Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Surgical Management of Symptomatic Adult Pes Planovalgus Secondary to Stage 2B Posterior Tibial Tendon Dysfunction: A Comparison of Two Different Surgical Treatments

  • 1 Accesses



This study compares radiological and functional outcomes of patients with symptomatic Adult Acquired Flat Foot Deformity (AFFD) secondary to stage 2B Posterior Tibial Tendon Dysfunction (PTTD) treated with either a Subtalar Arthroereisis (SA) implant or a Lateral Column Lengthening (LCL) procedure. The aim of the study is to determine if the Subtalar Arthroereisis procedure is an acceptable surgical adjunct in our treatment armamentarium.

Materials and Methods

21 patients (22 feet) were evaluated. 12 consecutive patients (n = 12) underwent a Subtalar Arthroereisis procedure while 9 patients (n = 10) underwent a Lateral Column Lengthening procedure. Functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Score (AOFAS) midfoot score, Short Form 36 (SF-36) and Visual Analog of Pain Scale (VAS), preoperatively and at 6 and 12 months postoperatively. 10 radiological parameters were analyzed. All complications were tabulated.


Significant improvements in functional outcomes were noted in both groups of patients. Radiographically, some loss of correction was noted in the SA group and no loss of correction in the LCL group, respectively. In the SA group, 6 patients complained of sinus tarsi pain in the postoperative period and 4 required removal of implants. No implants were removed in the LCL group.


The results suggest that subtalar arthroereisis may be a reasonable procedure to utilize in the treatment of AAFD, albeit with a relatively high implant-removal rate.

This is a preview of subscription content, log in to check access.

Fig. 1

Sourced from [25]

Fig. 2

Sourced from [25]

Fig. 3

Sourced from [25]

Fig. 4

Sourced from [25]

Fig. 5

Sourced from [25]

Fig. 6

Sourced from [25]

Fig. 7

Sourced from [25]

Fig. 8

Sourced from [25]

Fig. 9

Sourced from [25]

Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14


  1. 1.

    Pinney, S. J., & Lin, S. S. (2006). Current concept review: Acquired adult flatfoot deformity. Foot and Ankle International,27(1), 66–75. https://doi.org/10.1177/107110070602700113.

  2. 2.

    Carmody, D., Bubra, P., Keighley, G., & Rateesh, S. (2015). Posterior tibial tendon dysfunction: An overlooked cause of foot deformity. Journal of Family Medicine and Primary Care,4(1), 26. https://doi.org/10.4103/2249-4863.152245.

  3. 3.

    Ross, M. H., Smith, M. D., & Vicenzino, B. (2017). Reported selection criteria for adult acquired flatfoot deformity and posterior tibial tendon dysfunction: Are they one and the same? A systematic review. Plos One. https://doi.org/10.1371/journal.pone.0187201.

  4. 4.

    Carranza-Bencano, A., Zamora-Navas, P., & Fernandez-Velazquez, J. (1997). Viladots Operation in the Treatment of the Childs Flatfoot. Foot and Ankle International,18(9), 544–549. https://doi.org/10.1177/107110079701800903.

  5. 5.

    Scharer, B. M., Black, B. E., & Sockrider, N. (2010). Treatment of painful pediatric flatfoot with Maxwell-Brancheau subtalar arthroereisis implant a retrospective radiographic review. Foot and Ankle Specialist,3(2), 67–72. https://doi.org/10.1177/1938640010362262.

  6. 6.

    Giannini, S., Ceccarelli, F., Benedetti, M. G., Catani, F., & Faldini, C. (2001). Surgical treatment of flexible flatfoot in children. The Journal of Bone and Joint Surgery-American Volume,83, 73–79. https://doi.org/10.2106/00004623-200100022-00003.

  7. 7.

    Needleman, R. L. (2005). Current topic review: Subtalar arthroereisis for the correction of flexible flatfoot. Foot and Ankle International,26(4), 336–346. https://doi.org/10.1177/107110070502600411.

  8. 8.

    Needleman, R. L. (2006). A surgical approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant. Foot and Ankle International,27(1), 9–18. https://doi.org/10.1177/107110070602700103.

  9. 9.

    Kitaoka, H. B., Alexander, I. J., Adelaar, R. S., Nunley, J. A., Myerson, M. S., & Sanders, M. (1994). Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot and Ankle International,15(7), 349–353. https://doi.org/10.1177/107110079401500701.

  10. 10.

    Brodsky, J. W., Baum, B. S., Pollo, F. E., & Mehta, H. (2007). Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus. Foot and Ankle International,28(2), 162–165. https://doi.org/10.3113/fai.2007.0162.

  11. 11.

    Hadfield, M. H., Snyder, J. W., Liacouras, P. C., Owen, J. R., Wayne, J. S., & Adelaar, R. S. (2003). Effects of medializing calcaneal osteotomy on achilles tendon lengthening and plantar foot pressures. Foot and Ankle International,24(7), 523–529. https://doi.org/10.1177/107110070302400703.

  12. 12.

    Mani, S. B., & Deland, J. T. (2014). Lateral column lengthening and how to achieve good correction. Techniques in Foot and Ankle Surgery,13(1), 23–28. https://doi.org/10.1097/btf.0000000000000036.

  13. 13.

    Thomas, R. L., Wells, B. C., Garrison, R. L., & Prada, S. A. (2001). Preliminary results comparing two methods of lateral column lengthening. Foot and Ankle International,22(2), 107–119. https://doi.org/10.1177/107110070102200205.

  14. 14.

    Moseir-Laclair, S., Pomeroy, G., & Manoli, A. (2001). Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency. Foot and Ankle International,22(4), 283–291. https://doi.org/10.1177/107110070102200403.

  15. 15.

    Graves, S. C., Mann, R. A., & Graves, K. O. (1993). Triple arthrodesis in older adults. Results after long-term follow-up. The Journal of Bone and Joint Surgery.,75(3), 355–362. https://doi.org/10.2106/00004623-199303000-00006.

  16. 16.

    Fortin, P. T., & Walling, A. K. (1999). Triple arthrodesis. Clinical Orthopaedics and Related Research,365, 91–99. https://doi.org/10.1097/00003086-199908000-00012.

  17. 17.

    Haddad, S. L., Myerson, M. S., Pell, R. F., & Schon, L. C. (1997). Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot and Ankle International,18(8), 489–499. https://doi.org/10.1177/107110079701800806.

  18. 18.

    Chambers, E. F. (1946). An operation for the correction of flexible flat feet of adolescents. West Journal of Surgical Obstetric Gynecology,54, 77–86.

  19. 19.

    Myerson, M. S. (1996). Instructional course lectures, the American academy of orthopaedic surgeons—adult acquired flatfoot deformity. Treatment of dysfunction of the posterior tibial tendon. The Journal of Bone and Joint Surgery,78(5), 780–792. https://doi.org/10.2106/00004623-199605000-00020.

  20. 20.

    Fernández de Retana, P., Alvarez, F., & Bacca, G. (2012). Is there a role for subtalar arthroereisis in the management of adult acquired flatfoot? Foot and Ankle Clinics,17, 271–281. https://doi.org/10.1016/j.fcl.2012.03.006.

  21. 21.

    Lee, M. S., Vanore, J. V., Thomas, J. L., et al. (2005). Diagnosis and treatment of adult flatfoot. The Journal of Foot and Ankle Surgery,44(2), 78–113. https://doi.org/10.1053/j.jfas.2004.12.001.

  22. 22.

    Mann, R. A. (1993). Flatfoot in adults. In R. A. Mann & M. J. Coughlin (Eds.), Surgery of the foot and ankle (6th ed., Vol. 1, pp. 757–784). St. Louis: Mosby-Year Book.

  23. 23.

    Maxwell, J. R., & Cerniglia, M. W. (2001). Subtalar joint arthroereisis. In A. S. Banks, M. S. Downey, D. E. Martin, & S. J. Miller (Eds.), McGlamry’s comprehensive textbook of foot and ankle surgery (3rd ed., pp. 901–914). Philadelphia: Lippincott Williams and Wilkins.

  24. 24.

    Viladot, R., Pons, M., Alvarez, F., & Omaña, J. (2003). Subtalar arthroereisis for posterior tibial tendon dysfunction: A preliminary report. Foot and Ankle International,24(8), 600–606. https://doi.org/10.1177/107110070302400806.

  25. 25.

    Kang, S., Charlton, T. P., & Thordarson, D. B. (2013). Lateral column length in adult flatfoot deformity. Foot and Ankle International,34(3), 392–397.

Download references

Author information

The collection and analysis of the data, as well as writing the manuscript were prepared by both the first and second authors of this paper. We thank senior author Mr. Gowreeson Thevendran for his invauable counsel and guidance without which this manuscript would not have been written.

Correspondence to Gowreeson Thevendran.

Ethics declarations

Conflict of interest

All three authors of this original manuscript declare that we do not have any conflicts of interest in the publishing of this paper.

Ethical standard statement

No human or animal subjects were utilized as part of this study. We firmly believe and attest to the ethical standards of the paper.

Informed consent

Informed consent was not required for the publishing of this paper as the data collected was anonymous and not retrospectively identifiable.


No support in the form of grants, equipment, drugs, or any other form were utilized for the completion of this study. None of the authors involved in this study have any financial or other arrangements which constitute a conflict of interest. This manuscript has been read and approved by all authors of the study and will vouch for the integrity of the research conducted. This manuscript has not been submitted to any other journal for consideration and has not been previously published.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Fang Junxian, C., Kunnasegaran, R. & Thevendran, G. Surgical Management of Symptomatic Adult Pes Planovalgus Secondary to Stage 2B Posterior Tibial Tendon Dysfunction: A Comparison of Two Different Surgical Treatments. JOIO 54, 22–30 (2020). https://doi.org/10.1007/s43465-019-00011-7

Download citation


  • Pes planovalgus
  • Flatfeet
  • Subtalar arthroereisis
  • Lateral column lengthening