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PubMed2001

Treatment of stage II posterior tibial tendon dysfunction with flexor hallucis longus transfer and medial displacement calcaneal osteotomy.

Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibialis muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination, follow-up time 18 months (ave.). The AOFAS hindfoot score improved from 62.4/100 to 83.6/100. The subjective portion of the AOFAS hindfoot score improved from 31.0/60.0 to 48.9/60. Weightbearing preoperative and postoperative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform, or talonavicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, 6 patients satisfied with minor reservations, and 1 dissatisfied. No patient complained of donor deficit from the harvested FHL tendon. Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial displacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate.

Adult↗
PubMed1991

Surgical treatment of posterior tibial tendon dysfunctions.

Ruptures and dysfunctions of the tibialis posterior tendon are often overlooked or misdiagnosed and can cause considerable loss of function to the patient. This article reviews the etiology, clinical as well as radiologic diagnosis, classification, and alternative surgical approaches. Case reports and photography of magnetic resonance imaging examples are included as well as a description of flexor digitorum longus tendon transfer in the treatment of this disorder.

Adult↗
PubMed1997

Posterior tibial tendon dysfunction: secondary MR signs.

We evaluated four potential secondary magnetic resonance imaging signs to aid in clinical diagnosis of posterior tibial tendon (PTT) tears. Seventy-one ankles (25 PTT tears and 46 controls) were evaluated for the following secondary signs: (1) PTT sheath fluid, (2) a distal tibial spur located just anterior to the PTT, (3) unroofing of the talus, and (4) "bone bruise"--like medullary lesions. Two musculoskeletal radiologists rated their confidence using a scale and were compared for level of agreement. The presence of PTT sheath fluid had modest specificity and fair to moderate sensitivity. Tibial spurring and unroofing of the talus had excellent specificity and fair sensitivity. Bone bruise-like lesions were commonly seen in cases and controls. Examination of divergence of opinion between the two radiologists revealed pitfalls in interpretation of PTT sheath fluid and bone bruise-like lesions, which were commonly the result of adjacent vessels and inhomogeneous fat saturation, respectively. We conclude that secondary signs of PTT tears with high specificities include unroofing of the talus, tibial spurring, and PTT sheath fluid.

Adult↗
PubMedDate not supplied

Double calcaneal osteotomy in the treatment of posterior tibial tendon dysfunction.

This article presents an alternative treatment for tibialis posterior tendon rupture in a select group of patients with recent rupture and planovalgus foot structure. Double calcaneal osteotomy is used to realign weightbearing forces in situations where soft-tissue repair alone is not sufficient, and arthrodesis is premature. A single case is presented followed by a discussion, with encouraging results.

Bone Transplantation↗
PubMed2006

Changes in gait associated with acute stage II posterior tibial tendon dysfunction.

The purpose of this study was to examine differences in gait mechanics between patients with acute stage II PTTD and healthy volunteers. Hindfoot and midfoot kinematics, plantar foot pressures and electromyographic (EMG) activity of the posterior tibialis, gastrocnemius, anterior tibialis and the peroneals were measured in five patients with acute stage II PTTD. Kinematics and kinetics were compared to a database of 20 healthy volunteers. EMG and plantar pressure data were obtained from five healthy volunteers. Hindfoot moments and powers were also calculated. The center of pressure excursion index (CPEI) was calculated from the plantar pressures. Significant differences were observed between the two groups, which confirmed clinical observations. Limited hindfoot eversion and increased midfoot external rotation occurred during the first and third rockers. The EMG data suggested that tendon dysfunction in the posterior tibialis is associated with compensatory activity, not only in its antagonists (the peroneals), but also in the anterior tibialis and the gastrocnemius. These data suggest that non-operative treatment of patients with PTTD should consider minimizing the activity of the posterior tibialis as well as the peroneals, the anterior tibialis and the gastrocnemius.

Adult↗
PubMed2003

Issues relating to failure in the treatment of posterior tibial tendon dysfunction.

As our understanding of the underlying cause of flat foot progression improves so will our understanding of how best to catalog and treat the instabilities that are seen. Determining the failure of one type of treatment will be difficult until we can better define the varied pathology and give the treatment methods sufficient time to prove or disprove their premise. If an underlying systemic disease, where either unreliable motor function or unstable ligament support is present, joint arthrodeses are the preferred method of treatment. It is important not to fuse in situ, but rather effect the complete realignment of the foot through the fused joints. At a minimum, I believe that the subtalar fusion is the most appropriate method for gaining a stable correction. Any more stability will warrant a triple arthrodesis. Treatment for the diseased tendon should also be addressed appropriately. Tendon reconstruction alone provides no assurance of weight-bearing deformity correction or lasting function for most patients who have isolated type 2 dysfunction and should be avoided as a stand-alone procedure. It still serves a vital purpose in restoring function to the foot, and, combined with other procedures, aids in the preservation of dynamic response to weight-bearing loads. The choice of adjunctive procedures should be based on the pathology present. Each of the treatment regimens that is discussed in this article has a place in the overall treatment of the clinical disease but none, by itself, seems to correct all of the presentations that are possible for this pathologic entity. The possible exception may be the use of a subtalar realignment and fusion, but this may be overkill in many mild to moderate deformities. Care should be taken in choosing the proper treatment based on the pathology that is presented by each patient.

Adult↗
PubMed1999

The Cobb procedure for stage II posterior tibial tendon dysfunction.

Flexor digitorum longus transfer or augmentation is currently the most popular adjunctive procedure for the repair of an attenuated or ruptured tibialis posterior tendon. Although the procedure is efficacious, an important functional muscle is sacrificed. Results show that similar results can be achieved with a tenodesis procedure by way of a split anterior tibial tendon repair. The authors have modified the Cobb procedure, and do not create a hole through the medial cuneiform or navicular. The thick, fibrous periosteal tissue at the medial aspect of the cuneiform is a sufficient tunnel for securing and positioning the tibialis anterior tendon. An additional site of healing and potential complications are avoided. The Cobb procedure is a useful and successful treatment option for PTTD, provides strong autograft augmentation to the posterior tibial tendon without sacrificing function of other tendons, and offers the surgeon and patient predictable outcomes with long-term satisfaction.

Aged↗
PubMed1999

[Lateral column lengthening by calcaneal osteotomy combined with soft tissue reconstruction for treatment of severe posterior tibial tendon dysfunction. Methods and preliminary results].

The purpose of this paper is to present principle and technique of proximal lateral column lengthening by calcaneal osteotomy and to critically analyze our preliminary results. 16 patients (7 female, 9 male; average age 52.3 years [24-72 years]) were treated for stage II to III posterior tibial tendon insufficiency by calcaneal osteotomy and medial soft tissue reconstruction (tendon reconstruction, 15; tendon transfer, 8; deltoid ligament repair, 10). When the AOFAS Ankle-Hindfoot Rating Scale was applied, these patients were shown to have significantly increased their scores from an average preoperative value of 49.1 to a mean postoperative value of 91.1 after a mean follow-up of 24.6 months. In all but one case no loss of achieved foot correction was noted. In one case, a fusion of the calcaneocuboid joint had to be performed after 5 months due to painful degenerative joint disease. At follow-up, all patients had satisfactory restoration of their medial longitudinal arch, reduction of forefoot abduction, and restored arch height. All patients were able to fully weight-bear the operated foot, and all patients were satisfied with the achieved result. In the pes planovalgus deformity occurring in stage II to III (as significant degenerative joint disease has not already occurred), osteotomies appear to have a significant role in the operative management and to function by restoring more normal biomechanics, thus allowing tendon reconstruction and tendon transfers to return to successful function.

Adult↗
PubMedDate not supplied

[Medial flexor digitorum longus tendon augmentation and lateral foot column lengthening or reorienting triple arthrodesis as surgical therapy of posterior tibial tendon dysfunction].

QUESTION: The purpose of this study was to evaluate the alignment and functional outcome after surgical augmentation of the tibialis posterior by tendon transfer and lateral column lengthening by osteotomy of the os calcis, calcaneo-cuboidal arthrodesis or reorientating triple arthrodesis. METHODS: From 1991 to 1999 41 patients with the clinical and radiological diagnosis of dysfunction of the tibialis posterior tendon underwent surgical exploration and repair. These 41 patients (22 women, 19 men) had an average age of 44.3 years (range, 19-69 years) and had been symptomatic for an average of 2.3 years (range, 6 months to 6 years). All patients had the symptoms of a painful flatfoot deformity without dynamic support along the medioplantar aspect. Flexor digitorum longus (FDL) tendon transfer as reconstruction of the tibialis posterior tendon was performed in the cases without major deformity (n = 77). Patients underwent FDL transfer and lengthening osteotomy (n = 15) of the os calcis or calcaneocuboidal (c-c) arthrodesis (n = 12) if passive correction of the foot deformity was still possible and reorientating triple arthrodesis (n = 7) when a fixed flatfoot deformity had developed. AOFAS score and radiological examination were used preoperatively and in the follow-up. RESULTS: The AOFAS score improved for stage 1 patients after a mean follow-up of 43 months with FDL transfer from a preoperative mean of 54 to 84 points, for stage II patients with FDL transfer and lengthening osteotomy (mean follow-up 36 m) from 47 to 92 points, with c-c arthrodesis (follow-up 66 m) from 48 to 86 points, and for stage III patients with triple arthrodesis from 42 to 72 points. In two patients, the deformity failed to improve (stage I) necessitating a revision surgery with a calceneo-cuboidal lengthening arthrodesis for relapsing deformity. CONCLUSION: In order to correct deformity and provide substantial relief of foot pain and dysfunction, we recommend the transfer of the FDL tendon in flexible flat foot deformity together with lengthening osteotomy. This treatment will provide optimal restoration of a dynamic support along the medioplantar aspect of the foot and is functionally superior to a c-c arthrodesis. Reorientating triple arthrodesis showed fair functional results and is recommended--for fixed flatfoot deformity.

Adult↗
PubMed2001

Surgical management of severe deformity resulting from posterior tibial tendon dysfunction.

A retrospective case study format was used to evaluate the results of surgical treatment of severe deformities due to long-standing tibialis posterior tendon dysfunction. To be included in the study, the peri-talar (talonavicular) subluxation on a weight-bearing AP X-ray should have been at least 75%. This criterion limited the field to patients with long-standing, rigid, severe deformities. Surgical correction was obtained through a two-incision approach, dorsomedial and dorsolateral. Significant shortening of the medial column and extensive removal of adaptive bone formation was necessary to allow reduction of the hind- and midfoot deformity. Stable internal fixation using multiple screws was used to secure the reduction. Eleven patients, 12 feet were evaluated. The patients were evaluated using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Score as well as a questionnaire on footwear and satisfaction rating. The average score improved from 30 points pre-op to 74 points post-op (out of 100). P-value 0.0001. Pain score improved from 11/40 to 33/40. Function improved from 19/50 to 33/50. Alignment improved from 0/10 to 8/10. The radiological parameters showed an average improvement of 31 degrees in the lateral talo-1st metatarsal angle, 11 degrees in the calcaneal pitch, and 35 degrees in the AP talo-1st metatarsal angle. All three parameters were highly significant with P-values of 0.0001. Multiple complications occurred. This included two delayed unions with breakage of screws and partial loss of correction, four wound problems, two sural nerve impairments and three patients requiring hardware removal. Even though it is an extensive procedure with multiple potential complications it still offers a substantial improvement in quality of life.

Aged↗
PubMed2002

[Triple arthrodesis in the management of acquired flatfoot deformity in the adult secondary to posterior tibial tendon dysfunction. A retrospective study of 20 cases].

The authors have reviewed 20 cases of valgus flatfoot deformity in the adult, secondary to insufficiency of the tibialis posterior tendon, which were treated by triple arthrodesis from 1983 to 1998. The longitudinal arch was flat grade 3 in 18 cases and grade 2 in two. The rearfoot was in valgus in all cases. Dorsal flexion of the ankle was limited to 5 degrees with a short Achilles tendon in 10 cases Djian-Annonier's angle was 134 degrees on average. The talocalcaneal divergence was 32 degrees. Diffuse osteoarthritis was present preoperatively in 14 cases. Fusion of the arthrodesis was achieved in 18 cases. There were two nonunions: one affecting the talonavicular joint, and the other, the talonavicular and calcaneocuboid joint. Results evaluated according to Kitaoka's criteria were excellent in 35%, good in 35%, fair in 20% and poor in 10%. Xrays showed progression of osteoarthritis. These results were not as good as in Fortin and Waling's series but we did not use iliac grafts. There was no instance of talus necrosis. The nonunion rate was higher than in other series at the talonavicular level. In order to improve the results, we now believe that bone resection must be kept minimal and bone grafts should be used, in addition to internal fixation. Triple arthrodesis was found to give good result in the treatment of acquired flat foot deformity due to insufficiency of the tibialis posterior tendon. However on the long term it promotes degenerative changes in neighbouring joints.

Aged↗
PubMed2002

Use of the Cobb procedure in the treatment of posterior tibial tendon dysfunction.

Numerous surgical procedures have been described for the treatment of the adult acquired flatfoot deformity. The surgeon should review in detail all the clinical, radiographic and imaging tests and propose the best surgical procedure for the patient. Although flexor tendon transfer has shown excellent results, the split anterior tibial tendon transfer is a second option. If used properly, the Cobb procedure results in less functional loss, since only half of the anterior tibial tendon is transferred. Furthermore, the flexor tendon is not disrupted and continues its primary function in the foot and ankle. Ultimately, the goals of the surgical procedure are to alleviate the patient's symptoms and pain, restore a normal foot alignment, and limit the loss of foot and ankle function without causing any complications.

Foot Diseases↗