Foot and Ankle Clinics RSS feed: Current Issue. Foot and Ankle Clinics updates you on the latest trends in patient management; keeps you up to date on the newest advances; and provides a sound basis for choosing treatment options. Each issue focuses on a single topic in foot and ankle surgery and is presented under the direction of an experienced guest editor. http://www.foot.theclinics.com/?rss=yesElsevier Inc.en © 2012 Published by Elsevier Inc. All rights reserved. Foot and Ankle Clinics1083-7515172June 2012 © 2012 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.foot.theclinics.com/article/PIIS1083751512000344/abstract?rss=yesContributors10.1016/S1083-7515(12)00034-4Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4iiivhttp://www.foot.theclinics.com/article/PIIS1083751512000356/abstract?rss=yesContents10.1016/S1083-7515(12)00035-6Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4viixhttp://www.foot.theclinics.com/article/PIIS1083751512000368/abstract?rss=yesForthcoming Issues10.1016/S1083-7515(12)00036-8Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4xixihttp://www.foot.theclinics.com/article/PIIS1083751512000290/abstract?rss=yes The understanding of the pathomechanics of the Adult Acquired Flatfoot (AAFF) has undergone a major evolution since its first description by Kulowski in 1936. Initially described purely as a disorder of the posterior tibial tendon, we now understand that the deformity additionally involves, among other contributors, the support of the spring ligament (which makes up part of the medial ligamentous support of the ankle) and as such the deltoid ligament, as well as a contribution from the midfoot through ligamentous laxity or degenerative collapse.PrefaceSteven M. Raikin10.1016/j.fcl.2012.03.012Foot and Ankle Clinics 17, 2 (2012)2012-04-05Foot and Ankle Clinics2012-04-05172S1083-7515(11)X0007-4xiiixiiihttp://www.foot.theclinics.com/article/PIIS1083751512000198/abstract?rss=yesThe adult-acquired flatfoot (AAFF) is most commonly associated with dysfunction of the posterior tibial tendon (PTT) and presents clinically as a painful pes planus deformity. From the time posterior tibial tendonitis was initially described in 1936 by Kulowski until 1983, little can be found throughout the literature pertaining to this topic aside from a few case series. In 1983, Johnson was the first to discuss the signs and symptoms that resulted from rupture of the PTT. He described a valgus deformity of the hindfoot and abduction deformity of the forefoot, which has since become the hallmark of this disorder. From this work, he established the “too many toes” sign and the inability to perform a single-leg heel rise as indicators of loss of PTT function.The RAM Classification: A Novel, Systematic Approach to the Adult-Acquired FlatfootSteven M. Raikin, Brian S. Winters, Joseph N. Daniel10.1016/j.fcl.2012.03.002Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4169181http://www.foot.theclinics.com/article/PIIS1083751512000186/abstract?rss=yesFlexible flatfoot is one of the most common deformities of the human body. Whereas this condition is sometimes asymptomatic, it can also cause pain, difficulty walking, and physical impairment.The Calcaneo-Stop ProcedureF.G. Usuelli, U. Alfieri Montrasio10.1016/j.fcl.2012.03.001Foot and Ankle Clinics 17, 2 (2012)2012-04-05Foot and Ankle Clinics2012-04-05172S1083-7515(11)X0007-4183194http://www.foot.theclinics.com/article/PIIS1083751512000216/abstract?rss=yesThe diagnosis and treatment of tarsal coalition in the adolescent population have been well described, but there is a paucity of information regarding adult coalitions. The overall incidence, albeit rather unknown, has been stated to be less than 1%. As a large proportion of adult coalitions are discovered incidentally, the overall incidence may be higher than previously reported.Tarsal Coalitions in the Adult Population: Does Treatment Differ from the Adolescent?Steven W. Thorpe, Dane K. Wukich10.1016/j.fcl.2012.03.004Foot and Ankle Clinics 17, 2 (2012)2012-04-09Foot and Ankle Clinics2012-04-09172S1083-7515(11)X0007-4195204http://www.foot.theclinics.com/article/PIIS1083751512000150/abstract?rss=yesPosterior tibial tendon (PTT) dysfunction is a disorder in which there is a symptomatic pathologic condition involving the PTT and/or spring ligament complex. Some patients with PTT dysfunction previously had a normal or slightly cavus arch before acquiring a flexible flatfoot during adulthood. Other patients with PTT dysfunction may still have a normal or slightly cavus arch. However, more commonly there is a preexisting flatfoot that may have developed increased deformity that may be flexible or fixed. Per the Johnson and Strom classification as modified by Myerson, stage 1 PTT dysfunction has an intact arch, stage 2 has a flexible flatfoot deformity, stage 3 has a fixed flatfoot deformity, and stage 4 has an underlying stage 2 or stage 3 deformity with the addition of valgus tilt at the ankle joint secondary to deltoid ligament laxity or lateral ankle arthritis. In many patients with stage 2 PTT dysfunction the deformity may only be correctable with the ankle in equinus or the gastrocnemius relaxed by knee flexion.Tendon Transfer Options in Managing the Adult Flexible FlatfootMichael S. Aronow10.1016/j.fcl.2012.02.001Foot and Ankle Clinics 17, 2 (2012)2012-04-09Foot and Ankle Clinics2012-04-09172S1083-7515(11)X0007-4205226http://www.foot.theclinics.com/article/PIIS1083751512000162/abstract?rss=yesFlatfoot in adults caused by a dysfunction of the posterior tibial tendon is a frequent pathology for which several therapies have been proposed, for instance tendon transfers and bone procedures.Young's Procedure for the Treatment of Valgus Flatfoot Deformity Caused by a Posterior Tibial Tendon Dysfunction, Stage IINuri Schinca, Alicia Lasalle, Josefina Alvarez10.1016/j.fcl.2012.02.002Foot and Ankle Clinics 17, 2 (2012)2012-04-05Foot and Ankle Clinics2012-04-05172S1083-7515(11)X0007-4227245http://www.foot.theclinics.com/article/PIIS1083751512000174/abstract?rss=yesAdult acquired flatfoot deformity (AAFD) is a chronic, debilitating condition common beyond middle age. It is characterized by a painful flattening of the medial longitudinal arch and has been referred to as posterior tibial tendon deficiency. However, in recognition of the fact that other structures such as the plantar calcaneonavicular (spring) ligament and the deltoid ligament were also involved, the nomenclature has been changed to AAFD.Calcaneal Osteotomy in the Treatment of Adult Acquired Flatfoot DeformityAbhijit R. Guha, Anthony M. Perera10.1016/j.fcl.2012.02.003Foot and Ankle Clinics 17, 2 (2012)2012-04-12Foot and Ankle Clinics2012-04-12172S1083-7515(11)X0007-4247258http://www.foot.theclinics.com/article/PIIS1083751512000228/abstract?rss=yesIn the development of the adult acquired pes planovalgus foot deformity, the lateral column becomes relatively shortened in relation to the medial column. This gives the clinical appearance of an abduction deformity of the forefoot at Choparts joint and a hindfoot calcaneovalgus deformity. The Chopart joint is the transitional link between the hindfoot and the forefoot and it serves to compensate the forefoot for the hindfoot position. In the weight-bearing position, the internal rotation of the tibia imposes an eversion force on the subtalar joint. This subtalar position ensures the Choparts joints are essentially co-linear and are free to make compensatory adjustments on weight-bearing. During heel-rise and toe-off, lateral rotation of the tibia affects the subtalar joint to invert shifting the Achilles tendon medially initiated by the tibialis posterior muscle. This produces a rigid lever through Choparts joint and restricts motion at these joints because the joint axes are no longer parallel. Any loss of this effect at the subtalar joint results in loss of this rigid lever effect and the subtalar joint remains everted. The Chopart joint does not lock and gradually the effect of this is abduction of the forefoot on a calcaneovalgus deformity with lateral rotation of the navicular on the talus. On plain radiographs, this can be clearly seen with loss of talonavicular coverage on the anteroposterior view and loss of medial cuneiform to fifth metatarsal height or a relatively proximal calcaneocuboid joint to the talonavicular joint on the lateral view.Lateral Column Lengthening OsteotomiesAndrew J. Roche, James D.F. Calder10.1016/j.fcl.2012.03.005Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4259270http://www.foot.theclinics.com/article/PIIS108375151200023X/abstract?rss=yesAdult acquired flatfoot is a common problem for foot and ankle surgeons. The incidence is increasing and it is becoming more widely known among orthopedic surgeons in the last years. The main cause is rupture of posterior tibial tendon (PTT). The morphologic characteristics of this condition are heel valgus and flattening of the medial longitudinal arch. Other characteristics are usually observed, such as supination and abduction of the forefoot and tightening of the Achilles tendon. The deformity is progressive and patients describe “sinking” of their foot. There is no spontaneous correction with time and many patients become symptomatic. Treatment is required when there is progression of deformity and/or pain. Conservative treatment includes supportive footwear and ankle orthosis. The natural evolution of adult flatfoot and failure to treat this condition could lead to persistent pain in the hindfoot, hallux valgus, degenerative arthritis, metatarsalgia, and knee or low back pain.Is There a Role for Subtalar Arthroereisis in the Management of Adult Acquired Flatfoot?Pablo Fernández de Retana, Fernando Álvarez, Gustavo Bacca10.1016/j.fcl.2012.03.006Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4271281http://www.foot.theclinics.com/article/PIIS1083751512000204/abstract?rss=yesAdult acquired flatfoot deformity (AAFD) is a global term that applies to patients with varying degrees of hindfoot valgus, forefoot abduction, and forefoot varus. Most commonly, a patient complains of medial hindfoot pain and swelling with a variable degree of progressive pes planovalgus. The most common cause of AAFD is posterior tibial tendon (PTT) dysfunction. Function of the PTT is critical because it contributes to the static stability of the foot along with the spring ligament complex. Failure of the PTT to maintain the arch of the foot can lead to progressive hindfoot valgus and collapse of the medial column through the first metatarsocuneiform joint (also known as the first tarsometatarsal [TMT] joint), the naviculocuneiform (NC) joint, and/or the talonavicular (TN) joint. Other etiologies of AAFD include pathology such as posttraumatic deformity, osteoarthritis, inflammatory arthritis, Charcot neuroarthropathy, and neuromuscular disorders. Numerous combinations of bone and soft-tissue procedures have been described to address the different types of pes planovalgus deformity without a clear consensus on a treatment algorithm.Medial Column Procedures in the Correction of Adult Acquired Flatfoot DeformityJeremy J. McCormick, Jeffrey E. Johnson10.1016/j.fcl.2012.03.003Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4283298http://www.foot.theclinics.com/article/PIIS1083751512000241/abstract?rss=yesJohnson and Strom, as well as other authors, described a classification system for adult-acquired flatfoot deformity, which was later modified by Myerson and colleagues. The classification is helpful as it relates to directing treatment. Broadly speaking, stages I and II represent flexible flatfoot deformities, while stages III and IV represent more severe fixed deformities. Most authors agree, in stage I flatfoot refractory to conservative nonoperative management and mild to moderate stage II deformities, soft tissue reconstruction with posterior tibial tendon (PTT) debridement, tendon transfer, and medial displacement calcaneal osteotomy provide sufficient deformity correction while maintaining motion. More severe stage II deformities represent a slightly more controversial treatment dilemma as some surgeons advocate lateral column lengthening with or without a calcaneal osteotomy, spring ligament repair, and/or primary limited arthrodesis procedures to achieve deformity correction.Management of the Recurrent Deformity in a Flexible Foot Following Failure of Tendon Transfer: Is Arthrodesis Necessary?Safet O. Hatic, Terrence M. Philbin10.1016/j.fcl.2012.03.007Foot and Ankle Clinics 17, 2 (2012)2012-04-09Foot and Ankle Clinics2012-04-09172S1083-7515(11)X0007-4299307http://www.foot.theclinics.com/article/PIIS1083751512000253/abstract?rss=yesAppropriate management of the adult flatfoot deformity (AAFD) is highly dependent upon its severity. Upon failure of nonsurgical treatment, patients with a flexible flatfoot and no arthritic changes are amenable to soft-tissue reconstruction and bony osteotomies that correct deformity and preserve joints. Once adults develop a rigid, arthritic flatfoot, however, such joint-sparing procedures are neither appropriate nor sufficient. The traditional surgical treatment for the rigid arthritic flatfoot that has failed nonoperative management is a triple arthrodesis of the subtalar (ST), talonavicular (TN), and calcaneocuboid (CC) joints through a combined lateral and medial approach.Management of the Rigid Arthritic Flatfoot in Adults: Triple ArthrodesisJamal Ahmad, David Pedowitz10.1016/j.fcl.2012.03.008Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4309322http://www.foot.theclinics.com/article/PIIS1083751512000265/abstract?rss=yesThe human foot collapses in a finite number of patterns. This collapse can be driven by injury, time, and weight in a susceptible person. Symptoms occur at various points along the spectrum of the different patterns. But all patterns are united by the common denominator of medial column incompetence and gradual attenuation of the static and dynamic supports of the medial longitudinal and transverse arch in the presence of a progressive triceps surae contracture. Regardless of the cause, it is unclear why the supple deformity becomes rigid. After this threshold has been passed, treatment options become limited to arthrodesis, although there are alternatives to the triple arthrodesis.Management of the Rigid Arthritic Flatfoot in the Adults: Alternatives to Triple ArthrodesisChristopher E. Gentchos, John G. Anderson, Donald R. Bohay10.1016/j.fcl.2012.03.009Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4323335http://www.foot.theclinics.com/article/PIIS1083751512000277/abstract?rss=yesThere has been a proliferation of treatment options for flexible flatfoot deformity, but in cases where the deformities are more rigid and fixed, triple arthrodesis remained the most common surgical technique employed for treatment. Although triple arthrodesis can afford excellent deformity correction, it can be associated with disability owing to the stiffness created by the procedure. Patients may complain of continued pain with ambulation and extended weight bearing or when walking long distances. In addition, after triple arthrodesis, symptomatic arthritis often develops with time in the ankle, midfoot, and intertarsal joints. Extending the arthrodesis when progressive arthritis develops rarely improves the patient's function to their expectation. Converting a triple arthrodesis to a pan-talar arthrodesis leads to a very stiff and often chronically painful leg and, in the authors' opinion, should be avoided. Recognizing both the early and late problems associated with extended hindfoot fusions, increased interest in using the techniques developed for correction of flexible flatfoot has occurred. This dialogue is intended to provide alternatives to fusion surgery for the treatment of rigid flatfoot deformity while discussing the various osteotomy and soft tissue reconstructive options that may allow the surgeon to either avoid fusion or perform a more limited fusion than might otherwise be required.Minimizing the Role of Fusion in the Rigid FlatfootRoss Taylor, V. James Sammarco10.1016/j.fcl.2012.03.010Foot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4337349http://www.foot.theclinics.com/article/PIIS1083751512000289/abstract?rss=yesThe posterior tibial tendon plays a central role in maintaining proper foot alignment. Dysfunction of the posterior tibial tendon leads to acquired adult flatfoot deformity (AAFD), a condition that can be both painful and disabling. There are four stages of AAFD, which correlate to increasing deformity. Johnson and Strom described the first three stages in 1989. Stage I AAFD is paratenonitis of the posterior tibial tendon without deformity. The central components of stage II disease are flexible flatfoot deformity with hindfoot valgus, forefoot abduction, and forefoot varus. Stage III is characterized by a fixed hindfoot valgus and often fixed forefoot varus deformity. Myerson described a fourth stage, which occurs when the talus tilts into valgus within the ankle mortise secondary to deltoid ligament insufficiency (). Stage IV ankle malalignment is typically accompanied by the deformities present in stages II and III. Stage IV AAFD is subclassified into stage IV-A—flexible ankle valgus without substantial tibiotalar arthritis, and stage IV-B—rigid ankle valgus or flexible ankle valgus with significant tibiotalar arthritis.Update on Stage IV Acquired Adult Flatfoot Disorder: When the Deltoid Ligament Becomes DysfunctionalJeremy T. Smith, Eric M. Bluman10.1016/j.fcl.2012.03.011Foot and Ankle Clinics 17, 2 (2012)2012-04-12Foot and Ankle Clinics2012-04-12172S1083-7515(11)X0007-4351360http://www.foot.theclinics.com/article/PIIS108375151200037X/abstract?rss=yesIndex10.1016/S1083-7515(12)00037-XFoot and Ankle Clinics 17, 2 (2012)2012-06-01Foot and Ankle Clinics2012-06-01172S1083-7515(11)X0007-4361387