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

Abstract

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. 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. 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. 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.