A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot

Background: Biomechanical models have been used to study stress in the metatarsals, subtalar motion, lateral column lengthening and subtalar arthroereisis. Posterior tibial tendon dysfunction has been associated with increased loads in the arch of the acquired flat foot. We examine whether a 10 millimeter (mm) medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular reduces these increased loads in the flat foot. Methods: The response of a normal foot, a foot with posterior tibial tendon dysfunction, and a flat foot to an applied load of 683 Newton was analyzed using a multi-segment biomechanical model. The distribution of load on the metatarsals, the moment about each joint, the force on each of the plantar ligaments and the muscle forces were computed. Findings: Posterior tibial tendon dysfunction results in increased load on the medial arch, which may cause the foot to flatten. A 10 mm medial displacement calcaneal osteotomy substantially decreases the load on the first metatarsal and the moment at the talo-navicular joint and increases the load on the fifth metatarsal and the calcaneal-cuboid joint. Adding the flexor digitorum longus transfer to the medial displacement calcaneal osteotomy has only a small effect on the flattened foot. Interpretation: Our biomechanical analysis illustrates that when the foot becomes flat, the force on the talo-navicular joint increases substantially from its value for the normal foot, and that medial displacement calcaneal osteotomy can reduce this increased force back toward the value occurring in the normal foot. This study provides a biomechanical rationale for medial displacement calcaneal osteotomy treatments for posterior tibial tendon dysfunction. (c) 2009 Elsevier Ltd. All rights reserved.