Unstable Flat Foot in Female with Tethered Spinal Cord Syndrome


This 23 yo female suffers from tethered spinal cord syndrome. She has already had multiple back surgeries. Part of the disease process includes lower extremity muscle weakness, and neuropathy. This patient had decent epicritic sensation, but as seen – has profound genu recurvatum due to weakness. She had complaints of chronic ankle instability, forefoot instability (mostly due to bunion deformity), symptomatic pes planus and general gait problems due to the aforementioned.

Her chief complaint was unsteady gait. She also had an extremely tight heel cord – inability to get to 90 with knee extended and flexed. (toe walking common in these patients, which often allow the ankle instability)

To address as many complaints at once, but also not “over cook” the recipe we performed a TAL , ATF repair with modified Bröstrum, Evans osteotomy, and 1st MTP arthrodesis. We felt lesser toes would improve with TAL and Evans – they did (decrease pull of FDL).


  • When women in particular have narrow 1st phalanx we will abstain from lag screw at MTP, and it does not seem to effect union rate – she was NWB for Evans for 6 wks regardless…. Recovery more conservative in these instances
  • Oblique view allows best view of Evans union
  • Anytime neuropathy is considered we gravitate towards arthrodesis, however, hers is incomplete
  • Over time she will likely become fully neuropathic – likely not her last procedures
  • Xrays taken at 12 wk follow up visit
  • She’s very happy with result – in her words, she liked result of TAL and 1st MTP the most. But would not change any of the above thus far.

Implants used; Extremity Medical purely cancellous Evans allograft, and 1st MTP locking plate

Arthrex internal brace, and Fibertak suture anchors