Correction of the Rigid Flatfoot

Jonathan T. Deland

Austin E. Sanders

Preoperative Planning

Anteroposterior (AP), lateral, and oblique x-rays of the foot (Figure 6-1)
Bilateral Saltzman views of the hindfoot (Figure 6-2)

Figure 6-1. Standing anteroposterior view of the foot (A) and lateral view of the foot (B).

Figure 6-2. Hindfoot alignment view. Patient had previous surgery and the measurements are marked.

Positioning

Supine, with a bump under the hip to make toes straight to the ceiling

Surgical Approaches

Medial Talonavicular Joint

Incision and deep dissection is in between the posterior tibial tendon and anterior tibial tendon, retracting the saphenous vein and nerve dorsally.

This patient had previous surgery, with an incision that ended inferior and posterior to the medial malleolus. This old incision was resected. Otherwise, the incision would have been as marked in black in Figure 6-3.

Dorsal Talonavicular Joint

The incision, as shown in green in Figure 6-4, and deep dissection is carried out just medial to the neurovascular bundle at the medial border of the extensor hallucis longus (EHL) tendon, directly over the talonavicular joint.

Figure 6-3. Medial approach to the talonavicular joint.

Figure 6-4. Dorsal approach to the talonavicular joint and the approach for the first metatarsal tarsal fusion.
The neurovascular bundle is just lateral to the EHL tendon, so deep dissection laterally is carried out underneath the EHL tendon and neurovascular bundle.

Lateral Subtalar Joint

Use the sinus tarsi approach just dorsal to the peroneal tendons and sural nerve from the distal tip of the fibula to the anterior process of the calcaneus. Incision is marked in blue (Figure 6-5).

Figure 6-5. Sinus tarsi incision for subtalar fusion (blue) and posterior calcaneal osteotomy incision (red).

Combined Talonavicular and Subtalar Medial Approach

In cases of severe valgus deformity, where correction of deformity can place excess tension on the lateral skin, the subtalar joint, as well as the talonavicular joint, can be approached medially.
The incision is a long, oblique one from the tip of the navicular to the posterior aspect of the medial malleolus.¹
In addition, the dorsal talonavicular approach could also be used. The most commonly used approach is the lateral subtalar approach; if a posterior calcaneal osteotomy is needed, an additional oblique incision is made.

Posterior Calcaneal Osteotomy Approach

If there is significant valgus deformity of the hindfoot and the surgeon believes that a posterior calcaneal osteotomy will be needed, a posterolateral approach for the osteotomy is made.
The standard lateral oblique incision is made over the calcaneus at least two fingerbreadths posterior to the subtalar incision and somewhat more vertical than the subtalar incision (marked in red in Figure 6-5). Being more toward the vertical, there is less tension, and a somewhat larger skin bridge is achieved.

Preparation of Joints

Talonavicular