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Chronic rupture of the posterior tibial tendon is a common disorder causing a progressive flat foot deformity. MR imaging is an excellent modality for assessing dysfunction of the tendon. It can easily and accurately detect and grade the tears. A variety of secondary soft tissue and bony abnormalities are associated with the tear and can be useful in confirming the diagnosis.
PURPOSE OF THE STUDY: Recurrent dislocations of the superior tibiofibular joint are rare. We report three cases of Weinert and Giachino ligament reconstruction. MATERIALS: From 1989 to 1994, two soccer players and one young girl (10 years old) presented recurrent dislocation of the superior TFJ. The mechanism was a direct trauma, and the type of dislocation was antero-lateral. These patients were free of tibial fracture, major ligament lesion of the knee, and neurologic symptoms (peroneal nerve injury). Pain was over the fibular head, mechanical and increased by jumping. A lateral "cracking" was present. Examination showed an antero-posterior mobility of the fibular head. X-ray showed horizontal proximal tibiofibular joint. M.R.I. eliminated a lateral meniscal pathology and collateral ligament injury. METHODS: The biceps tendon was split longitudinally for approximately seven centimeters. The posterior one half was transected proximally and mobilized. Secondly, the free end of the graft was passed posterior to anterior through a tibial tunnel. Thirdly, the tendon was sutured to the anterior tibial periosteum under tension with the fibular head reduced. RESULTS: Follow up at one year revealed that all the patients were active, free of dysfunction and laxity, with no further episodes of instability and no loss of ankle mobility. DISCUSSION: The diversity of treatments reported for this rare dislocation led us to believe that none proved its superiority. Resection of the proximal end of the fibula involves extensive dissection and creates a risk for the peroneal nerve vacuum and a lateral laxity. Arthrodesis of the superior tibiofibular joint without fibular osteotomy leads ankle pain, instability and a loss of ankle mobility. This procedure may also be complicated by screw loosening or breakage or by stress fracture of the fibula at the screw site. Arthrodesis of the superior tibiofibular joint with fibular osteotomy avoids these risks, but is possible for pain in the diaphyseal resection during the first 6 post operative months. Weinert and Giachino procedure, using a portion of the biceps tendon to reconstruct the superior tibiofibular ligament successfully stabilizes the superior tibiofibular joint, preserves all physiological function of the fibula and avoids resection or arthrodesis complications. CONCLUSION: Based on our experience with these three patients and on literature review, ligament reconstruction for recurrent dislocation of the superior tibiofibular joint gives stability and indolence, and avoids complications of resection and arthrodesis.
An autopsy case of chronic inflammatory demyelinating polyradiculoneuropathy was reported. It took a progressive course and terminated fatally in eight years. A 41-year-old man noticed motor disturbances when he tried to lift a bath pail and to write on July, 1978. Neurological examination revealed proximal dominant muscle atrophy, weakness of all extremities, and moderately diminished tendon reflex. Sensation was normal. The CSF showed albumin cytologic dissociations. Electromyogram showed neurogenic changes. Histological examination of biopsy specimen obtained from the anterior tibial muscle revealed severe neurogenic changes and showed axonal degeneration on the ventral tibial nerve. The treatment by corticosteroids was not effective, and the disease gradually progressed with repeated improvements and exacerbations. Three years after the onset, he showed vesicorectal dysfunctions. He died of respiratory failure on May, 1986. Neuropathological examination showed severe degeneration of middle root zones in the posterior columns, loss of myelinated fibers in Clarke's columns, demyelination and mild loss of axons accompanied by lymphocytic infiltration in the spinal roots, especially in the anterior roots. The histogram of cervical ventral root, ventral and dorsal roots of thoracic and lumbar regions revealed a decreased number of large myelinated fibers. A characteristic finding of this case was the dissociation of clinical features and neuropathological findings; the clinical features showed a typical motor neuropathy, but neuropathological examination showed severe degeneration on posterior columns of spinal cord like a sensory-ataxic neuropathy. Our observation suggest that the pathway which originates from posterior ganglion cells and runs into Clarke's columns passes through the middle root zones, since severe demyelination in Clarke's columns was observed.
OBJECTIVE: To determine whether knee flexion influenced bony contact movements during flexion. DESIGN: Accurate three-dimensional (3D) measurements of tibiofemoral bony contact points in vivo was performed using magnetic resonance imaging technology at 0 degrees, 30 degrees and 60 degrees of flexion. BACKGROUND: Magnetic resonance imaging is an accurate non-invasive tool for visualizing muscles, tendons, and bone, and provides precise 3D co-ordinates. METHODS: Magnetic resonance imaging recordings were made from the right knee of 16 subjects with no history of knee dysfunction at 0 degrees, 30 degrees and 60 degrees of flexion. Joint contact movements were reported as changes of the contact point's position on the medial and lateral tibial condyle with respect to a fixed reference point for each flexion angle. RESULTS: The dominant motion of the centroid of the contact area was posterior with a concomitant inferior and lateral displacement when flexing from 0-30 degrees. Increased flexion to 60 degrees the contact points moved slightly anterior, superior and continued laterally. Comparing movements between the medial and lateral compartments, larger displacement magnitudes were observed laterally. Additionally, tibial rotations of 3-5 degrees were noted relative to the femur. CONCLUSION: Based on magnetic resonance imaging co-ordinates and the rotated anatomical reference frame, the geometric equations to derive the contact point between the tibiofemoral articulating surfaces is a viable means to investigate tibiofemoral bony contact movement. RELEVANCE: Contact areas and pressure distributions have been reported using cadaveric specimens but interpretation of the results is limited. Other investigations have been restricted to sagittal plane movement. Using kinematic magnetic resonance imaging, accurate non-invasive 3D recordings of the normal knee at increments of flexion are possible. The normative baseline date can be compared against that of the pathological knee, such as cruciate ligament injury or the status of post-operative meniscectomy in order to examine skeletal joint motion and stability.
For treatment of a symptomatic flat foot in a child or an acquired flatfoot from posterior tibial dysfunction in the adult, an understanding of the biomechanics and function of the foot and leg is essential to achieve an excellent outcome. Evaluation of supramalleolar deformity directly influences the procedure choice and eventual success of the procedure. An understanding of the level of deformity also indicates the procedure to be used. Subtalar and midtarsal joint function, although related, have their own primary source of deformity. Correction through the subtalar and midtarsal joints must be individualized. Augmentation of the primary repair must be performed when overall instability is present, such as an elongated or deformed posterior tibial tendon or medial ligamentous structure. Evaluation of the gross deforming force of the triceps suri also must be evaluated to provide and ensure predicted outcomes.
AIM: The present retrospective study investigates the mid-term results after medial displacement calcaneal osteotomy combined with flexor digitorum longus transfer for the treatment of acquired flatfoot deformity due to posterior tibial tendon insufficiency at stage II (Johnson and Strom Classification). METHOD: 30 feet in 29 patients (6 male, 23 female) with an average age of 58 years (from 43 to 68 years) had surgery between 1995 and 2001. All feet were examined at an average follow-up of 58.5 months (range 35-97 months) and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score. RESULTS: The average AOFAS-Score was 88.8+/-10.7 points (range 48 to 100) at final follow-up. The AOFAS-pain-subscale score was 34+/-6.2 points. At the latest follow-up were 14 feet (47%) painfree, 14 feet (47%) noted mild pain and 2 feet (6%) had daily pain. One foot (3%) had pain due to subluxation of the musculus flexor digitorum longus tendon, in another one pain was caused by a contract Chopart joint (3%). Further complications were painful prominent hardware (17%) and neuralgia of the sural nerve (7%). CONCLUSION: The authors conclude that the combination of the medial calcaneal displacement osteotomy with flexor digitorum longus transfer may provide optimal results in patients with adult acquired flatfoot deformity and posterior tibialis tendon dysfunction.