Flexor Digitorum Longus Tendon Transfer Research Articles

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction.

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

Anatomic Landmarks for Minimally Invasive Exposure for Flexor Digitorum Longus (FDL) Tendon Transfers and Spring Ligament Reconstruction

Category: Other; Basic Sciences/Biologics; Hindfoot; Midfoot/Forefoot Introduction/Purpose: The approach for identification of the FDL tendon is classically described through an incision proximal to the medial malleolus extending past the navicular following the inferior border of the first metatarsal.1This incision is lengthy, and we believe that the navicular tuberosity, medial malleolus, and/or sustentaculum tali can be used as reliable landmarks for identification of the FDL more precisely and reliably. The purpose of this study is to detail spatial anatomy of the medial arch to allow for a more reliable and less invasive exposure of the FDL. Methods: Ten cadaver specimens were used for a total of 20 extremities. Anatomic locations were identified and pinned with the foot positioned in neutral dorsiflexion. Anatomic locations pinned included tip of the anterior colliculus, navicular tuberosity, proximal portion of the sustentaculum tali, and the distal portion of the sustentaculum tali. Photographs were taken of each cadaveric specimen with pins in place. Image J calibrated software was then used to calculate the distance between anatomic points. Averages were calculated for all measurements. Results: On average the superior margin of the sustentaculum tali was located 8 mm from the FDL with a range of 5-15 mm. Average distance from inferior sustentaculum tali to the FDL was 9 mm with a range of 5-12 mm. Average distance from medial malleolus to superior FDL was 18 mm with a range of 11-27 mm. Average distance from medial malleolus to inferior FDL was 27 mm with a range of 20-36mm. Average distance from navicular tuberosity to anterior FDL was 22 mm with a range of 11-27 mm. Average distance from navicular tuberosity to posterior FDL was 30 mm with a range of 19-42 mm. Conclusion: The 'lighthouse' for the harvest of the FDL tendon is the sustentaculum tali. Intraoperatively, the FDL tendon is found 22-31 mm directly posterior to the navicular and 18-27 mm inferior to the medial malleolus. This provides a reliable anatomic region where a 40 mm oblique approach can be made to access the FDL and spring ligament complex for a more minimally invasive approach in all of the studied specimen.

The Surgical Learning Curve for Modified Lapidus Procedure for Hallux Valgus Deformity.

Hallux valgus is one of the most common orthopaedic deformities of the foot, affecting as much as 23% of the population age 18 to 65. In addition to its high prevalence, it has a complex multifactorial pathogenesis. Surgical correction options have variable rates of success and new techniques are being developed. The modified Lapidus procedure attempts to correct in 3 planes of deformity, which may create a steeper learning curve for those newly adopting the technique. A retrospective review was performed on patients who underwent hallux valgus reconstruction with a modified Lapidus procedure between March 2018 and July 2020. Exclusion criteria included revision surgery, 6 or more concurrent procedures, or a flexor digitorum longus tendon transfer for adult acquired flatfoot correction. There were a total of 81 modified Lapidus procedures for hallux valgus within the study time frame and 68 were included in the study. Over a period of 2 years there was a significant decrease in overall surgery duration from 78.93 minutes at month 0 to 61.80 minutes at 24 months (P = .036). The average preoperative/postoperative intermetatarsal angles were 15.08° and 4.91°, respectively. There was an average decrease of 10.17°. The rate of nonunion was 4.41% (3/68), and the rate of recurrence at 6 months was 5.88% (4/68). There was not a significant difference in the rate of recurrence (P = .394) or the rate of nonunion (P = .817) as the surgeon increased in experience. Although there is a significant learning curve for the modified Lapidus procedure, it is largely overcome by the 23rd case. Additionally, experience with the technique does not appear to affect the patient outcomes of nonunion or recurrence. Level IV: Retrospective.

Consensus on Indications for Isolated Subtalar Joint Fusion and Naviculocuneiform Fusions for Progressive Collapsing Foot Deformity

Peritalar subluxation represents an important hindfoot component of progressive collapsing foot deformity, which can be associated with a breakdown of the medial longitudinal arch. It results in a complex 3-dimensional deformity with varying degrees of hindfoot valgus, forefoot abduction, and pronation. Loss of peritalar stability allows the talus to rotate and translate on the calcaneal and navicular bone surfaces, typically moving medially and anteriorly, which may result in sinus tarsi and subfibular impingement. The onset of degenerative disease can manifest with stiffening of the subtalar (ST) joint and subsequent fixed and possibly arthritic deformity. While ST joint fusion may permit repositioning and stabilization of the talus on top of the calcaneus, it may not fully correct forefoot abduction and it does not correct forefoot varus. Such varus may be addressed by a talonavicular (TN) fusion or a plantar flexion osteotomy of the first ray, but, if too pronounced, it may be more effectively corrected with a naviculocuneiform (NC) fusion. The NC joint has a curvature in the sagittal plane. Thus, preserving the shape of the joint is the key to permitting plantarflexion correction by rotating the midfoot along the debrided surfaces and to fix it. Intraoperatively, care must be also taken to not overcorrect the talocalcaneal angle in the horizontal plane during the ST fusion (eg, to exceed the external rotation of the talus and inadvertently put the midfoot in a supinated position). Such overcorrection can lead to lateral column overload with persistent lateral midfoot pain and discomfort. A contraindication for an isolated ST fusion may be a rupture of posterior tibial tendon because of the resultant loss of the internal rotation force at the TN joint. In these cases, a flexor digitorum longus tendon transfer is added to the procedure. Level V, consensus, expert opinion.

The tibialis posterior tendon footprint: an anatomical dissection study

BackgroundThe tibialis posterior tendon (TPT) is the main dynamic stabilizer of the medial longitudinal arch of the foot. Especially in adult acquired flatfoot deformity (AAFD) the TPT plays a detrimental role. The pathology and function of the tendon have been extensively investigated, but knowledge of its insertional anatomy is paramount for surgical procedures. This study aimed to analyze the complex distal footprint anatomy of the TPT.MethodsForty-one human anatomical specimens were dissected and the distal TPT was followed to its bony footprints. After tendon removal the footprints were marked with ink. Standardized photographs were taken and consecutively analyzed by digital imaging measurements. Footprint length, width, area of insertion, location, and shape was studied regarding the main insertion at the navicular bone.ResultsAll specimens had the main TPT insertion at the navicular bone (41/41, 100%). Sixty-three percent of navicular TPT insertions were located at the plantar aspect. The mean navicular footprint measured 12.1 mm × 6.9 mm in length and width, respectively. The tendon further spread into several slips which anchored the tibialis posterior deep in the plantar arch. TPT insertions were highly variable with an involvement of up to eight distinct bony footprints in the mid- and hindfoot. The second most common additional footprint was the lateral cuneiform (93% of dissected feet), followed by the medial cuneiform (80%), the metatarsal bases [1–5] (80%), the cuboid (46%), the intermediate cuneiform (19%), and the calcaneus (12%).ConclusionsThe present study adds to current knowledge on the footprint anatomy of the TPT. Based on the findings of this study we advocate a plantar location of flexor digitorum longus tendon transfer in flexible AAFD in order to restore the anatomical lever and insertion of the TPT.

Lateral Flexor Digitorum Longus Transfer for Peroneal Tendinopathy

Category:SportsIntroduction/Purpose:Flexor digitorum longus (FDL) transfer to the lateral foot for concomitant irreparable rupture of the peroneal tendons has been reported in few clinical series. The purpose of this study is to provide midterm outcomes including subjective outcome scores, clinical examination data, and objective power after single-stage FDL tendon transfer.Methods:Twenty-five consecutive patients over a 7 year period (2008-2015) underwent FDL to fifth metatarsal transfer for irreparable peroneal tendon tears. Fifteen patients with a mean follow-up of 53.7 months completed the pain visual analog score (VAS), Foot Function Index (FFI), Short Musculoskeletal Functional Assessment (SMFA), and Foot and Ankle Ability Measure (FAAM) scores and participated in range of motion, peak force, and peak power testing.Results:All 15 patients were satisfied with their surgery and reported a reduction in their pain level with the average decrease in VAS of 5.59 +/- 2.5 (range: 1 - 9). The mean FAAM was 86.4 +/- 9.7 (range: 52.4 - 100). The mean FFI was 12.8 +/- 9.2 (range: 0 - 21.4). The mean SMFA Function index was 12.4 +/- 8 and the mean SMFA Bothersome Index was 11.5 +/- 11. Patients had on average 58% less eversion and 28% less inversion compared to the nonoperative side. Both isometric peak torque and isotonic peak velocity were decreased by 38.4% and 28.8%, respectively. On average, power in the operative limb was diminished by 56% compared to the nonoperative limb.Conclusion:FDL transfer to the lateral foot for significant, non-reconstructable peroneal tendinopathy is an effective, and durable treatment option.

Lateral Transfer of the Flexor Digitorum Longus for Peroneal Tendinopathy.

Few studies have reported midterm outcomes after single-stage flexor digitorum longus (FDL) tendon transfer to the lateral foot for irreparable rupture of the peroneal tendons. Over a 7-year period (2008-2015), 25 consecutive patients underwent transfer of the FDL to the fifth metatarsal for irreparable peroneal tendon tears. Of these, 15 patients were available for inclusion with a mean follow-up of 53.7 ± 23.3 months, mean age at surgery of 48.4 years, and mean body mass index (BMI) of 29.8 kg/m2. Patients completed the pain visual analog scale (VAS), Foot Function Index (FFI), Short Musculoskeletal Function Assessment (SMFA), and Foot and Ankle Ability Measure (FAAM) and participated in range of motion, peak force, and peak power testing. All 15 patients were satisfied with their surgery and reported a reduction in their pain level with a decreased VAS of 5.6 ± 2.5. The mean FFI was 12.8 ± 9.2, the SMFA Function Index was 12.4 ± 8, and the mean SMFA Bothersome Index was 11.5 ± 11. The mean FAAM was 86.4 ± 9.7. Patients had on average 58% less eversion and 28% less inversion compared with the nonoperative side. Isometric peak torque and isotonic peak velocity were 38.4% and 28.8% less compared with the contralateral side, respectively. The average power in the operative limb was diminished by 56% compared with the nonoperative limb. In this small case series with midterm follow-up, FDL transfer to the lateral foot for significant, irreparable peroneal tendinopathy was an effective and durable treatment option. Level IV, retrospective case series.

Flexor digitorum longus tendon transfer to the navicular: tendon-to-tendon repair is stronger compared with interference screw fixation

PurposeTo assess whether early rehabilitation could be safe after flexor digitorum longus (FDL) tendon transfer, the current biomechanical study aimed to measure tendon displacement under cyclic loading and load to failure, comparing a traditional tendon-to-tendon (TT) repair with interference screw fixation (ISF).Methods24 fresh-frozen cadaveric below knee specimens underwent FDL tendon transfer. In 12 specimens a TT repair was performed via a navicular bone tunnel. In a further 12 specimens ISF was performed. Using a materials testing machine, the FDL tendon was cycled 1000 times to 150 N and tendon displacement at the insertion site measured. A final load to failure test was then performed. Statistical analysis was performed using two-way ANOVA and an independent t test, with a significance level of p < 0.05.ResultNo significant difference in tendon displacement occurred after cyclic loading, with mean tendon displacements of 1.9 ± 1.2 mm (mean ± SD) in the TT group and 1.8 ± 1.5 mm in the ISF group (n.s.). Two early failures occurred in the ISF group, none in the TT group. Mean load to failure was significantly greater following TT repair (459 ± 96 N), compared with ISF (327 ± 76 N), p = 0.002.ConclusionMinimal tendon displacement of less than 2 mm occurred during cyclic testing in both groups. The two premature failures and significantly reduced load to failure observed in the ISF group, however, indicate that the traditional TT technique is more robust. Regarding clinical relevance, this study suggests that early active range of motion and protected weight bearing may be safe following FDL tendon transfer for stage 2 tibialis posterior tendon dysfunction.

Outcomes of flexor digitorum longus (FDL) tendon transfer in the treatment of Achilles tendon disorders

BackgroundIn patients with chronic Achilles tendon disorders, Achilles tendon debridement can be supplemented with a tendon transfer, with the flexor hallucis longus tendon (FHL) transfer representing the most common used technique. Our study describes clinical and functional results of patients treated with flexor digitorum longus (FDL) tendon transfer in the treatment of patients with chronic Achilles tendon disorders. MethodsRetrospective study of prospectively collected data of thirteen patients (15 feet) that underwent FDL tendon transfer as part of the treatment of chronic Achilles tendon disorders. Preoperative and postoperative assessment included visual analogue score (VAS) for pain, SF-36 survey and lower extremity functional scale (LEFS). The average follow-up was 26.4 (range, 14–56) months. Patients were also assessed for ability to perform single leg heel rise test, muscle power for plantar flexion of the lesser toes, surgical scar condition and associated complications. ResultsAt final follow-up, we found significant postoperative improvement in VAS score (6.6 ± 2.99 vs 1.06 ± 1.43; p < .0001), SF-36 physical component summary (PCS) (28.20 ± 10.71 vs 45.04 ± 11.19; p < .0001) and LEFS (36.13 ± 20.49 vs 58.73 ± 18.19; p < .0001). Twelve patients (92%) could perform a single leg heel rise test in the operated extremity, although there was significant difference when comparing operated and uninvolved sides (4.86 ± 3.36 cm vs 7.18 ± 3.40 cm; p = .0002). One patient reported weakness for plantar flexion of the lesser toes, without balance or gait disturbances. Two patients (2 feet, 13.3%) had superficial infections and one patient (one foot, 6.6%) needed operative debridement for a deep infection. ConclusionsFDL tendon transfer represent an operative alternative in the treatment of chronic Achilles tendon disorders. Our study showed good clinical outcomes with low complications and donor site morbidity. Level of evidenceObservational study, case series – level IV.

Outcomes of Flexor Digitorum Longus (FDL) Tendon Transfer for the Treatment of Chronic Achilles Tendinopathy

Category: Hindfoot, Sports Introduction/Purpose: Flexor hallucis longus (FHL) tendon transfer is a common surgical technique used for augmentation during the surgical treatment of chronic Achilles tendinopathy and reconstruction. Flexor digitorum longus (FDL) tendon transfer represents a viable surgical alternative for patients with failed FHL transfers or athletes where compromise of the hallux push off strength could negatively impact their level of activity. There is no reported clinical outcome data about this technique in the current literature. Our study describes the clinical and functional results after FDL tendon transfer for the treatment of patients with chronic Achilles tendinopathy. Methods: We retrospectively assessed prospectively collected data on patients that underwent FDL tendon transfer in the treatment of chronic Achilles tendinopathy (March 2012 - March 2015). Charts were reviewed for clinical data, associated treatments and complications. Preoperative assessment included the Visual Analogue Score (VAS), SF-36 health status survey and the lower extremity functional scale (LEFS). At final follow up we evaluated pain level, range of motion of the ankle and the toes, ability to perform single leg raise and toe walking, calf atrophy and complications. Postoperative outcomes were assessed by Visual Analogue Score (VAS), SF-36 health survey, Lower Extremity Functional Scale (LEFS), Foot Function Index (FFI), VISA-A score and the Foot and Ankle Ability Measure (FAAM). Fifteen patients (seventeen feet), 6 males and 9 females, mean age of 53.6 years (27- 76 years) and an average body mass index of 31.4 kg/m2 (20.5 to 45.4 kg/m2) were included in the study. Results: Mean follow-up was 27.5 months (15-49). Four patients (6 feet) had prior surgeries, including two patients with failed FHL transfer. We found significant clinical improvement when comparing pre-operative and postoperative VAS scores (6.0±3.3 versus 1±1.36; p&lt;0.001), SF-36 physical component summary (28.2±10.7 versus 45.0±11.1; p&lt;0.002) and LEFS (36.4±22 versus 57.9±20.5; p&lt;0.011). At final follow up, 6/7 patients (86%) returned to prior levels of recreational sport activities. No differences were found on single leg raise test when compared to uninvolved side. One patient reported weakness for plantar flexion of the toes, without gait complaints. Mean VISA-A was 52.6 points (15-85), Foot Function Index (FFI) 21.2% (0-65%) and FAAM 86.2% (55.3-100%) for the FAAM. Three patients had superficial infection and two patients had deep infection, requiring surgical debridement. Conclusion: FDL tendon transfer represents a safe surgical alternative as a method of augmentation during the treatment of chronic Achilles tendinopathy. Our study showed comparable clinical and functional outcomes to FHL tendon transfer and minimal complications or donor site morbidity.

Passive Engineering Mechanism Enhancement of a Flexor Digitorum Longus Tendon Transfer Procedure

Category: Ankle, Basic Sciences/Biologics, Hindfoot, Midfoot/Forefoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) associated with posterior tibial tendon (PTT) dysfunction remains a common orthopaedic problem for which a definitive solution has yet to be identified. Controversy has surrounded the diversity of treatment approaches utilized in current practice, which collectively fail to restore physiologic posterior tibial tendon function. In this proof-of-concept study we proposed a novel passive engineering mechanism (PEM) enhanced flexor digitorum longus (FDL) tendon transfer to address this deficiency. The objective of this study was to determine if PEM-enhancement would better restore physiologic PTT function and gait using a biomechanical flatfoot model. We hypothesized that compared to standard treatment, PEM-enhancement would increase applied FDL tendon force and improve pedobarographic and kinematic gait parameters. Methods: An AAFD model consistent with stage II PTT dysfunction was induced in 8 cadaveric lower-limb specimens. Specimens were tested using a robotic gait simulator (RGS) under conditions in randomized order simulating flatfoot, standard treatment, and PEM-enhanced treatment. Three trials were performed for each condition per specimen for a total of 120 trials. In PEM conditions, a custom pulley was fixed in series to the PT tendon along its normal line of action to provide biorealistic passive mechanical advantage (Fig. 1). Pedobarographic (plantar pressures and CoP) and foot bone kinematics during the stance phase of gait were assessed with a RGS-integrated pressure mat and motion capture system respectively. Twenty-five independent RGS trials were completed to measure PEM force scaling using a custom load cell. For statistical analysis, a linear mixed-effects regression was used to determine if mean biomechanical outcome differed by condition. Significance was set at p = 0.05. Results: Cadaveric flatfoot induction and robotic gait simulation produced a statistically validated biomechanical AAFD model. Throughout stance phase, PEM-enhancement significantly increased applied FDL tendon forces while reflecting physiologic tendon action, with mean FDL force increased 32.6 ± 10.7% at the physiologic force peak. Pedobarographic data demonstrated that PEM- enhancement consistently increased lateral pressure and decreased medial pressure during stance phase, with significantly decreased hindfoot pressure (-21 to -24 kPa) and laterally shifted CoP (3.9 to 4.8 mm) observed in comparison to standard treatment. Kinematic data generally showed that PEM-enhancement caused adduction, inversion, and elevation of the medial longitudinal arch during stance phase, with significant joint motion differences (~1 to 2 degrees) observed from standard treatment for the tibiotalar, naviculocuneiform, and first MTP. Conclusion: Using a well-documented biomechanical flatfoot model, we demonstrated that an innovative PEM-enhanced FDL tendon transfer better restored physiologic PTT force and gait characteristics compared to standard treatment. Further, PEM- enhancement enabled desired gait changes not previously observed in the literature for a modeled tendon transfer procedure, changes which compared to those found by other investigators who applied combined tendon transfer and bony procedures to achieve such results. These findings establish PEM-enhancement as a potential solution to PTT muscular imbalance following current surgical methods, and suggest that it may be a valuable feature of novel approaches to improve outcomes in AAFD treatment.

Outcomes of flexor digitorum longus (FDL) tendon transfer in the treatment of Achilles tendinopathy

Outcomes of flexor digitorum longus (FDL) tendon transfer in the treatment of Achilles tendinopathy

Acute Tears of the Tibialis Posterior Tendon Following Ankle Sprain.

Traumatic tears of the tibialis posterior (TP) tendon following an ankle sprain are rare. The purpose of this study was to report our case series of TP tendon tears following an ankle sprain. Patients with persistent TP tendon pain after an ankle sprain were retrospectively identified over a 4-year period and reviewed. A comparison of magnetic resonance imaging (MRI) interpretations by a radiologist and surgeon was made. Patients failing conservative management underwent operative repair of the TP tendon tear and concomitant pathology. Failure of the index surgery was defined as TP tendinosis, which was treated with excision and flexor digitorum longus tendon transfer. Outcomes were measured with the Foot Function Index (FFI) and American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot scores. Thirteen patients were found to have a TP tendon tear following an ankle sprain. The incidence for TP tears with sprains presented to our clinic was 1.04%. MRI identified TP tendon pathology in 4 patients by a radiologist review and in 11 patients by a surgeon review. The most common concomitant pathology was a talar osteochondral defect in 13 of 13 patients and ligament instability in 12 of 13 patients (5/13 lateral, 3/13 medial, 4/13 multidirectional instability). Four of 13 patients failed the index surgery. Of the 9 remaining patients, 4 had clinical follow-up at an average of 4.6 years postoperatively. The average FFI subscale scores were the following: pain, 40.4; disability, 28.9; and activity, 23.6. The average AOFAS hindfoot score was 68.8. Despite being rare, a TP tendon tear should be included in the differential diagnosis for persistent medial-sided pain following an ankle sprain. MRI findings can be subtle. Associated pathology was very common and likely confounded the diagnosis and outcomes. Patients should be counseled on the possibility of poor outcomes and long-term pain. Level IV, case series.

Surgical Planning for Flexor Digitorum Longus Tendon Transfers: An Anatomic Study

Posterior tibial tendon dysfunction is often coupled with various degrees of hindfoot valgus and equinus. Preoperative planning is essential to appropriate procedure choice and surgical efficiency. The purpose of the present study was to assess the anatomy at the harvest site for flexor digitorum longus tendon transfer, specifically at the master knot of Henry. Thirty fresh-frozen below-the-knee cadavers were used for dissection. A standard anatomic approach was performed for posterior tibial tendon debridement and flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was harvested and measured at the master knot of Henry. The present anatomic study evaluated the tendon width of the flexor digitorum longus tendon at a common harvest site. Of the 30 specimens, 20 (67%) measured 5 mm and 10 (33%) measured 4 mm. A 5.0-mm interference screw would be acceptable in each specimen and therefore would be the safest choice. A 4.0-mm interference screw would be acceptable in only 33% of the specimens. Males have a slightly more robust flexor digitorum longus tendon than females at the harvest site. This information will assist surgeons in preoperative planning during stage II flatfoot correction for posterior tibial tendon dysfunction.

Surgical treatment results for flexible flatfoot in adolescents

ObjectiveIdiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults. MethodsA total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances. ResultsAll procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet.Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again. ConclusionSoft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults. Level of clinical evidenceLevel IV, Therapeutic study.

The Application of Calcaneal Z Osteotomy in Treating Type ⅡB Adult Acquired Flatfoot Deformity

Category: Hindfoot Introduction/Purpose: A retrospective control study to evaluate the application of calcaneal Z osteotomy in treating type ⅡB adult acquired flatfoot deformity. Methods: From September 2011 to March 2013, 20 cases of typeⅡB adult acquired flatfoot (according to Myerson’s classification) were treated by calcaneal Z osteotomy combined with medial soft tissue reconstructing. There were 4 males and 16 females with a mean age of 52.6 years (range 49 to 72 years). A Z osteotomy of the calcaneus was performed instead of a lateral column lengthening or a double calcaneal osteotomy for purpose of correct the forefoot abduction and hind foot valgus deformity. The medial soft tissue procedure included posterior tibial tendon resection and Flexor digitorum longus tendon transfer. American Orthopaedic Foot and Ankle Society (AOFAS) score and radiological assessments were used to evaluate the conditions before and after operation. Results: Eventually, 19 patients were followed up with an average duration of 26.5 months (range, 18-56 months). AOFAS scores were 80-90 points in 11 patients, 90-100 points in 6 patients and the excellent and good rate was 89% (17/19). The specific indexes of X-ray improved obviously (P &lt; 0.01). The anteroposterior talocalcaneal angle decreased by 12°, lateral talar first metatarsal angle decreased by 15°, and talonavicular coverage angle decreased by 7°. There was no calcaneal-cuboid joint symptom in this group of patients. All these cases got good bone healing. Conclusion: The calcaneal Z osteotomy can correct the hind-foot deformity in three dimensions and can act as a lateral column lengthening in treating type ⅡB adult acquired flatfoot. The complication of this procedure is minimal.

Outcome of Lateral Transfer of the FHL or FDL for Concomitant Peroneal Tendon Tears.

Concomitant tears of the peroneus longus and brevis tendons are rare injuries, with literature limited to case reports and small patient series. Only 1 recent study directly compared the results of single-stage lateral deep flexor transfer, and no previous series objectively evaluated power and balance following transfer. The purpose of this study was to evaluate clinical outcomes, patient satisfaction, and objective power and balance data following single-stage flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon transfers for treatment of concomitant peroneus longus and brevis tears. Over an 8-year period (2005-2012), 9 patients underwent lateral transfer of the FHL or FDL tendon for treatment of concomitant peroneus longus and brevis tears. All but 1 patient underwent additional procedures to address hindfoot malalignment or other contributing deformity at the time of surgery. Mean age was 56.9 years, and average body mass index was 27.9. Lateral transfer of the FHL was performed in 5 patients, and FDL transfer performed in 4 with mean follow-up 35.7 months (range: 11-94). Eight of 9 patients completed SF-12 and Foot Function Index (FFI) scores, and 7 returned for range of motion (ROM) and manual strength testing of the involved and normal extremities. These 7 patients also completed force plate balance tests, in addition to peak force and power testing on a PrimusRS machine with a certified physical therapist. All patients were satisfied with the results of the procedure. Mean SF-12 physical and mental scores were 32 and 55, respectively; mean FFI total score was 56.7. No postoperative infections were noted. Two patients continued to utilize orthotics or braces, and 2 patients reported occasional pain with weightbearing activity. Three patients noted mild paresthesias in the distribution of the sural nerve and 2 demonstrated tibial neuritis. All patients demonstrated 4/5 eversion strength in the involved extremity. Average loss of inversion and eversion ROM were 24.7% and 27.2% of normal, respectively. Mean postoperative eversion peak force and power were decreased greater than 55% relative to the normal extremity. Patients demonstrated nearly 50% increases in both center-of-pressure tracing length and velocity during balance testing. There were no statistically significant differences between the FHL and FDL transfer groups with regards to clinical examination or objective power and balance tests. The FHL and FDL tendons were both successful options for lateral transfer in cases of concomitant peroneus longus and brevis tears. Objective measurements of strength and balance demonstrated significant deficits in the operative extremity, even years following the procedure. These differences, however, did not appear to alter or inhibit patient activity levels or high satisfaction rates with the procedure. Although anatomic studies have demonstrated benefits of FHL transfer over the FDL tendon, further studies with increased patient numbers are needed to determine if these differences are clinically significant. Level IV, retrospective case series.

Biomechanical Assessment of Flexible Flatfoot Correction

Options for surgical correction of acquired flexible flatfoot deformity involve bone and soft-tissue reconstruction. We used an advanced cadaver model to evaluate the ability of key surgical procedures to correct the deformity and to resist subsequent loss of correction. Stage-IIB flatfoot deformity was created in ten cadaver feet through ligament sectioning and repetitive loading. Six corrective procedures were evaluated: (1) lateral column lengthening, (2) medial displacement calcaneal osteotomy with flexor digitorum longus transfer, (3) Treatment 2 plus lateral column lengthening, (4) Treatment 3 plus "pants-over-vest" spring ligament repair, (5) Treatment 3 plus spring ligament repair with use of the distal posterior tibialis stump, and (6) Treatment 3 plus spring ligament repair with suture and anchor. Correction of metatarsal dorsiflexion and of navicular eversion were quantified initially and periodically during postoperative cyclic loading. Metatarsal dorsiflexion induced by arch flattening was initially corrected by 5.5° to 10.6°, depending on the procedure. Navicular eversion was initially reduced by 2.1° to 7.7°. The correction afforded by Treatments 1, 3, 4, 5, and 6 exceeded that of Treatment 2 initially and throughout postoperative loading. Inclusion of spring ligament repair did not significantly enhance correction. Under the tested conditions, medial displacement calcaneal osteotomy with flexor digitorum longus tendon transfer was inferior to the other evaluated treatments for stage-IIB deformity. Procedures incorporating lateral column lengthening provided the most sagittal and coronal midfoot deformity correction. Addition of spring ligament repair to a combination of these three procedures did not substantially improve correction. An understanding of treatment effectiveness is essential for optimizing operative management of symptomatic flatfoot deformity. This study provides empirical evidence of the advantage of lateral column lengthening and novel information on resistance to postoperative loss of correction.

Comparison of transfer sites for flexor digitorum longus in a cadaveric adult acquired flatfoot model

Posterior tibialis tendon (PTT) dysfunction (PTTD) is associated with adult acquired flatfoot deformity. PTTD is commonly treated with a flexor digitorum longus (FDL) tendon transfer (FDLTT) to the navicular (NAV), medial cuneiform (CUN), or distal residuum of the degraded PTT (rPTT). We assessed the kinetic and kinematic outcomes of these three attachment sites using cadaveric gait simulation. Three transfer locations (NAV, CUN, rPTT) were tested on seven prepared flatfoot models using a robotic gait simulator (RGS). The FDLTT procedures were simulated by pulling on the PTT with biomechanically realistic FDL forces (rPTT) or by pulling on the transected FDL tendon after fixation to the navicular or medial cuneiform (NAV and CUN, respectively). Plantar pressure and foot bone motion were quantified. Peak plantar pressure significantly decreased from the flatfoot condition at the first metatarsal (NAV) and hallux (CUN). No difference was found in the medial-lateral center of pressure. Kinematic findings showed minimal differences between flatfoot and FDLTT specimens. The three locations demonstrated only minimal differences from the flatfoot condition, with the NAV and CUN procedures resulting in decreased medial pressures. Functionally, all three surgical procedures performed similarly.

Anatomic Comparison of Lateral Transfer of the Long Flexors for Concomitant Peroneal Tears

Lateral transfers of the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) tendons have been described for treatment of concomitant, irreparable peroneal tears. This study evaluated the anatomic benefits and constraints of lateral FHL and FDL tendon transfers with regard to available tendon length, diameter, and proximity to the posterior neurovascular bundle. In 9 cadaveric specimens, the FHL and FDL tendons were transected through a medial approach distal to the knot of Henry. Each tendon was transferred into a lateral incision, passing the FDL tendon both posterior and anterior to the tibial neurovascular bundle. The tendons were individually secured to the base of the fifth metatarsal with the foot in maximal eversion and dorsiflexion. The length of donor tendon available for fixation at the fifth metatarsal was measured. After the FDL tendon transfer was secured, the posterior neurovascular bundle was examined for signs of compression. Average FHL tendon diameter measured 5.1 mm; the FDL measured 4.5 mm. After passage through a bone tunnel, an additional 4.9 cm of FHL tendon remained to suture to itself; only 0.5 cm remained for the posterior and anterior FDL transfers. Transfer of the FHL did not increase muscle bulk within the retrofibular groove. Every FDL transfer posterior to the neurovascular bundle produced obvious visual compression of the tibial nerve with plantar flexion and inversion of the foot. Use of the FHL tendon for lateral transfer consistently provided sufficient length of tendon for multiple fixation options and a stronger muscle for transfer. Fixation options for the FDL were limited due to its shorter length. Lateral transfer of the FDL tendon posterior to the neurovascular bundle caused visible compression on the tibial nerve with ankle and hindfoot range of motion. This anatomic study confirmed several advantages for the use of the FHL tendon transfer in cases of concomitant peroneal tears.