) with tendon
transfer and medializing calcaneal oste-
otomy (22 patients), the cohort includ-
ing lateral column lengthening was
associated with increased lateral-sided
foot pain at 45% compared with 17%
for the group without lateral column
lengthening43. Although the amount
of lengthening is believed to affect lateral
foot pressures, there is no consensus on
the correct amount of lengthening re-
quired to achieve correction without al-
tering lateral forefoot pressure. A recent
cadaveric study evaluated the effect of
graft size (6, 8, and 10 mm) on correc-
tion achieved and amount of lateral
plantar pressure generated70. Their re-
sults showed that all graft sizes ade-
quately reduced forefoot abduction
but also persistently increased lateral
plantar pressure. One of the main limi-
tations of the study was that it did not
include medializing calcaneal osteot-
omy, which is not only commonly per-
formed in association with lateral
column lengthening, but is also proven
to increase lateral plantar pressure72.
The effect of graft shape on lateral
column lengthening outcomes has also
been studied. In a cadaveric model,
Baxter et al. found that a graft with a
longer taper may lower the amount of
lateralized forefoot pressure following
correction73.
Chan et al.33 retrospectively
reviewed 41 patients who underwent
flatfoot reconstruction using lateral col-
umn lengthening via an Evans osteot-
omy64. They compared the preoperative
and postoperative talonavicular cover-
age angle, talonavicular uncoverage
percent, talus-first metatarsal angle,
and lateral incongruency angle as indi-
cators of forefoot abduction. They
evaluated 14 demographic and intra-
operative variables including age, height,
weight, body mass index, amount of
lateral column lengthening, medializing
calcaneal osteotomy, lateral column
lengthening graft type, flexor digitorum
longus transfer, spring ligament recon-
struction, Cotton osteotomy, first tar-
sometatarsal fusion, and gastrocnemius
recession for association with forefoot
abduction. They found that the amount
of lateral column lengthening was the
sole factor to significantly affect the lat-
eral incongruency angle, with 6.8° pro-
duced for each millimeter of lateral
column lengthening (p , 0.001). Given
the risk of lateral overload with lateral
column lengthening overcorrection,
Chan et al. believed that this might
serve as a valuable preoperative mea-
surement for adequate forefoot abduc-
tion correction33.
In an effort to avoid the lateral
column symptoms associated with lat-
eral column lengthening, Vander
Griend described a rotational step-cut
osteotomy of the calcaneus74. Correc-
tion is achieved via rotation of the fore-
foot with less lengthening. However,
proximity to the peroneal tendons,
possible injury to the medial neurovas-
cular bundle, and loss of fixation are
potential concerns with this osteotomy.
Demetracopoulos et al. reported on 37
patients who underwent a step-cut
osteotomy for management of stage-IIB
adult-acquired flatfoot deformity, not-
ing that significant improvement in
patient outcomes but complications
including lateral column discomfort
and iatrogenic peroneal tendon injury
occurred (p , 0.001)75.
Subtalar Arthroereisis
Subtalar arthroereisis entails the place-
ment of a screw-like implant into the
sinus tarsi between the middle and pos-
terior facets via a small lateral incision.
It prevents excessive hindfoot eversion
and talar plantar flexion and rotation,
thereby restoring hindfoot alignment
and correcting talonavicular uncover-
age76. Although its use in adult-acquired
flatfoot deformity is controversial,
intermediate-term clinical studies have
shown encouraging results76-78. A
common complication is persistent
pain in the sinus tarsi. Other potential
· VOLUME 5, ISSUE 8 · e7

complications include implant fracture,
implant dislocation, foreign body reac-
tion, and development of talar cysts76-79.
The authors believe that this procedure
may be a good supplement to protect
the repair in some patients, especially
those who are not compliant or who
have additional risk factors including
tobacco exposure or diabetes.
Supplemental Procedures
Forefoot supination may persist follow-
ing treatment with other reconstructive
procedures. Treatment depends on
the condition of the first tarsometatarsal
joint. In the absence of arthritis, hyper-
mobility, or other medial column
pathology, a dorsal opening-wedge
osteotomy of the medial cuneiform
(Cotton osteotomy)80 can be performed
to depress the first ray. A first tarsomet-
atarsal arthrodesis or medial column
fusion is performed if degenerative
changes, hypermobility, or medial col-
umn sag is present81,82.
The spring ligament has received
recent attention both as a cause of adult-
acquired flatfoot deformity and as a
structure that must be addressed when
correcting severe abduction deformity.
Deland recommended spring ligament
reconstruction if forefoot abduction re-
mains following lateral column length-
ening83. It is also indicated if correction
of forefoot abduction requires exces-
sively large grafts in the lateral column
lengthening. Unfortunately, the exact
graft size that leads to poor outcomes or
that necessitates spring ligament recon-
struction remains unknown.
Isolated naviculocuneiform ar-
throdesis has also been described for
management of patients in whom the
naviculocuneiform joint represents the
apex of the deformity84,85. In addition
to deformity correction, this procedure
poses the theoretical advantage of pre-
serving motion at the subtalar and
Chopart joints. Ajis and Geary reported
on 33 feet (28 patients) that underwent
isolated naviculocuneiform fusion, 20
of which had symptomatic flatfoot as
the underlying etiology. They reported
improvement in the lateral talar-first
AUGUST 2017 · VOLUME 5, ISSUE 8 · e7
metatarsal angle and talonavicular cov-
erage angle. The mean time to union was
21.7 weeks and union occurred in 97%,
all of whom reported improvement in
pain and deformity correction86.
Stage III
Both triple and double arthrodesis has
been successfully used to treat rigid de-
formity87-93. The goal is to achieve a
plantigrade foot with neutral to slight
heel valgus (,5°) and a neutral forefoot.
This may warrant a supplementary
medializing calcaneal osteotomy, first
metatarsal osteotomy (Cotton osteot-
omy), or fusion as well as gastrocnemius
recession or Achilles lengthening. Triple
arthrodesis has been classically per-
formed via a 2-incision technique. Jeng
et al. described a single medial approach
for triple arthrodesis in a cadaver model.
The single approach was used in 5 ca-
davers, and the 2-incision approach
was used in a single cadaver, which
served as a control. The authors reported
a 90% success rate in the ability to pre-
pare the 3 joints, with comparable re-
sults with the 2-incision technique94.
The double arthrodesis involves
fusion of the subtalar and talonavicular
joints. This calcaneocuboid joint-
sparing approach is thought to prevent
adjacent joint arthritis and to eliminate
the risk of calcaneocuboid nonunion (up
to 20% has been reported in the litera-
ture) and the development of stiffness in
the foot’s otherwise mobile lateral
column87,90.
Pell et al. reported on 111 patients
treated with subtalar arthrodesis with a
mean follow-up of 5.7 years (minimum,
2 years). The mean patient satisfaction
score was 8.3 of 10, the reported union
rate was 98%, and 91% of patients
reported that they would undergo the
procedure again93.
Following triple arthrodesis, pa-
tients reported an inability to adapt to
uneven ground95. Other complications
include nonunion, stiffness, and in-
creased risk of progressive ankle valgus
deformity with subsequent deltoid in-
sufficiency and ankle arthritis5. The
mean nonunion rates range from 10% to
Adult-Acquired Flatfoot Deformity |
23% in the literature, mostly affecting
the talonavicular joint88,90,92.
Stage IV
Stage-IV adult-acquired flatfoot defor-
mity is characterized by a flatfoot de-
formity in the setting of valgus tilt in the
ankle. Both flexible and rigid ankle de-
formities can occur. In patients with
flexible ankle deformity, deltoid liga-
ment reconstruction is indicated. In a
study using peroneus longus tendon
autograft, the valgus tilt improved from
7.7° to 2.1° at the 9-year follow-up. The
ankle had a mean range of motion of 40°
and the hindfoot alignment showed a
mean valgus of 4°96. Jeng et al. described
a technique of minimally invasive del-
toid ligament reconstruction with triple
arthrodesis in a selected group of pa-
tients with stage-IVA deformity and
,10° valgus tilt on preoperative im-
ages97. At the time of the final follow-up
(mean, 36 months), 5 of 8 patients were
considered as having successful treat-
ment, defined as #3° of valgus talar tilt
and $2 mm of maintained lateral joint
space.
Ankle fusion or replacement, in
conjunction with flatfoot deformity
correction, is indicated when rigid de-
formity is present (stage IVB). Ankle
replacement is gaining popularity in this
setting, because of poor results of pan-
talar fusion98,99.
Conclusions
Although our understanding of adult-
acquired flatfoot deformity has evolved
with advances in research and treatment,
it remains a challenging problem for
surgeons, as no consensus on treatment
exists. The goals of management are to
alleviate patients’ symptoms, to correct
alignment, and to preserve motion when
possible. Operative treatment is indi-
cated after failed conservative interven-
tions or with worsening deformity. The
outcomes of arthrodesis are generally
poor, so there is a generalized tendency
toward early surgical management and
deformity correction before progression
of the deformity and establishment
of arthritis.
9
 | Adult-Acquired Flatfoot Deformity
Mostafa M. Abousayed, MD1,
Maxwell C. Alley, BA1,
Rachel Shakked, MD2,
Andrew J. Rosenbaum, MD1
1Division of Orthopaedic Surgery, Albany
Medical College, Albany, New York
2Division of Orthopaedic Surgery,
The Rothman Institute at Jefferson,
Philadelphia, Pennsylvania
E-mail address for M.M. Abousayed:
mostafa.abousayed@gmail.com
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