Correction of multiplanar hindfoot deformity with osteotomy, arthrodesis, and internal fixation

Multiplanar deformity of the hindfoot is among the most daunting deformities of the foot and ankle to correct. Deformity correction must attempt to fix the overall orientation of the foot, and prior surgical procedures, arthritic conditions, neurologic abnormalities, musculotendinous insufficiency, and patient goals must be considered. The procedure must relieve pain, arthritis, or instability of the hindfoot and ankle, as well as pressure overload of the lateral foot, midfoot, and/or forefoot. The foot should achieve a plantigrade position that allows for easier shoe fitting and provide a stable plaform for weight bearing. When multiple deformities are present, a staged approach to surgical correction is needed. The goal is to create a plantigrade and stable hindfoot first, and then focus on the forefoot. Multiplanar and severe deformities require a variation of basic arthrodesis and osteotomy techniques. Properly placed wedge excisions and soft-tissue releases will enable a plantigrade correction. In some situations, even arthrodesis is insufficient to correct deformity, and residual hindfoot varus or valgus must be corrected with various types of osteotomy of the calcaneus. Osteotomies of the mid-tarsal region can be considered for residual pes cavus, forefoot supination, adduction, or abduction. An algorithmic approach is used in which the hindfoot is corrected first,followed by the midfoot and forefoot. Correction using multiplanar cuts and internal fixation to establish a plantigrade foot provides the best opportunity for a successful result.