Professional Documents
Culture Documents
Selected
Arthrodesis Techniques
in the Management of
Stage-II and III Acquired
Adult Flatfoot Deformity
BY JEFFREY E. JOHNSON, MD, AND JAMES R. YU, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Arthrodesis is indicated for the man- adult acquired flatfoot deformity. The talus. With longer-standing deformity,
agement of an acquired adult flatfoot pathological process by which this dys- compensatory forefoot varus often de-
disorder with a fixed deformity or de- function occurs varies and may be in- velops (Figs. 1-A and 1-B).
generative joint disease. In general, flammatory, degenerative, or traumatic Johnson and Strom2 described
limited fusions of the hindfoot and in nature. Acquired adult flatfoot defor- three clinical stages of posterior tibial
midfoot preserve more motion than do mity can occur in younger patients tendon dysfunction (Stages I, II, and
extensive fusion procedures such as tri- (thirty to forty years old) with inflam- III). This staging system was subse-
ple arthrodesis. However, full correc- matory arthropathy, but it is more com- quently modified to include Stage IV,
tion of the deformity is important for a mon in older women (fifty to sixty years or the so-called tilted-ankle deformity,
durable outcome, and this may require old) with degenerative tears1. Posterior which indicates valgus tilt of the talus in
a more extensive fusion procedure or tibial tendon dysfunction with loss of the ankle mortise1.
the inclusion of adjunctive procedures. the dynamic stabilizer of the medial Surgical intervention is indi-
Triple arthrodesis provides the aspect of the hindfoot can lead to a pro- cated following failure of nonoperative
most reliable and predictable correction gressive valgus deformity of the hind- treatment. The surgical management
of a fixed deformity. Careful preopera- foot. Once the posterior tibial tendon of a flexible flatfoot without degenera-
tive and intraoperative physical exami- ruptures or becomes elongated, the dy- tive changes has been reviewed in detail
nation and radiographic evaluation are namic forces of weight-bearing contrib- elsewhere1,3-6. Every attempt should be
critical to developing an operative plan ute to attritional rupture or laxity of the made to fully correct the deformity with
that will address all of the components static hindfoot stabilizers and collapse hindfoot osteotomies, midfoot osteoto-
of this complex deformity and to mini- of the medial longitudinal arch. There is mies, soft-tissue balancing, and tendon
mizing the chance of its recurrence. sagging of the medial column of the transfers in order to fuse as few joints as
Posterior tibial tendon dysfunc- foot with eversion and external rota- possible; however, full correction of the
tion is the most common etiology of tion of the calcaneus in relation to the deformity may necessitate fusion of one
or more joints. Although there is con-
troversy about whether full correction
Look for this and other related articles in Instructional Course Lectures, of the deformity is absolutely necessary
Volume 55, which will be published by the American Academy of Ortho- for a good outcome7, residual hindfoot
paedic Surgeons in February 2006: valgus deformity following hindfoot
fusion with only partial correction will
• “Treatment of a Recurrent Clubfoot After Correction with the Pon- lead to substantially increased valgus
seti Technique,” by Frederick Dietz, MD stresses at the ankle and may result in
late valgus deformity of the tibiotalar
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Arthrodesis Procedures for longus tendon transfer to the navicular evaluated as well. Additional surgery,
Acquired Adult Flatfoot Deformity or the first cuneiform has been advo- such as a lateral column lengthening
In general, the proper selection of surgi- cated to improve function and stabilize with a bone block placed in the calca-
cal procedures depends on the severity the talonavicular joint even when an neocuboid joint, may be indicated
and flexibility of the deformity as well as isolated subtalar joint fusion is being to fully correct the abducted forefoot
the presence and location of degenera- performed10. to a neutral position. Any residual
tive changes about the foot and ankle. Patients with Stage-III disease varus deformity of the forefoot needs
Activity level, age, body habitus, and require a more extensive repositional to be corrected (Figs. 2-A and 2-B).
medical comorbidities need to be con- arthrodesis in order to fully correct the This may require an osteotomy of the
sidered as well. Surgical goals include fixed deformity. Triple arthrodesis is medial column, such as a plantar flex-
relief of pain, establishment of a stable indicated for a rigid subtalar joint and ion osteotomy of the medial cunei-
plantigrade foot without the need for a fixed varus deformity of the fore- form, or an extended arthrodesis of
bracing, and maintenance of the integ- foot. It may be necessary to include the medial column.
rity of adjacent unfused joints, especially adjunctive procedures to fully correct At our institution, most of these
the ankle joint. This review will focus on all components of the deformity. The procedures are performed with the pa-
the indications, surgical techniques, and decision to utilize these adjunctive tient under general anesthesia and
complications of the various arthrodesis procedures is highly dependent on with preemptive ankle block regional
procedures used for the management of the degree of deformity and the intra- anesthesia. Antibiotic prophylaxis, a
Stage-II disease with degenerative operative assessment of the correction pneumatic tourniquet, and fluoros-
changes and Stage-III disease. obtained with the initial realignment. copy are used routinely. Patients are
In Stage-II disease, the deformity After reducing the subtalar, calca- initially cared for in the hospital and
is flexible, and hindfoot osteotomies are neocuboid, and talonavicular joints, then are discharged on the day follow-
usually performed because they spare the surgeon should determine whether ing the surgery. Splints and sutures are
the important hindfoot joints and are a the foot will be plantigrade. The heel removed and a cast is applied in the
powerful means with which to correct a should be evaluated for excessive resid- clinic at approximately two weeks
wide range of deformities. Limited ar- ual hindfoot valgus, which, if present, postoperatively.
throdesis may be indicated, especially may require additional correction with
when there is a moderate deformity that a medial displacement calcaneal os- Medial Column Arthrodesis
cannot be fully corrected with recon- teotomy. The position of the forefoot Loss of the medial longitudinal arch
struction of the posterior tibial tendon relative to the hindfoot should be may be due to pathological changes in
and joint-sparing osteotomy alone.
Limited fusions are especially useful
when the deformity is flexible and there
is evidence of arthrosis in the hindfoot.
According to Mann and Beaman, tal-
onavicular arthrodesis is indicated for
management of an unstable talonavicu-
lar joint associated with a flexible subta-
lar joint in patients who are older than
fifty years of age, whereas double ar-
throdesis is preferred for an unstable
talonavicular joint associated with a
flexible subtalar joint in a younger
patient9. Isolated arthrodesis of the
subtalar joint is indicated for a fixed
deformity of the subtalar joint associ-
ated with a flexible forefoot as well as
for a flexible hindfoot deformity in
the presence of degenerative changes
in the subtalar joint. Subtalar fusion is
also indicated for salvage of a failed re-
construction of a foot with acquired
adult flatfoot deformity when there is
residual subluxation, degenerative Fig. 2-A
changes, or pain at the subtalar joint. Figs. 2-A and 2-B Evaluation for varus forefoot deformity. Fig. 2-A Forefoot varus with the subta-
The addition of a flexor digitorum lar joint corrected to neutral.
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the talonavicular, naviculocuneiform, Surgical Technique for lated screws are placed across the tal-
and/or metatarsocuneiform joints. In- Talonavicular Arthrodesis onavicular joint in a retrograde fashion.
stability or hypermobility, degenerative A dorsomedial longitudinal incision is Occasionally, a third cannulated screw
changes, or residual forefoot varus at made over the talonavicular joint, along can be placed percutaneously from the
these joints are the primary indications the lateral edge of the anterior tibial lateral aspect of the navicular into the
for medial column fusion11. Isolated ar- tendon to the tibialis anterior tendon. talus or a staple may be placed across
throdesis of the talonavicular joint es- The talonavicular joint capsule is iden- the dorsal joint line. In severely sclerotic
sentially eliminates motion in the rest tified and is incised longitudinally. bone, a tricortical iliac bone allograft or
of the hindfoot8. A patient with a flexi- Subperiosteal dissection exposes the autograft can be placed as a slot graft
ble hindfoot deformity who has no ar- remainder of the talonavicular joint. A across the joint to augment the fusion.
throsis in adjacent joints may be a small lamina spreader can help distract A saw is used to cut a rectangular
candidate for isolated talonavicular and expose the joint. The talonavicular trough perpendicular to the joint line.
arthrodesis; however, the specific in- articular surfaces are then débrided. The slot graft is then impacted into the
dications remain controversial, and The forefoot is then reduced to the talus trough, spanning the joint line. The
nonunion rates are higher than those by adducting, plantar flexing, and pro- wound is closed in the usual manner. It
following other hindfoot fusions12. Pa- nating it. Lateral counter pressure is ap- is important to assess the foot for exces-
tients with residual hindfoot valgus, in- plied to the medial aspect of the talar sive heel valgus, forefoot varus, or heel-
stability at multiple midfoot joints, or head. Provisional fixation can be ob- cord contracture preoperatively. The
ankle arthrosis may require additional tained with use of Kirschner wires or presence of these problems signifies the
procedures such as a calcaneal osteot- the guide pins for the cannulated screw need for additional or different surgery
omy, midfoot fusions, ankle fusion, or system. The hindfoot should be in 5° to to address them.
ankle arthroplasty13. Arthrodesis of the 10° of valgus. It is imperative that the Postoperatively, a bulky compres-
naviculocuneiform joint is usually per- hindfoot not be fused in varus and that sive Robert Jones dressing and splint are
formed in conjunction with other pro- the forefoot not be left in varus relative applied. Sutures are removed at two
cedures to correct hindfoot deformity to the hindfoot. The reduction should weeks. A short leg non-weight-bearing
and is done when there is residual fore- be confirmed fluoroscopically as well as cast is applied and worn for four weeks.
foot varus secondary to severe instabil- clinically. Once the reduction is deemed The patient then wears a short leg
ity or arthritis at this joint. to be satisfactory, two 4.5-mm cannu- weight-bearing cast for another four to
six weeks.
ity15. Twelve patients had Stage-II Surgical Technique in thirty-six patients did not result in
posterior tibial tendon dysfunction, A lateral longitudinal incision is made healing18. Distraction arthrodesis of
and nine patients had Stage-III disease over the anterolateral aspect of the cal- the calcaneocuboid joint causes some
with talonavicular degenerative joint caneus from just anterior to the tip of loss of motion in the foot, but less than
disease. Most of the patients experi- the fibula toward the base of the fourth is seen after subtalar or talonavicular
enced daily pain postoperatively. Radio- metatarsal. Dissection through the soft arthrodesis21.
graphic evidence of subtalar arthrosis tissues is performed to expose the ex-
developed in eight patients, and twelve tensor digitorum brevis, with care taken Isolated Subtalar Arthrodesis with
patients had pain at the subtalar joint to avoid injury to the anterior branch of Flexor Digitorum Longus Transfer
on examination. Six patients had a the sural nerve. Other cutaneous There is support in the literature for
nonunion. nerves, such as the intermediate branch the use of isolated subtalar arthrodesis
Complications of talonavicular of the superficial peroneal nerve, can to treat acquired adult flatfoot defor-
arthrodesis include residual lateral mid- occasionally enter the surgical field, and mity when the patient has a fixed defor-
foot pain, malunion, nonunion, and they need to be protected. The peroneal mity of the subtalar joint and a flexible
the development of arthrosis at adja- tendons and sural nerve are retracted forefoot22,23. Mann et al. stated that 10°
cent joints. For these reasons, talonavic- inferiorly. The extensor digitorum to 15° of forefoot varus or joint hyper-
ular fusion alone is not commonly brevis is retracted superiorly; the exten- mobility is a contraindication to iso-
performed for Stage-II acquired adult sor digitorum brevis origin and the lated subtalar joint fusion10. In such a
flatfoot deformity. plantar aspect of the muscle may be ele- situation, isolated subtalar joint arthro-
vated to facilitate exposure of the calca- desis will overload the lateral border
Lateral Column Lengthening neocuboid joint. during gait as a result of the fixed fore-
Calcaneocuboid distraction arthrodesis The articular surfaces of the cal- foot varus. Other indications for iso-
or lateral column lengthening arthro- caneocuboid joint are then débrided. A lated subtalar joint arthrodesis include
desis has been advocated for the treat- lamina spreader without teeth is used to degenerative changes in the subtalar
ment of Stage-II posterior tibial tendon distract the joint. joint and salvage of a failed hindfoot re-
dysfunction with dorsolateral peritalar Care must be taken to avoid over- construction. The procedure allows re-
subluxation16. Lengthening of the lateral correcting the heel into varus or push- sidual motion at the talonavicular and
column has been shown to restore the ing the forefoot into varus. A tricortical calcaneocuboid joints (26% and 56%
medial arch and correct hindfoot valgus iliac crest bone allograft or autograft is residual motion, respectively8). This
and forefoot abduction17,18. The decision then fashioned to fit into the distracted may have a protective effect on the
whether to perform a lengthening os- calcaneocuboid joint. This graft usually development of ankle arthritis when
teotomy through the distal part of the measures between 8 and 12 mm in compared with triple arthrodesis23.
calcaneus or with distraction arthro- width16. Fixation is obtained with a 4.0 However, the authors of an in vitro bio-
desis of the calcaneocuboid joint is con- or 4.5-mm cannulated screw inserted in mechanical study concluded that iso-
troversial7,19. Proponents of distraction a retrograde direction. However, an iso- lated subtalar or calcaneocuboid fusion
arthrodesis of the calcaneocuboid joint lated distraction arthrodesis of the cal- cannot achieve full correction of a mod-
cite the potential for the development caneocuboid joint usually requires erate flatfoot deformity with substan-
of degenerative changes at the calca- additional fixation to help prevent a tial transverse tarsal joint laxity; in
neocuboid joint following osteotomy nonunion, and a lateral plate is often contrast, a talonavicular, double, or tri-
of the calcaneus as a result of increased added. The extensor digitorum brevis is ple arthrodesis completely corrected the
contact pressures at the calcaneocuboid reapproximated, and the skin is closed deformity24. We believe that, when an
joint4,16-21; however, the nonunion rate in the usual manner. Postoperative care isolated subtalar fusion is performed to
following distraction arthrodesis of the is similar to that described above. treat acquired adult flatfoot deformity,
calcaneocuboid joint is approximately the addition of a flexor digitorum lon-
20%. Typically, if lateral column length- Outcomes and Complications gus transfer helps to support the tal-
ening is required as a component of the Complications of calcaneocuboid ar- onavicular joint and balances the pull
correction of a flexible Stage-II acquired throdesis include cutaneous neuroma of the peroneus brevis22.
adult flatfoot deformity, a lengthening of the sural or superficial peroneal
osteotomy of the calcaneal neck with nerve, residual lateral midfoot pain, Surgical Technique
interposition of bone graft is per- malunion, nonunion, and the develop- An oblique longitudinal skin incision is
formed. When lateral column lengthen- ment of arthrosis at adjacent joints. made from the tip of the lateral malleo-
ing is needed for a Stage-III acquired Symptomatic nonunion is treated with lus toward the base of the fourth meta-
adult flatfoot deformity, distraction ar- bone-grafting and plate, screw, or staple tarsal, centered over the sinus tarsi.
throdesis of the calcaneocuboid joint is fixation. Chi et al. reported that eight Alternatively, an oblique Ollier-type in-
performed with interposition of bone of forty-one attempted distraction ar- cision can be used, but this may limit
graft as part of a triple arthrodesis. throdeses of the calcaneocuboid joint the placement of a calcaneal osteotomy
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Mann and Beaman reported the formity when the subtalar joint or posure and allows easier correction of
outcomes of twenty-four double arthro- transverse tarsal joint is not passively the deformity.
deses at an average of fifty-six months9. correctable, when there are degenera-
Sixteen of the double arthrodeses were tive changes at the subtalar joint or Surgical Technique
performed for acquired adult flatfoot transverse tarsal joint, and for the sal- Two incisions are utilized for this proce-
deformity due to posterior tibial tendon vage of a failed hindfoot reconstruction. dure. The lateral incision is made ob-
insufficiency, and eight were done for The radiographic criteria for triple ar- liquely from the tip of the distal part
other diagnoses. Similar outcomes were throdesis are controversial and are of of the fibula to the base of the fourth
observed in the two groups of patients, limited value27. Myerson recommended metatarsal. Occasionally, branches of
with eighteen patients having a good or triple arthrodesis for a fixed hindfoot the intermediate branch of the superfi-
excellent result overall. Complications deformity with subfibular impinge- cial peroneal nerve may cross the surgi-
were more frequent in the patients who ment1. Others have stated that medial cal field near the anterior aspect of the
had flatfoot deformity. Talonavicular foot pain associated with dorsal per- calcaneus. If they do, these branches are
nonunion was the most frequent com- italar subluxation should be corrected identified and are retracted cephalad.
plication, occurring in four patients, with triple arthrodesis28. The goal of tri- The subcutaneous exposure involves
three of whom required revision arthro- ple arthrodesis is to fuse the subtalar, creation of full-thickness flaps with
desis. The development of arthrosis in talonavicular, and calcaneocuboid meticulous soft-tissue handling. Care
the surrounding joints was common joints with the hindfoot in 5° of valgus should be taken to identify and protect
but asymptomatic. For this reason, tri- and to correct midfoot and forefoot the sural nerve and any branches of the
ple arthrodesis may be preferred for deformities to neutral through reposi- superficial peroneal nerve.
most patients. tional arthrodesis. A single extensile The peroneal tendons are identi-
lateral or extensile medial incision fied and retracted. The extensor digi-
Triple Arthrodesis could be used if needed for access to the torum brevis is incised along its muscle
Triple arthrodesis is indicated for the joint in a triple arthrodesis, but a two- fibers and is sharply raised from the
treatment of acquired adult flatfoot de- incision technique provides better ex- calcaneal insertion. The subtalar joint
is exposed as described above. The lat-
eral talonavicular, calcaneocuboid, and
naviculocuboid articulations are identi-
fied. A useful landmark for localizing
the talonavicular joint is the insertion
of the bifurcate ligament (ligament of
Chopart). The bifurcate ligament con-
sists of the lateral calcaneonavicular
and medial calcaneocuboid ligaments
and inserts into the calcaneonavicu-
locuboid region. The lateral aspect of
the calcaneus is followed distally to the
calcaneocuboid joint. The calcaneo-
cuboid joint capsule is incised sharply
both laterally and dorsally. The lateral
aspect of the talonavicular joint may
then be partially exposed and débrided
through the lateral incision. The navic-
ulocuboid articulation is débrided in a
similar manner. Exposure of the calca-
neocuboid joint can be facilitated by
use of a small lamina spreader. The ar-
ticular surfaces of the calcaneocuboid
joint are then débrided. The articular
Fig. 5 surfaces of the subtalar joint are pre-
Lateral view showing flatfoot deformity and forefoot abduction deformity (top) and reduction of pared as described above.
those deformities (bottom) with a lamina spreader placed between the anterior aspect of the cal- The dorsomedial approach, as de-
caneus and the lateral shoulder of the talus. Cross-hatched locations on the talus and the calca- scribed above, is used to expose the re-
neus demonstrate proper placement of the lamina spreader. (Reprinted, with permission, from: mainder of the talonavicular joint and
Hansen ST Jr. Functional reconstruction of the foot and ankle. Philadelphia: Lippincott Williams allow complete débridement of the tal-
and Wilkins; 2000. p 302-3.) onavicular joint. The foot is placed into
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nically, it is important to countersink the foot deformity. The need to perform formity and restoring the weight-
head of the screw in the navicular to these procedures is determined by care- bearing tripod of the foot. The osteot-
minimize hardware prominence. The ful preoperative and intraoperative as- omy is oriented in the coronal plane
calcaneocuboid articulation is internally sessment of the hindfoot alignment and through the midportion of the medial
fixed with two 30 to 40-mm-long 4.5- the degree of fixed varus deformity of cuneiform at the level of the second tar-
mm cannulated screws or a staple device. the forefoot. Tendo Achillis lengthen- sometatarsal joint (Fig. 6). The first ray
Postoperative care is similar to ing or gastrocnemius-soleus lengthen- is then plantar flexed through this os-
that following any arthrodesis of the ing is almost always necessary to correct teotomy site by gently levering the site
hindfoot. Initially, a bulky compressive the equinus contracture seen with ac- open with a small osteotome. The re-
Robert Jones dressing and splint are ap- quired adult flatfoot deformity. These sulting gap in the cuneiform is mea-
plied. At two weeks, the foot is placed in procedures are indicated when the pa- sured once the first ray is plantar flexed
a cast, which is worn for an additional tient lacks 10° of ankle dorsiflexion with to a neutral position. A wedge-shaped
four weeks. Protected weight-bearing the knee extended. Tendo Achillis tricortical allograft bone block is then
in a cast is begun at six weeks. At ten lengthening can be performed percuta- cut to this width. It is usually between
weeks, a removable walker boot is ap- neously or with an open technique, and 4 and 7 mm thick. The graft is im-
plied, and the patient gradually resumes gastrocnemius-soleus lengthening is pacted into the osteotomy site. The
shoe wear at twelve to fourteen weeks. performed in the midcalf through a osteotomy site is secured with internal
small medial or midline incision. We fixation with a 4.0-mm screw or a per-
Outcomes and Complications prefer an open Z-lengthening of both cutaneous 0.062-inch (1.575-mm)
Outcomes after triple arthrodesis have the gastrocnemius and the soleus mus- Kirschner wire. If the forefoot varus is
been well described27,29-36. Graves et al. cle at the myotendinous junction, as secondary to instability, subluxation,
reported on a series of eighteen feet in this allows a more controlled release of or degenerative arthritis at the first tar-
seventeen patients who had undergone the gastrocnemius muscle either alone sometatarsal joint, reduction and fusion
triple arthrodesis30. At an average of 3.5 or in combination with the soleus, de- of this joint is performed.
years, pain was decreased in all patients, pending on which is tight. However,
although eleven feet were the source of excellent results can be obtained with Overview
residual discomfort. A substantial prev- either method. The proper management of acquired
alence of degenerative changes in the Medial displacement calcaneal adult flatfoot deformity requires care-
ankle and foot was noted. The authors osteotomy is useful for correcting resid- ful history-taking and physical exami-
concluded that triple arthrodesis is a sat- ual hindfoot valgus after initial realign- nation of the foot, ankle, and lower
isfactory salvage operation but is techni- ment of the heel. Medial displacement extremity. Accurate assessment of foot
cally difficult an.d is associated with a calcaneal osteotomy helps to remove flexibility and localization of pain will
relatively high complication rate. Fortin the deforming force of the Achilles aid in decision-making. Nonoperative
and Walling29 and Haddad et al.36 both tendon on the valgus heel by displacing management is the recommended ini-
noted effective pain relief and improved its insertion medially. It may be used tial treatment, but it may not be suc-
function at four to six years following in conjunction with a lateral column cessful for the treatment of advanced
triple arthrodesis for deformity correc- lengthening by means of calcaneo- disease, particularly when there are de-
tion. Both concluded that triple arthro- cuboid distraction arthrodesis if there generative changes. Surgical manage-
desis was an acceptable treatment for is excessive residual hindfoot valgus ment of advanced acquired adult
late-stage disease and noted a propensity along with excessive forefoot abduction. flatfoot deformity (Stages III and IV) is
for secondary degenerative changes to The need for a medial displacement indicated if nonoperative management
develop at the ankle joint. Similarly, in calcaneal osteotomy can be assessed has failed. Adjunctive procedures, such
a report on the results twenty-five and intraoperatively after provisional re- as tendo Achillis lengthening, medial
forty-four years after triple arthrodesis, duction and fixation of the calcaneus displacement calcaneal osteotomy, lat-
Saltzman et al. reported that sixty-four under the talus. The surgeon can then eral column lengthening, stabilization
of sixty-seven feet had a satisfactory assess the hindfoot for any residual val- of the first tarsometatarsal joint, and
result37. Twenty feet had degenerative gus deformity. If excessive hindfoot val- plantar flexion osteotomy of the medial
changes at the ankle at twenty-five years, gus is noted, either repeat repositioning column of the foot are useful for cor-
and all had degenerative changes at of the subtalar joint can be performed recting residual deformities after hind-
forty-four years. Interestingly, the radio- if full correction was not obtained or a foot realignment intraoperatively.
graphic appearance of the ankle did not medial displacement calcaneal osteot-
correlate with symptoms. omy can be utilized to correct the resid-
ual valgus. Jeffrey E. Johnson, MD
Adjunctive Procedures A plantar flexion osteotomy James R. Yu, MD
Adjunctive procedures may be neces- through the medial cuneiform is useful Department of Orthopaedic Surgery, Washing-
sary to fully correct a severe fixed flat- for reducing residual varus forefoot de- ton University School of Medicine, 660 South
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Euclid Avenue, Box 8233, St. Louis, MO commitment or agreement to provide such Printed with permission of the American
63110. E-mail address for J.E. Johnson: benefits from a commercial entity. No com- Academy of Orthopaedic Surgeons. This arti-
foot@msnotes.wustl.edu mercial entity paid or directed, or agreed to cle, as well as other lectures presented at the
pay or direct, any benefits to any research Academy’s Annual Meeting, will be available in
The authors did not receive grants or outside fund, foundation, educational institution, February 2006 in Instructional Course Lectures,
funding in support of their research or prep- or other charitable or nonprofit organiza- Volume 55. The complete volume can be or-
aration of this manuscript. They did not tion with which the authors are affiliated or dered online at www.aaos.org, or by calling
receive payments or other benefits or a associated. 800-626-6726 (8 A.M.-5 P.M., Central time).
References
1. Myerson MS. Adult acquired flatfoot deformity: quired flatfoot in the adult. Clin Orthop Relat Res. 25. Hansen ST Jr. Functional reconstruction of the
treatment of dysfunction of the posterior tibial ten- 1999;365:65-8. foot and ankle. Philadelphia: Lippincott Williams and
don. Instr Course Lect. 1997;46:393-405. Wilkins; 2000.
15. Below SK, McCluskey LC. Isolated talonavicular
2. Johnson KA, Strom DE. Tibialis posterior ten- arthrodesis for posterior tibial tendon dysfunction 26. Coughlin MJ, Mann RA, editors. Surgery of the
don dysfunction. Clin Orthop Relat Res. 1989; and degenerative joint disease of the talonavicular foot and ankle. 7th ed. St. Louis: Mosby; 1999.
239:196-206. joint. Read at the Annual Summer Meeting of the
27. Bednarz PA, Monroe MT, Manoli A 2nd. Triple
American Orthopaedic Foot and Ankle Society; 2002
3. Myerson MS, Corrigan J, Thompson F, Schon LC. arthrodesis in adults using rigid internal fixation:
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