Adult-Acquired Flatfoot Deformity

Adult-acquired FlatfootDeformity

AbstractOriginally known as posterior tibial tendon dysfunction orinsufficiency, adult-acquired flatfoot deformity encompasses a widerange of deformities. These deformities vary in location, severity,and rate of progression. Establishing a diagnosis as early as possibleis one of the most important factors in treatment. Prompt early,aggressive nonsurgical management is important. A patient inwhom such treatment fails should strongly consider surgicalcorrection to avoid worsening of the deformity. In all four stages ofdeformity, the goal of surgery is to achieve proper alignment andmaintain as much flexibility as possible in the foot and anklecomplex. However, controversy remains as to how to manageflexible deformities, especially those that are severe.

Adult-acquired flatfoot deformity(AAFD) encompasses a wide

range of deformities.1 Originallyknown as posterior tibial tendondysfunction or insufficiency, AAFDwas first described as tendon fail-ure.2,3 However, failure of the liga-ments that support the arch also oc-curs, often resulting in progressivedeformity of the foot.1,4-6 Deformi-ties vary in severity, rate of progres-sion, and location along the arch.Treatment has been effective in re-lieving pain. However, achievingmaximum function remains a chal-lenge. When the deformities becomemore severe and fixed, the results oftreatment are more limited. Contro-versies persist regarding how to treatAAFD, especially the more severeflexible deformities.

The presenting symptoms ofAAFD vary according to the stage ofdisease. Early on, a patient presentswith pain and swelling medially overthe posterior tibial tendon. The ten-don failure is a degenerative process.Even though the tendon may notrupture, it often becomes dysfunc-

tional. Tendon failure occurs most of-ten just distal to and at the level ofthe medial malleolus. The etiology ofthe condition is multifactorial. Pre-existing flatfoot is common, and obe-sity is often present. Relative hy-povascularity in this area of thetendon is another possible factor.7

AAFD is more common in females,with peak incidence at age 55 years.

With time, medial foot paincaused by tendon failure may dissi-pate, although swelling may persist.Ligament failure commonly occursalong with the tendon dysfunction.However, it may take place after or,less commonly, before tendon fail-ure. The spring ligament complexthat supports the talonavicular jointoften is involved, resulting in in-creasing deformity at this joint.Along with subluxation at the ta-lonavicular joint comes involve-ment of the interosseous ligamentand subluxation at the subtalarjoint.6 A combination of plantar andmedial migration of the talar headoccurs, resulting in flattening of thearch as the foot displaces from un-

Jonathan T. Deland, MD

Dr. Deland is Chief, Foot and AnkleService, and Associate AttendingOrthopaedic Surgeon, Hospital forSpecial Surgery, New York, NY.

Dr. Deland or a member of hisimmediate family has stock or stockoptions held in Tornier and serves as apaid consultant to Nexa Orthopaedics,Tornier, and Zimmer.

Reprint requests: Dr. Deland, Hospitalfor Special Surgery, 535 East 70thStreet, New York, NY 10021.

J Am Acad Orthop Surg 2008;16:399-406

Copyright 2008 by the AmericanAcademy of Orthopaedic Surgeons.

Volume 16, Number 7, July 2008 399

derneath the talus. The ligamentssupporting the naviculocuneiformand tarsometatarsal joints also maydegenerate, resulting in deformitiesat these joints. Thus, deformitiescan occur along the entire mediallongitudinal arch. With progressionof hindfoot deformity, a patient candevelop lateral pain from bony im-pingement at the lateral subtalarjoint and distal tip of the fibula.There may be a significant period oftime between resolution of medialpain and the development of lateralpain, when the symptoms may con-sist more of a weakness in the footthan pain. However, pain eventu-ally returns when the deformityprogresses.

Diagnosis

The diagnosis of AAFD is based onpatient history, physical examina-tion, and standing radiographs of thefoot and ankle. Magnetic resonanceimaging may confirm the tendon pa-thology; however, it is not required.An important clinical sign is the in-ability to perform a single heel risenormally. For a normal heel rise, thepatient must be able, with the oppo-site foot off the ground, to raise theheel off the ground; the physicianshould see normal inversion of theheel occur during heel rise. To prop-erly perform the test, a second per-son is needed to balance the patient.Alternatively, the patient may place

his or her hands against the wall forbalance. The examiner kneels be-hind the patient and asks the patientto stand on one foot. While the kneeof the affected leg is held straight,the patient is asked to lift the heeloff the ground and go up onto thetoes. This may be impossible on theaffected side. Some patients can liftthe heel off the ground or maintainthe heel in valgus without the nor-mal shift into the varus or invertedposition. The test is considered pos-itive when the patient is unable tolift the heel off the ground or normalheel inversion does not occur. Otherconditions, such as Achilles rupture,arthritis, and fusion involving thetalonavicular or subtalar joints, maygive a false-positive result. However,this test is usually a good indicatorof posterior tibial tendon dysfunc-tion.

Stages ofAdult-acquired FlatfootDeformity

Staging of AAFD is based on the de-formity; four stages have been de-scribed (Table 1). The first threestages were originally described byJohnson and Strom.4 The patientwith stage I AAFD presents withflatfoot that has been presentthroughout adulthood but withoutdeformity. Tenosynovitis and/or ten-dinosus may be present. A subgroupof patients in stage I present withspondyloarthropathy.1

In stage II, AAFD causes a changein alignment of the foot (ie, devel-oped deformity). The distinguishingcharacteristic of stage II is passivelycorrectible deformity. The talonavic-ular joint can be placed into an in-verted position and the heel align-ment passively corrected. Stage II hasbeen further divided into stages IIaand IIb.8,9 Stage IIa AAFD involvesdeformity with minimal abductionthrough the midfoot (ie, <30% talarhead uncoverage on the standing an-teroposterior [AP] radiograph [Figure1]). In Stage IIb, patients generally ex-

Table 1

The Four Stages of Adult-acquired Flatfoot Deformity

Stage Deformity Surgical Treatment

I No deformity from AAFD(may have preexistingflatfoot)

Tenosynovectomy, possible tendontransfer, and/or medial slideosteotomy

IIa Mild/moderate flexibledeformity (minimalabduction throughtalonavicular joint, <30%talonavicular uncoverage)

Tendon transfer, medial slideosteotomy, possible Cottonprocedure

IIb Severe flexible deformity(abduction deformitythrough talonavicularjoint, >30% talonavicularuncoverage)

Tendon transfer, medial slideosteotomy, and possible lateralcolumn lengthening or hindfootfusion (subtalar or talonavicularand calcaneocuboid fusion)

Cotton procedure ormetatarsal-tarsal fusionperformed as needed forelevation of the first ray

III Fixed deformity (involvingthe triple-joint complex)

Hindfoot fusion, most commonlytriple arthrodesis. Correctionrequires fusion of all three joints.

IV Foot deformity and ankledeformity (lateral talartilt)

Complete correction of footdeformity, possible deltoidreconstruction. For severearthritis, perform ankle fusion ortotal ankle arthroplasty,including correction of footdeformity.

IVa Flexible foot deformity Foot deformity corrected as withstage IIb

IVb Fixed foot deformity Foot deformity corrected as withstage III

AAFD = adult-acquired flatfoot deformity

Adult-acquired Flatfoot Deformity

400 Journal of the American Academy of Orthopaedic Surgeons

hibit more deformity clinically, with>30% talar head uncoverage onstanding AP radiographs. As the de-formity through the talonavicularjoint becomes more severe, greaterfoot abduction occurs at that joint.This can be seen when the standingAP alignment of the foot is inspectedclinically and on radiographs thatdemonstrate uncoverage of the me-dial talar head (Figure 2). The lateraltalonavicular joint can be inspectedfor incongruency on an AP radio-graph. The lateral margins of the ta-lonavicular joint demonstrate lateralrotation/displacement of the navicu-

lar with respect to the talar head. Thestanding AP radiograph may under-estimate the extent of abduction ifthe patient holds up the arch whilethe radiograph is being made or if po-sitioning does not allow full weightbearing with the lower leg directlyover the foot. Thus, it is important toevaluate the patient’s standing clin-ical alignment as well (Figure 3).

Stage III AAFD involves fixed de-formity, meaning that passive inver-sion of the triple-joint complex (ie,talonavicular, subtalar, calcaneo-cuboid joints) beyond the neutralplantigrade position of the foot is not

possible (Figure 4). Most commonly,there is fixed hindfoot valgus and ab-duction through the midfoot.

In stage IV AAFD, as defined byMyerson,1 the patient has deformityin the ankle joint in addition to thefoot. An AP radiograph of the ankleshows a lateral talar tilt, indicatingfailure of the deltoid ligament (Fig-ure 5). In stage IV, the foot deformi-ty may be either flexible or fixed. Itis more common for the deformityto be fixed but it can be flexible. Thisstage can be subclassified into IVa(ie, flexible foot deformity) and IVb(ie, fixed foot deformity) to differen-tiate these different types (Table 1).

Treatment

NonsurgicalNonsurgical treatment is recom-

mended first because it may be help-ful in alleviating symptoms.10-12 A re-movable boot or cast is most oftenhelpful as initial treatment in the pa-tient who is highly symptomatic.Although nonsteroidal anti-inflam-matory medications may be helpful,immobilization followed by supportis the most effective means of nonsur-gical management. Depending onthe results of immobilization, as well

Figure 1

Anteroposterior (AP) (A) and lateral (B) standing radiographs of a patient withstage IIa adult-acquired flatfoot deformity. Note the talonavicular sag on the lateralview, with minimal (<30%) talonavicular uncoverage on the AP view.

Figure 2

AP (A) and lateral (B) standing radiographs of a patient with stage IIb adult-acquired flatfoot deformity. Note the uncoverage of the medial talar head on the APview.

Figure 3

Clinical photograph of a patient withstage IIb adult-acquired flatfootdeformity demonstrating abductionthrough the midfoot.



as the level of deformity and durationof symptoms, support may beachieved with a customized brace. Ashort articulated ankle-foot orthosisallows ankle motion and providessupport via the tibia and the mediallongitudinal arch.10,11 The Arizonabrace (Arizona, Inc, Mesa, AZ) pro-vides excellent support with its firmleather lace-up design, but it limits

ankle motion.12 These braces aremost often used longer than 2 monthsin patients with considerable prona-tion in the foot (ie, moderate to severeincreased heel valgus and abductionthrough the midfoot, resulting in low-ering of the medial longitudinal arch).They can be used long-term if neces-sary or, if the deformity is not severe,for several months, then followed bya foot orthosis. A foot orthosis (ie, anorthotic with a medial longitudinalarch support and medial heel wedge)is less cumbersome than a brace, butit provides less support. A foot ortho-sis is most suitable once the initialsymptoms have improved. Orthosesdo not provide adequate support formore severe deformities.

No study has been done to docu-ment whether these devices slow orprevent the progression of deformity.A short-term study on patients withstage I and II deformity demonstratedan 89% satisfaction rate with a pro-gram that included orthotic support(eg, short articulated ankle-foot ortho-sis, foot orthosis [when the pain sub-sided]) and adequate physical thera-py.10 This study had 1-year follow-up.Long-term results of nonsurgicaltreatment have not been reported.

Although nonsurgical treatment isan appropriate option, patients shouldbe watched for increasing deformity.

A patient may progress slowly,quickly, or not at all. Each patientshould be made aware of the advan-tages and disadvantages of waiting.The patient should be advised that ifdeformity increases considerably, sur-gical treatment may not be as suc-cessful. The author prefers to immo-bilize a patient in a removable bootfor 3 to 6 weeks, often with a footorthosis to correct heel valgus. If thisis successful and the deformity ismild to moderate, the patient can beprogressed out of the boot, and thefoot orthosis is used in a lace-up shoeor sneaker.10 For more severe defor-mities, a short articulated ankle-footorthosis or an Arizona brace is usedinstead. Device selection is madebased on deformity and patientpreference.10-12 Physical therapy canbe helpful after the initial inflamma-tion has dissipated. A program ofAchilles tendon stretching, inversion,and toe flexor strengthening alongwith proprioception exercises is used.When immobilization followed byorthotic or brace support fails toalleviate symptoms or when theamount of deformity is increasing,surgery is strongly advised.

SurgicalStage I

Surgical treatment of stage IAAFD classically includes tenosyn-ovectomy, tendon repair, or tendontransfer, depending on the conditionof the tendon. Surgery is performedonly after the failure of 3 months ofnonsurgical care. In the author’s ex-perience, surgical treatment with dé-bridement or repair has a significantlong-term failure rate when the pa-tient has a flatfoot, even when thepatient and physician believe therehas been no increase in the flat-foot.13 The patient who presentswith symptoms lasting >3 months isa candidate for surgical treatment.Although controversial in stage I, acalcaneal medial slide osteotomymay be added to the tendon proce-dure for the patient with a flat-foot.14

Figure 5

Standing AP radiograph of the ankle ofa patient with stage IV adult-acquiredflatfoot deformity. Note the lateral tilt ofthe talus in the ankle mortise.

Figure 4

AP (A) and lateral (B) radiographs of a patient with stage III adult-acquired flatfootdeformity.



Stage IIaSurgical treatment selection for

stage IIa deformity is based on thetype and amount of deformity. Witha flexible mild deformity and a com-promised tendon, tendon transfer(usually of the flexor digitorum lon-gus) is performed along with bonyprocedures. A medial calcaneal heelslide has been shown to correct de-formity and provide satisfactory re-sults in patients with stage IIaAAFD.14 The medial heel slide cor-rects heel valgus and takes strain offthe medial ligaments and posteriortibial tendon, resulting in minimalstiffness.15 There are differences ofopinion regarding the severity of de-formity that can be adequately treat-ed with a medial heel slide in con-trast with when other procedures inthe hindfoot are required.8,16,17 Somesurgeons have attempted an arthro-ereisis implant without a calcanealosteotomy. Preliminary results onthese procedures have shown patientsatisfaction.17 The procedure doesnot require osteotomy or fusion, butsinus tarsi pain from the implant canoccur; long-term follow-up data arenot available. Procedures to treatdeformity at the metatarsal-tarsaljoints and the naviculocuneiformjoints may include first metatarsal-tarsal fusion, Cotton or openingwedge medial cuneiform osteotomy,and naviculocuneiform fusion.18

Surgeons should weigh the sympto-matic benefit of these proceduresagainst the morbidity. A stable firstray, one that is not in dorsiflexion incomparison with the second meta-tarsal, is important to the alignmentof the arch. Metatarsal-tarsal fusioncan be used to bring the first raydown. However, when the first ray isstable, plantar flexion of the first raymay be gained with an openingwedge cuneiform osteotomy ratherthan a metatarsal-tarsal fusion. Na-viculocuneiform fusion can stabilizeinstability at that joint, but correc-tion must be weighed against the dif-ficulty of achieving fusion in thesejoints. Some remaining deformity at

the naviculocuneiform joint is oftenwell tolerated.

Postoperative care following ten-don transfer and medial slide oste-otomy requires non–weight bearingor touch-down weight bearing in acast or removable cast/brace for 6weeks. This is followed by progres-sion to full weight bearing by 8weeks after surgery. From 6 to 12weeks, the patient is kept in a remov-able boot. Range-of-motion exercisesare begun at 6 weeks, and progressivestrengthening exercises are begun 12weeks postoperatively when the ten-don transfer has healed. These exer-cises are done with a physical thera-pist or by the patient alone, usinggentle strengthening at first. A footorthosis is recommended when thepatient progresses to lace-up shoes(12 to 14 weeks postoperatively). Thepatient should be informed that im-provement is not expected until 4 to6 months after surgery.

Stage IIbTreatment of the more severe

stage IIb AAFD is controversial com-pared with treatment of other stagesof the disease. Some surgeons com-monly use lateral column length-ening,19-21 while others use it rarely,if at all.16 Lateral column lengtheningprovides correction to the abductedtalonavicular joint and raises thearch.22 However, it also decreaseseversion and increases the pressurealong the plantar lateral border of thefoot.23 Lateral column lengtheningmay be performed through the ante-rior calcaneus or the calcaneocuboidjoint.24,25 Either autograft or allograftmay be used for the lengthening; ahigh union rate has been shown forboth when the graft is used throughan osteotomy in the anterior calca-neus.26 Calcaneocuboid distractionarthrodesis has a high incidence ofnonunion and, even with healing, theprocedure results in more residualdiscomfort in the foot.8,25 Preciselywhen lateral column lengthening isneeded has not been defined. Becauseit is very powerful in the correction

of abduction and because overcorrec-tion occurs easily, it should be doneonly in the presence of abduction de-formity (ie, >30% to 40% talar headuncoverage or incongruency at thelateral talonavicular joint on a stand-ing AP radiograph). Lengthening mayresult in lateral foot overload, fifthmetatarsal stress fracture, and signif-icant stiffness.25 However, a patientwith moderate to severe abductiondeformity at the talonavicular jointmay not achieve sufficient correctionwith a medial slide osteotomy.

Because of the potential problemsrelated to lateral column lengthen-ing, some surgeons opt to acceptlimited correction with a medialslide osteotomy or to proceed to ahindfoot fusion, such as a subtalarfusion.25,27,28 For the more severe de-formities, the surgeon may elect toproceed to a fusion that includes thetalonavicular joint. A comparisonstudy of patients treated for stage IIawith a medial slide osteotomy ver-sus patients with stage IIb treatedwith medial slide osteotomy and lat-eral column lengthening did show ahigher incidence of lateral discom-fort and stiffness in the group thatunderwent medial slide osteotomyand lateral column lengthening.8

Forty-five percent of patients in thegroup treated with medial slide os-teotomy and lateral column length-ening had some degree of lateral dis-comfort, whereas 55% did not.8

Admittedly, medial slide osteotomyplus lateral column lengthening wasdone on patients with a greater lev-el of deformity. Interestingly, thosepatients who had lateral discomfortafter a medial slide osteotomy andlateral column lengthening also hada statistically significant (P < 0.05)greater incidence of perceived stiff-ness. Thus, minimizing stiffnesswhile providing only the amount ofcorrection necessary is likely to behelpful in minimizing lateral dis-comfort when a lateral columnlengthening is performed. Becauseovercorrection is easy to do, it is im-portant to carefully choose the



amount of correction in this power-ful procedure. Correction should bedone judiciously to avoid excessivestiffness on the lateral side of thefoot. The goal is not to obtain a higharch or stiff foot; rather, it is toachieve acceptable alignment (ie, novalgus or abduction deformity), withno excessive stiffness on the lateralside. Normal but not excessive ever-sion motion should remain in thefoot. Further work needs to be doneon how to avoid stiffness and mini-mize residual symptoms after later-al column lengthening.

Postoperative care after tendontransfer and medial slide osteotomywith lateral column lengthening issomewhat longer than after tendontransfer and medial slide osteotomy.The patient is kept non–weight bear-ing or touch-down weight-bearing ina cast or removable boot for 8 weeks,with progression to full weight bear-ing between weeks 8 and 10. Range-of-motion exercise is begun at 8weeks and strengthening, by 10weeks.

Spring ligament repair or recon-struction has a place in the treat-ment of stage IIa and IIb AAFD,although its role has not been pre-cisely defined. Because the springligament is often degenerated, repairalone should not be counted on toprovide correction of bony align-ment. Repair is most commonlydone for a gross tear in the ligament.There are no data to prove its effica-cy, given that it is done in conjunc-tion with concomitant proceduressuch as calcaneal osteotomy. How-ever, repair of tears, whether acute orchronic, is recommended. In someinstances, flexible deformity thatcannot be corrected with a medialslide osteotomy and lateral columnlengthening may be successfullymanaged with the addition of springligament reconstruction using ten-don graft. This has provided furthercorrection of alignment in the oper-ating room that has lasted in clinicalfollow-up. No clinical series of theseprocedures has been published, but

the author’s experience to date isthat such procedures can add smallamounts of correction of alignmentto bony procedures.

Stage IIIStage III AAFD is not passively

correctable even under anesthesia.Arthrodesis is required to correct de-formity and stabilize the foot. Mostoften, correction requires fusion of atleast the talonavicular joint becausemuch of the deformity occursthrough that joint. The author preferstriple arthrodesis because adequatecorrection commonly requires fusionof all three joints. Major bone graft isnot required, but small amounts ofgraft are commonly used, which areobtained from the tibia, either medi-ally above the ankle or laterally justbelow the knee or using a bone graftsubstitute. It is important to care-fully check the alignment set at thetime of hindfoot fusion. In situ fu-sions should be avoided. Adequatecorrection of deformity without over-correction into varus offers the bestresult. The heel should be in ≤5° ofvalgus with the forefoot in neutral(ie, no forefoot supination or eleva-tion of the first ray and no forefootpronation). When excessive heel val-gus remains even after realignmentof the forefoot and triple-joint com-plex, then a medial slide osteotomyis added. A metatarsal-tarsal fusionfor an unstable first ray or a Cottonosteotomy is used to correct an ele-vated first metatarsal. A plantigradefoot with the heel properly aligned(ie, no increased heel valgus but noheel varus) and the forefoot out of su-pination are important goals.

The functional result after a triplearthrodesis has limitations.8,29 Walk-ing on uneven ground and walkingfor exercise are often hindered. Inone study, the function of patientswith stage II AAFD treated with ei-ther medial slide osteotomy or medi-al slide osteotomy and lateral col-umn lengthening was comparedwith that of patients with stage IIbor III AAFD who were treated with

hindfoot arthrodesis.8 Greater limi-tation of function was evident in thearthrodesis group. This supports thehypothesis that with progressive de-formity, it is best to correct the footearly, before more advanced fusionprocedures are required.

Stage IVLittle has been published on the

surgical results of the treatment ofstage IV AAFD. Different techniquesfor reconstruction of the deltoid havebeen published.30,31 One small clini-cal series on reconstruction of thedeltoid ligament using tendon graftand simultaneous correction of footdeformity showed correction of thetalar tilt at the ankle.30 The patientwith the most severe deformity atthe ankle was the only patient of fivein this study who did not gain correc-tion of the talar tilt. Drill holes in thetibia and talus were used to approx-imate the insertions of the deep del-toid ligament. Correction of foot de-formity, including full correction ofheel valgus, elevation of the first ray,and abduction through the midfoot,is felt to be critical to the success ofthe procedure. This correction can bedone without a triple arthrodesis ina flexible foot (stage IVa). Instead, thepatient can be treated with medialslide osteotomy, lateral columnlengthening, and possibly a meta-tarsal-tarsal fusion or Cotton osteot-omy. With fixed deformity (stageIVb), a triple arthrodesis is used.When >5° of heel valgus is stillpresent, a medial slide osteotomy isadded at the time of the triple arthro-desis. It is not known how much re-construction of the deltoid contrib-utes to the success of the procedure.Without full correction of the footdeformity, reconstruction of the an-kle deformity is expected to fail.

In the patient with stage IVAAFD who has severe arthritis inthe ankle (ie, bone-on-bone contactwith correction of the talar tilt), an-kle arthrodesis or total ankle arthro-plasty is required. Because of thestiffness and limitation of ambula-



tion with a pantalar fusion, the useof tibiocalcaneal arthrodesis or totalankle arthroplasty with reconstruc-tion of the foot should be considered.When deformity can be adequatelycorrected without fusing the talo-navicular joint, it is important tomaintain motion of the transversetarsal joint.

In all stages, the Achilles tendonor the gastrocnemius-soleus complexcan be contracted. Contraction ismore common in the more severe de-formities in stage IIa and IIb as wellas in stages III and IV. Surgeon pref-erence varies regarding the frequencyof lengthening the Achilles tendon.Tightness of the Achilles should beexamined with the knee extended andin 90° of flexion. When the hindfootand ankle cannot be brought into anydorsiflexion with the knee extendedand the foot in the corrected position,consideration should be given to gas-trocnemius recession. With the footin the corrected position and the kneeflexed, dorsiflexion should be presentto confirm that just a gastrocnemiusrecession will provide adequate reliefof the contracture. Triple-cut length-ening of the Achilles tendon is per-formed when the gastrocnemius andsoleus are both contracted (ie, no dor-siflexion of the ankle with the kneein 90°of flexion). The surgeon shouldbe careful to avoid overlengtheningwith the triple-cut procedure. Postop-erative care of the reconstruction con-sists of non–weight bearing or touch-down weight bearing in a cast for 10to 12 weeks, followed by increasingweight-bearing in a removable bootfor 2 to 4 weeks.

Summary

There is considerable surgeon-to-surgeon variability in the treatmentof AAFD, particularly in stage II dis-ease. A patient with stage I AAFDoften can be treated nonsurgically,which should be considered in theinitial treatment in all stages ofAAFD. In stage IIa deformity, surgi-cal treatment with a medial slide os-

teotomy and tendon transfer hasbeen shown to provide consistentlygood results. Lateral column length-ening provides more correction;thus, it should be considered for thepatient with more severe deformity(ie, stage IIb). However, there is arisk of lateral overload with this pro-cedure, and care should be taken toavoid overcorrection and excessivestiffness. When multiple osteoto-mies are being performed, temporaryfixation is recommended so that thefinal position and flexibility of thefoot can be assessed before definitivefixation is placed. The patient withstage III AAFD requires hindfoot fu-sion, most commonly involving thetalonavicular joint. Positioning isimportant in achieving optimalfunctional result. Care should againbe taken to avoid over- and under-correction. More progress is neededin the management of stage IV dis-ease. An initial study has shown thatcorrection of deformity in both thefoot and ankle is possible.30

The end result of surgical treat-ment of the patient with AAFD hasmuch to do with the management ofthe associated deformity. The princi-ple of correcting the deformity whileavoiding overcorrection and exces-sive stiffness is important in deter-mining the outcome of the surgicaltreatment in these patients. In allstages, there are benefits to achiev-ing proper alignment and maintain-ing as much flexibility as possible.Working on the maximum achieve-ment of these two goals is likely tocontinue to optimize the results forpatients with AAFD.

References

Evidence-based Medicine: There isone level I prospective, randomizedstudy (reference 6). There are no lev-el II studies. Most of the referencesare level III/IV (case-control or co-hort reports) or level V (expert opin-ion).

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Adult-Acquired Flatfoot Deformity

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