Current Concepts on the Operative Management of Adult Acquired Flatfoot
INTRODUCTION • AAFD is a common deformity that is encountered by orthopedic surgeons. • The pathophysiology is still debated. • A clear understanding of the normal function of the PTT and the static restraints of the medial longitudinal arch is essential to understanding the operative and non-operative TTT options for AAFD.
AIM OF THE WORK • The aim of this essay is to highlight the recent trends in understanding of the pathophysiologyof AAFD and increase the awareness among orthopedic surgeons regarding its evaluation and management.
RELEVANT ANATOMY • The human foot is a complex structure adapted to allow orthograde bipedal stance, locomotion. • The foot HINDFOOT MIDFOOT FOREFOOT ARCHES OF THE FOOT Medial longitudinal arch. Lateral longitudinal arch Transvers arch
Medial longitudinal arch. Posterior pillar Anterior pillar Posterior part of inferior calcaneal surface. The three metatarsal heads A tie beam The plantar aponeurosis
ShortMuscles of Sole of the Foot Tendons of Long Muscles STRUCTURES SUPPORTING THE ARCHES Ligaments Bony Arrangement Plantar Aponeurosis
Phases of the walking cycle. Stance phase constitutes approximately 62% of the cycle, and swing phase 38%.
Biomechanics of flatfoot • The weight bearing axis passes through the anterior superior iliac spine down through the patella to the middle of the foot at the level of the second metatarsal. • The weight-bearing axis is shifted medially, thus disrupting the entire kinetic chain of the lower extremity.
Causes of AAFD • Loss of the supporting structures : 1. PTTD. 2. Tear of the spring ligament (rare). 3. Tibialis anterior rupture (rare). • Degenerative changes secondary to: 1. Inflammatory arthropathy. 2. Osteoarthropathy. 3. Fractures. • Charcot foot secondary to: 1. Diabetes mellitus. 3. Profound peripheral neuritis of any cause.
AAFD 2ry to Arthritic Deformity • In RA, soft tissue inflammation occurs with subsequent erosion of the talonavicular and subtalar joints and possible PTTD. AAFD 2ry to Osteoarthrosis • Degenerative changes with loss of joint space, irregularity & depression of the articular surface leading to collapse of the medial longitudinal arch.
AAFD 2ry to Charcot Foot Diabetes mellitus is the most common cause of this disorder. AAFD 2ry to Plantar Fascia Rupture • Post traumatic or spontaneous rupture may occur with subsequent limited flattening of the longitudinal arch.
HISTORY • May include feet tire easily pain and swelling over the collapsed medial longitudinal arch, an insidious onset of the bilateral or unilateral deformity. SYMPTOMS & SIGNS • Pain. • Swelling & deformity.
PHYSICAL EXAMINATION • A full general examination & MSK examination is due. INSPECTION • Walking Gait; A toe-in gait in an attempt to shift the weight-bearing axis laterally. • While standing: Limb alignment(genuvalgum in flatfeet). Foot:(flatfoot) - heel valgus, low arch, forefoot abduction & supination.
Standing on tiptoe: Differentiate between flexible and rigid flatfeet. • Too many toes sign: From behind more toes are seen on the lateral side of the leg. • While sitting: Patient to be asked to locate the primary focus of pain.
Too many toes sign Single heel raise test
PALPATIONAND STABILITY: • Bony prominences &ankle ligaments • Stability of the lateral ankle ligaments to be assessed with anterior drawer test. • NEUROVASCULAR EXAMINATION. • RANGE OF MOTION. • Contracture of Achilles tendon. • MUSCLE TESTS.
I. RADIOGRAPHIC INVESTIGATIONS • Plain radiographs. • Computed tomography. • Magnetic resonance imaging.
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