Stage I: Tenosynovitis Without Deformity

In stage I disease, the tendon is inflamed or partially ruptured and may or may not be accompanied by systemic inflammatory disease. In either case, deformity is absent or minimal and the overall continuity of the tendon is maintained. Tendon continuity is confirmed on physical examination with an intact single-leg heel raise and good resisted foot inversion strength with the foot plantarflexed. Stage I is subdivided into three categories:

• A.
  

  Inflammatory disease: PTT rupture that results from a systemic disease such as rheumatoid arthritis and the other inflammatory arthritides is recognized as a separate entity. In stage IA, hindfoot anatomy is maintained and the foot alignment is normal. Surgical treatment consists of tenosynovectomy, which may easily be performed endoscopically.

  
  
• B.
  

  Partial PTT tear with normal hindfoot anatomy: care for this stage typically begins with a conservative treatment consisting of antiinflammatory medications and immobilization in a cast, walking boot, or custom brace. If refractory to nonsurgical treatment, then one must consider at the very least a tenosynovectomy with or without a calcaneus osteotomy as later in stage IC

  
  
• C.
  

  Partial PTT tear with hindfoot valgus: presence of a slight (deviation of 5 degrees or less) deformity distinguishes stage IC from stage II disease. Although care begins with conservative treatment, this stage may represent a more incipient rupture, and the foot should be monitored closely. Surgical treatment consists of a tenosynovectomy and a medial translational osteotomy of the calcaneus. If additional deformities are present, including medial arch sag, then this must be treated with medial column stabilization (NC or first TMT instability) or a Cotton osteotomy (if no instability) based on the apex of the deformity.

• 1.
  

  The hindfoot valgus

  
  
• 2.
  

  The muscle imbalance as a result of the PTT rupture

  
  
• 3.
  

  The fixed forefoot supination deformity

  
  
• 4.
  

  The abduction deformity of the midfoot

  
  
• 5.
  

  Management of the hypermobile medial column or what has been referred to as medial column instability.

Stage II: Ruptured Posterior Tibial Tendon and Flexible Flatfoot

Stage II disease is defined by presence of PTT tendon rupture/tendinosis, as evidenced on physical examination by a clinically apparent flatfoot, weakness with inversion of the plantarflexed foot, and inability to perform a single-leg heel raise. Stage II disease is subdivided into five categories on the basis of the most salient feature present. Because some patients exhibit several of the following features, some degree of overlap always exists.

• A.
  

  Hindfoot valgus: in stage IIA, once the heel is reduced from valgus to neutral, there is minimal residual forefoot supination. Treatment options include an FDL tendon transfer combined with a medial displacement calcaneal osteotomy (MDCO) to reduce hindfoot valgus. A subtalar arthrodesis must be selected in appropriate patients who are obese, or who have slightly more deformity than the FDL and calcaneus osteotomy can support. In lower-demand patients, a selected subtalar arthrodesis may be the most reliable operation if severe deformity is present. We believe that the muscle balance of the hindfoot is essential. The FDL cannot possibly compensate for the loss of the PTT, and over time the stronger peroneals will cause the hindfoot to evert and failure to occur. For this reason, approximately 8 years ago, we began performing a peroneus brevis to peroneus longus tendon transfer to improve the balance of the hindfoot ( Fig. 14.3 ). Wherever possible, we should try to preserve the power of the posterior tibial muscle. Under appropriate circumstances discussed subsequently, we use an allograft tendon to replace the torn PTT in conjunction with additional procedures as required.

  
  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  Peroneal tendon transfer of the longus to brevis can be performed with a minimal incision 5–6 cm proximal to tip of the fibula (A). Identification of the longus (arrow) and brevis is easily noted, as the brevis (arrowhead) has associated muscle and is anterior to the longus (B). We prefer to perform the tenodesis with absorbable suture with use of monofilament for a portion of the tenodesis (C). The brevis is isolated distal to the tenodesis and carefully transected (D). Following completion of the transfer, tension on the brevis will result in distal tension on the longus (arrow) (E).

  
  
  
  
• B.
  

  Flexible forefoot supination: in stage IIB, reducing the hindfoot from valgus to neutral results in forefoot supination because of gastrocnemius muscle contracture ( Fig. 14.4 ). However, the forefoot deformity is flexible; if the ankle is plantarflexed to relax the gastrocnemius muscle, the forefoot supination is corrected ( Fig. 14.5 ). Recommendations for this stage would be exactly the same as those for stage IIA, but with the addition of a gastrocnemius muscle recession. In this stage, we did not originally perform a medial cuneiform osteotomy (Cotton), but this became a fairly routine procedure even with mild supination of the forefoot. We found that by adding a cuneiform osteotomy, it had a protective effect on the medial column, and corrected mild sag at either the TMT or NC joints.

  
  

  
  

  
  

  

  
  

  
  

  (A) The hindfoot is in valgus, with moderate abduction of the forefoot at rest. (B) The foot is very flexible and can be completely restored to a neutral position by holding the heel in neutral. The lack of supination differentiates Stage IIA from Stage IIB (see Fig. 14.5 ), while flexibility of the forefoot supination differentiates Stage IIB from Stage IIC (rigid supination).

  
  

  
  

  
  

  

  
  

  
  

  (A) In this case, slight forefoot supination is apparent with the heel reduced to neutral. (B) This forefoot supination disappears when the forefoot is held in equinus, demonstrating that the supination is a result of a gastrocnemius contracture and not intrinsic to the medial column of the foot.

  
  
  
  
• C.
  

  Fixed forefoot supination: in stage IIC, as a consequence of long-standing hindfoot valgus, adaptive changes have occurred in the frontal plane of the forefoot. Thus although the hindfoot deformity is supple and reducible to neutral, the forefoot deformity becomes fixed once the heel is held in a reduced position. In other words, when the ankle is plantarflexed while the hindfoot is held in reduction, the forefoot remains supinated. The operative treatment recommendation for stage IIC is to angulate the medial ray plantarward to rectify the fixed forefoot supination and restore a plantigrade foot (in addition to the treatment for stage IIA or IIB disease). Correction is typically accomplished with a dorsal opening wedge osteotomy of the medial cuneiform with insertion of an allograft bone wedge or metallic cage. The alternative we commonly use is to perform an arthrodesis of the first TMT joint to stabilize and plantarflex the medial column. While we recognize that some surgeons use an arthrodesis of the NC joint fairly commonly to stabilize the medial column, this is not a procedure that we have found to be routinely necessary. In a recent study, we examined all patients who had undergone a Cotton osteotomy in addition to the appropriate hindfoot procedures and focused specifically on the first TMT and NC joints, finding that the cuneiform osteotomy improved the sag that had been present preoperatively at the NC joint. This is not to imply that an arthrodesis of the NC joint is not necessary, since severe sag should be corrected with arthrodesis ( Fig. 14.6 ).

  
  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  This patient presented with greater than 50% abduction of the talonavicular joint with collapse through the naviculocuneiform (NC) joint as well (A and B). To maintain some hindfoot motion and focus on the major site of sagittal collapse (arrow) , which was noted to be the NC joint, a subtalar and NC fusion, combined with a spring ligament reconstruction, gastrocnemius recession, and peroneus brevis to longus transfer, was performed. Note that although a first tarsometatarsal (TMT) fusion may be considered for the medial column, the first TMT joint (arrowhead) is symmetric without subluxation and is not a site of instability. In this 18-year-old patient, an attempted NC and lateral column lengthening failed to correct the deformity and resulted in violation to the calcaneocuboid (CC) joint (C and D). The focus of collapse is clearly the NC joint (arrow) , and the initial proposed surgery did focus on the appropriate site of deformity, which is not the first TMT (arrowhead) . A revision NC fusion with a lengthening through the CC joint was performed along with a medial displacement calcaneal osteotomy to achieve correction.

  
  
  
  
• D.
  

  Forefoot abduction: this may occur at the transverse tarsal joint (most commonly) or at the TMT joints. The first TMT joint instability can be either a primary deformity or a result of TMT joint arthritis. The simplest way to make this distinction is through examination of the lateral view radiograph for a gap at the plantar joint surface, which is present with primary deformity. Primary deformity of the first TMT joint may also result in secondary hindfoot deformity, including rupture of the PTT. Surgical treatment consists of an arthrodesis of the first TMT joint, an FDL tendon transfer combined with a lateral column lengthening procedure such as a modified Evans procedure but only if necessary, since this depends on the apex of the deformity. If abduction is present associated with arthritis at the TMT joints, then these need to be fused focusing in particular on the first ray. If the apex is at the TN joint, then a lateral column lengthening is indicated. This is accomplished with a lateral opening wedge osteotomy of the calcaneus 1 to 1.5 cm posterior to the calcaneocuboid (CC) joint with insertion of allograft bone or metallic cage.

  
  
• E.
  

  Medial ray instability: as in stage IIC (fixed forefoot supination), the stage IIE foot retains forefoot supination with reduction of the valgus heel to neutral. This supination persists even with ankle plantar flexion, as a result of instability of the medial column, and may arise from any component structure of the medial column. It may occur at the TN, NC, or first TMT joints, or a combination thereof. This situation is similar to that in stage IIA; after the heel is corrected to neutral, however, the unstable medial ray will tend to dorsiflex; this dorsiflexion causes the foot to collapse to pronation, leading to painful subtalar joint impingement. In general, the treatment used is the same as for stage IID disease. The addition of medial column arthrodesis should be considered. This arthrodesis is usually unnecessary for most patients, however, because medial column stability is commonly restored after lateral column lengthening with the addition of an opening wedge osteotomy of the medial cuneiform. However, in this group of patients, there is fairly gross instability associated with more than 50% uncovering of the TN joint, and one can consider an arthrodesis of the TN joint here, even in the presence of a flexible flatfoot. However, one must be aware that arthrodesis of the hindfoot will increase the stress on the deltoid ligament and may result in postoperative ankle valgus. The most recent data suggests that approximately 27% of patients without ankle valgus preoperatively will have postoperative ankle valgus following a triple arthrodesis (TN arthrodesis effectively results in the same rigidity). The alternative is to perform a lateral column lengthening and then perform a spring ligament reconstruction, providing adequate support to the TN joint. In patients with hypermobility, this latter combination may not work successfully, and an arthrodesis of the TN joint can be considered. In general, a calcaneus osteotomy is added as well as any additional medial column procedure such as a first TMT arthrodesis or a Cotton osteotomy. We attempt to maximize the mobility of the hindfoot in most cases to the minimize the risk of postoperative ankle valgus and tend to perform a subtalar arthrodesis over a TN arthrodesis if gross instability of the hindfoot is noted. We are aware that mild persistent deformity may remain; however, resolution of subfibular impingement is predictable which is critical in these patients.

Stage III: Rigid Hindfoot Valgus

Stage III disease is generally associated with a more advanced course of tendon rupture and deformity and is typically characterized by rigid hindfoot valgus. Forefoot deformity may also be present and usually consists of rigid forefoot abduction.

• A.
  

  Hindfoot valgus: treatment usually consists of triple arthrodesis.

  
  
• B.
  

  Forefoot abduction: treatment also consists of triple arthrodesis, but in certain cases lateral column lengthening with a bone block arthrodesis of the CC joint is also required to fully adduct the forefoot back to neutral. Sparing the CC joint has become a popular method of treatment and can be quite effective for many patients. However, one must understand that this does not apply to every case of rigid hindfoot valgus. In cases of coalition, arthritis of the CC joint, or revision arthrodesis, the subtalar joint cannot be mobilized effectively, which prevents the ability to appropriately correct abduction. In the case of CC arthritis, residual pain will be present if not arthrodesed. To correct the severely abducted foot, one can either lengthen the lateral column—that is, the CC joint—or shorten the medial column by way of resecting more bone from the head of the talus. We do not believe that this is anatomic, or ideal, and despite the need for bone healing on both sides of the graft at the CC joint, we believe that this is the appropriate procedure ( Fig. 14.7 ).

  
  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  Preoperative radiographs (A and B) of a 17-year-old with a subtalar coalition. Intraoperative fluoroscopy following correction of the TN joint before fixation of the subtalar joint demonstrates gapping at the calcaneocuboid (CC) joint (C). Given the lack of mobility of the subtalar joint in this case, correction of the medial column will result in distraction across the CC joint, as opposed to a severely deformed flexible flatfoot or in hindfoot arthritis. To achieve correction, the CC joint is arthrodesed with an allograft interposition to maintain the new length of the lateral column (D and E).

  
  

Stage IV: Ankle Valgus

Stage IV disease occurs after chronic tendon rupture and is associated with deltoid ligament rupture and medial ankle instability, leading to ankle (tibiotalar) joint valgus deformity. It can occur in the setting of previous triple arthrodesis. Several variants of this condition have been seen. It may or may not be associated with ankle instability and arthritis and a flexible or rigid hindfoot. Over the past decade, we have treated patients with a valgus ankle deformity, a rupture of the deltoid ligament, but an intact PTT. This is unusual and is not consistent with the classification of stage IV PTT rupture. In these patients, the focus of treatment is on the deltoid reconstruction, and then correction of additional deformity, which usually includes a calcaneus osteotomy, a first TMT arthrodesis, and a gastrocnemius recession. A stress x-ray (XR) under fluoroscopy is always necessary to plan treatment for the ankle valgus deformity, since one must ascertain the flexibility of the ankle joint.

• A.
  

  Flexible ankle valgus: in this setting, reconstructing ankle deformity with medial-sided ankle procedures is appropriate in conjunction with additional procedures of the hindfoot and midfoot as necessary.

  
  
• B.
  

  Rigid ankle valgus: this is the more common presentation of stage IV disease. In stage IVA, the ankle valgus deformity is mostly rigid and is almost irreducible. Nonoperative treatment consists of use of an ankle orthosis such as a custom Baldwin or Arizona brace, and operative treatment is with ankle arthrodesis (in the setting of previous triple arthrodesis), pantalar arthrodesis, and tibiotalocalcaneal arthrodesis. One also has the option of correcting the hindfoot deformity, correcting the ankle valgus with a ligament reconstruction, and then at a future stage, performing an ankle replacement in order to preserve some ankle motion.

Tenosynovectomy

A tenosynovectomy is indicated in patients who have inflammatory changes in the PTT but do not have deformity. Usually tenosynovectomy is necessary early in the course of the disease process as the tendon is beginning to tear. In some patients, however, an inflammatory tenosynovitis may be associated with a seronegative spondyloarthropathy. We are more inclined to perform earlier surgery in these patients, because infiltrative tenosynovitis will eventually cause rupture of the tendon ( Fig. 14.8 ). A tenosynovectomy is indicated after failure of nonoperative care. The nonoperative regimen generally consists of a period of immobilization in either a boot or a cast, followed by use of some sort of brace or orthosis. In addition, a decision has to be made whether to correct any (mild) deformity of the hindfoot along with the tenosynovectomy.

Inflammatory changes in the tendon in a patient who had psoriasis with multiple additional symptoms, including pain of 2 months’ duration in the posteromedial ankle.

If, as is probable, tenosynovitis represents the early stage of rupture of the PTT, then some hindfoot deformity is also likely to be present, and indeed a gastrocnemius contracture is invariably present. This deformity usually consists of valgus of the heel, slight supination at the midfoot, and contracture of the gastrocnemius-soleus muscle. In patients with such deformity, therefore, the performance of a medial translational osteotomy of the calcaneus, along with the tenosynovectomy, and a gastrocnemius recession may be prudent. Certainly, adding this procedure would be a good idea if minor fissuring indicative of early rupture were present in association with the tenosynovitis. This additional surgery is usually not necessary, however, when the tenosynovitis is associated with a seronegative inflammatory disorder. In patients with such disorders, the tenosynovitis develops as part of a spondyloarthropathy and enthesopathy, and deformity occurs much later, after complete rupture of the tendon. The goals of the tenosynovectomy are to decrease pain and to remove any of the inflammatory tissue that may hasten the rupture. Then the foot should be rested until healing takes place.

If one has the endoscopic skills to perform the procedure, this is quite straightforward, with debridement of the tendon and release of the retinaculum, called the laciniate ligament. To begin the open tenosynovectomy, an incision is made posteromedially along the length of the tendon, and the retinaculum is opened completely ( Fig. 14.9 ). Occasionally, the tenosynovitis is a result of a stricture or stenosis of the retinaculum immediately behind the medial malleolus. This stricture creates an hourglass shape to the tendon, with obvious deformity and inflammatory change visible in the tendon. Once the retinaculum has been opened, the tendon is inspected. The inflammatory change is not always that obvious and is frequently on the posterior surface of the tendon and tendon sheath. The tendon must then be rotated to inspect the posterior surface. We find that skin hooks are the easiest way to do this, by flipping the tendon around to inspect the posterior surface. The inflammatory tissue is then removed from the tendon sheath and the tendon itself; either dissection scissors or a knife blade is used in this procedure. Rubbing the tendon vigorously with a sponge also facilitates removal of this inflammatory tissue. Finally, the tendon should be inspected for any tears, which, as stated, are usually on the posterior surface ( Fig. 14.10 ). If a minor tear is identified, it is repaired with a running suture of monofilament absorbable suture. We use a 2-0 suture and bury the knot and then run the suture along the length of the tendon, imbricating the tendon along the way as the repair is performed. We do not repair the flexor retinaculum, because the tendon will not subluxate provided that the foot is immobilized for a few weeks after surgery. It is always a good idea to support the tendon if there is a tear, which is simultaneously repaired; in such instances, a calcaneus osteotomy can be performed. We are aware of the popularity of arthroereisis in the adult patient in some countries, but from our own personal experience as well as those of colleagues, the complication rate is high. It is associated with pain in the sinus tarsi in a high percentage of patients necessitating removal in more than 60% of patients, some of whom develop arthritis of the subtalar joint as a result of chronic irritation and valgus impingement. The hindfoot must be in neutral and the forefoot plantigrade for an arthroereisis to work. If any residual valgus is present, impingement and pain will develop. This is completely different in the child’s foot, which adapts very quickly to the use of arthroereisis.

(A) The tendon sheath is then opened. (B) Note the extensive tenosynovitis along the length of the tendon, evident in (A). Involved tissue was removed by sharp dissection.

A 44-year-old athletic patient presented with posteromedial ankle pain of 6 months’ duration. (A) Opening the tendon sheath revealed hypertrophic and proliferative tenosynovitis. (B) On further exploration, the tendon was noted to be torn longitudinally and was repaired. No associated deformity whatsoever was present. To protect the tendon during the healing process, a medial translational osteotomy of the calcaneus was performed simultaneously.

Medial Translational Osteotomy of the Calcaneus

Correction of the flexible flatfoot deformity, with or without an associated tear of the PTT, begins with the lateral approach, including calcaneus osteotomy ( Fig. 14.11 ). Once the osteotomy has been completed, the tendon transfer of the peroneus brevis to longus is performed (see later). The incision is then closed, and the patient is turned from the lateral to the supine position for the tendon transfer and PTT correction and medial sided procedures. Alternatively, the patient may be placed in a supine position with a bump to a neutral position to perform both the medial and lateral sided procedures without the need to change positions. However, the surgeon will be required to work from the lateral aspect which may be uncomfortable for some. The medial approach will be similar as the bump may simply be removed, allowing for natural external rotation for the medial side.

The incision for the calcaneus osteotomy is made slightly further posteriorly than one would normally make, so as to leave a wider skin bridge between the two incisions.

This osteotomy is extremely utilitarian, and we use the calcaneus osteotomy for correction of multiple types of deformities whenever hindfoot valgus is present and when the medial aspect of the foot needs to be supported. Restructuring the medial column of the foot, leaving the hindfoot in valgus, does not correct the hindfoot deformity. The rationale for the medial translation is not only the movement of the calcaneal tuberosity medially, with corresponding improvement of the mechanical tripod of the heel with respect to the forefoot, but also the medialization of the insertion of the Achilles tendon relative to the axis of the subtalar joint.

Many clinical and biomechanical studies have supported this osteotomy, with its positive impact on both the foot and the ankle. The osteotomy can be used to improve the mechanics of the tibiotalar joint, because medial translation will increase the contact pressure on the medial aspect of the tibiotalar joint when valgus deformity is present in the ankle. The osteotomy can also be added to a triple arthrodesis to improve the mechanical support of the ankle in a stage IV rupture of the PTT in conjunction with reconstruction of the deltoid ligament. This is an extremely reliable operation, and nonunion is not a problem. With internal fixation, the tuberosity can be shifted at least 12 mm without any concern for instability or nonunion. Overcorrection into slight varus can occur, albeit rarely. If an osteotomy is performed in conjunction with a subtalar arthrodesis, then following debridement and preparation of the joint, the osteotomy is performed, shifted medially, and the same screw(s) can be used to stabilize the osteotomy and the arthrodesis. Alternatively, the screws to fix the osteotomy are placed from posterior to anterior, allowing room for screws to be directed toward the subtalar joint ( Fig. 14.12 ).

Mortise ankle radiograph demonstrating severe ankle valgus (A) in association with significant collapse of the longitudinal arch (B). Given the deformity and arthritic changes noted on computed tomography scan, a triple arthrodesis was performed (C), with a concomitant medial displacement calcaneal osteotomy (MDCO) (D) to minimize risk of worsening ankle valgus. Screw fixation of the MDCO was performed first, with a second screw used to transfix the subtalar joint. Six months postoperatively, the correction of the hindfoot valgus with reduction of subtalar joint under the talus is clearly seen (E), however, with persistent ankle valgus. Successful arthrodesis is noted, demonstrating the safety of a combined triple arthrodesis with a MDCO (F).

An incision is made two fingerbreadths below the tip of the fibula in line with the peroneal tendon ( Fig. 14.13 ). The incision is deepened into subcutaneous tissue, and immediately the sural nerve and lesser saphenous vein must be identified and retracted. A retractor is inserted into the tissue, and then once the nerve is retracted, the incision is deepened onto periosteum, which is reflected to expose the calcaneus. Given the level of the osteotomy, the nerve is commonly anterior to the incision, although this may not be the case if the osteotomy is placed too anterior. We try to perform the osteotomy as close as possible to the axis of the subtalar joint. After subperiosteal dissection, two curved soft tissue retractors are inserted on the dorsal and inferior aspect of the tuberosity. The inferior retractor is pushed between the calcaneus and the plantar fascia and serves as a retractor of the soft tissues during the osteotomy. The cut is made perpendicular to the axis of the tuberosity at a 45-degree angle with respect to the calcaneal pitch angle. An osteotome should not be used, because more control is afforded by the use of a saw blade. A punching action of the saw is used for the osteotomy, to permit the perforation through the medial aspect of the tuberosity to be felt. Alternatively, a 9-by-30-mm saw can be used to minimize the risk of overpenetration of the medial cortex and damage to the neurovascular bundle. If this saw type is used, the medial cortex commonly requires completion with an osteotome. A smooth laminar spreader with no teeth is inserted into the osteotomy site to distract the calcaneus, and the medial periosteum is separated. The medial translation is then facilitated, but cephalic translation is avoided. Once the calcaneus is held in the desired position, which is approximately 10 to 12 mm of medial shift, it may be fixed with a custom plate designed specifically for the osteotomy (Paragon, Englewood Colorado) ( Fig. 14.14 ;Video 14.1 ). This has the advantage of secure compression, easy maintenance of the position of the calcaneus tuberosity before fixation, no prominent hardware, and immediate weight bearing permitted. Considering the removal rate of screws inserted from the heel to be at about 15% or more, the use of a plate is recommended. Furthermore, even following painful screw removal, many patients still complain about the sensation of painful scar at the apex of the heel. Alternatively, to avoid the complaints of prominent hardware, headless screws can be used to achieve compression, with two screws preferred. Compressing the overhanging lateral ledge of bone is not important. Although this bony ridge could theoretically cause irritation on the soft tissues and sural nerve, it is rare, something that we noted following smaller incision percutaneous osteotomy and plate insertion where the overhanging bone ridge was not debrided. If an isolated osteotomy is performed, it is a stable osteotomy, and weight bearing can start after 10 days, either in a cast or in a boot, depending on the additional procedures performed. Clearly, if a custom calcaneus plate is not available, then screw(s) for fixation are used. Compression of the osteotomy is not necessary, and fully threaded screws may be used. In well over 30 years of practice we have never experienced a nonunion of the calcaneus osteotomy. Malunion may occur if the calcaneus is pushed too far medially or if a varus tilt is introduced during fixation. Both of these will cause a varus overload of the lateral foot and a sensation of instability. The width of the calcaneus at the level of the osteotomy is about 30 mm, and one can easily shift the calcaneus 12 mm medially without causing a varus deformity, unless the medial structures are too tight. In general, a 10-mm medial shift is sufficient.

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