Johnson Classification
| Stage 1 | Stage 2 | Stage 3 | Stage 4 |
|---|---|---|---|
| T posterior tendonitis | T posterior rupture | Fixed deformity subtalar joint |
Varus angulation talus |
| Able to single heel raise |
Unable to single heel raise Correctable subtalar joint |
+/- subtalar OA | +/- ankle joint OA |
|
IIA: As above IIB: Forefoot abduction |
Management options
| Stage 1 | Stage 2 | Stage 3 | Stage 4 |
|---|---|---|---|
|
Orthotics
Tibialis posterior debridement +/- FDL transfer |
Medial displacement calcaneal osteotomy + FDL transfer
Lateral column lengthening
|
Triple arthrodesis |
Pantalar fusion |
Non operative management
Indications
Stage 1 Tendonitis
Stage 2 Flexible planovalgus
Options
UCBL
- worn inside the shoe
- ends under malleoli
- controls the heel (which must be flexible) & supports the arch
Operative management
Tibialis Posterior Synovectomy
Technique
Incision
- tip of medial malleolus to navicular
- open tendon sheath
- perform synovectomy +/- repair
+/- FDL transfer
FDL transfer
Technique
Incisions
- along entire length T posterior
- 10 cm proximal to medial malleolus
- to metatarsal cuneiform joint
Deep dissection
- abductor hallucis reflected plantarward
- Knot of Henry - crossover of FDL & FHL
- FDL plantar to FHL
- suture together and release proximal FDL
Expose navicular
- reinsert FDL into underside of navicular
- plantar to dorsal
- ankle in equinus & forefoot in varus
+/- repair spring ligament
Medial displacement calcaneal osteotomy
Technique
Lateral approach
- curve just behind peroneals
- homann in front of tendoachilles
- homann under calcaneum
Oblique osteotomy behind posterior facet
- 45o
- open with lamina spreader
- split periosteum medially with osteotome
- avoid damage to medial structures
- transfer medially 1 cm
- screw fixation
Evans Calcaneal Lengthening Osteotomy
Technique
Vumedi calcaneal lateral lengthening osteotomy video
Incision over anterolateral distal calcaneum
- sural nerve retracted plantar
- P longus retracted plantar
- identify CCJ
- Z lengthen P brevis
- homan retractor in sinus tarsi (between middle and anterior facets)
- homan retractor inferior calcaneum
- K wire into CCJ to prevent subluxation
Opening wedge osteotomy
- 1.5cm proximal to CCJ
- between middle and anterior facets medially
- begin with saw, complete with osteotome
- open 1 cm
- triangular / trapezoidal bone graft (allograft, iliac crest / mid fibular autograft)
- fixation with plate / staple / screw
+/- tendoachilles lengthening
+/- modified Kidner procedure (imbricate spring ligament, Tibialis posterior advancement)
Triple Arthrodesis
Indication
Fixed hindfoot deformity with lateral joint pain
Aim
Realign hindfoot with plantigrade foot
Issues
1. Fuse TNJ first
- this should passively align STJ
- need medial approach to reduce TNJ
2. Fuse STJ
- slight valgus not neutral or varus
- lateral approach
- may need large lateral bone wedge
- may have issues with lateral skin closure