Posterior Tibial Tendon Dysfunction Research Articles

CSP2023: 229 - Physiotherapy Management of Posterior Tibial Tendon Dysfunction – A qualitative study of experienced physiotherapists' perspectives

CSP2023: 229 - Physiotherapy Management of Posterior Tibial Tendon Dysfunction – A qualitative study of experienced physiotherapists' perspectives

Effects of Instrument Assisted Soft Tissue Mobilization and Foot Strengthening Exercise on Navicular Height and Ankle Range of Motion in College Students with Flexible Flat Feet: A Comparative Study

Background: The medial longitudinal arch (MLA) plays a major role in maintaining the biomechanics of the foot and is maintained with the help of active and passive systems. Dysfunction of active and passive support system can lead to a reduction of navicular height, leading to excessive pronation of the foot known as pes planus. Pes planus is caused by injury, prolonged stress on the foot, obesity, and faulty biomechanics which will result in posterior tibial tendon dysfunction, collapse of the foot archand flat foot.The patients with posterior tibial tendon dysfunction and pesplanus have reduced dorsiflexion and increased eversion.So, the aim was to study the effects of instrument assisted soft tissue mobilization and foot strengthening exercise on navicular height and ankle range of motion in college students with flexible flat feet. Method: Total 40 students were recruited for the study as per selection criteria and were divided into two groups (20 in each group). Group A was treated with Instrument Assisted Soft Tissue Mobilization(IASTM)and group B was treated with Foot Strengthening Exercise for five days a week for 4 weeks. Inter-group analysis by Mann Whitney U-test showed statistically significant improvement in navicular height and ankle range of motion (P value ≤ 0.001). Conclusion: This study showed statistically significant improvement in navicular height and ankle ROM with the use of IASTM and foot strengthening exercise. However, IASTM was found to be more effective in improving ankle ROM and foot strengthening exercise was found to be more effective inincreasingnavicular height.

Assessments Associated with the Diagnostics and Non-Surgical Treatment of Posterior Tibialis Tendon Dysfunction: A Systematic Review

Objectives: To investigate the efficacy of the assessment methods that are used to diagnose posterior tibialis tendon dysfunction (PTTD) and investigate how the results of these assessments can be used to instruct non-surgical treatments. Design: Systematic review. Data sources: Searches were conducted up to January 2023 in the PubMed, Scopus, Science Direct, Embase, Web of Science and Lilacs databases. Study eligibility criteria: Studies which included patients over 18 years of age, diagnosed with PTTD, which describe the assessments used to aid in the non-surgical treatment of PTTD in comparison with another type of assessment. All types of studies apart from protocols, letters to editor and other systematic reviews and meta-analysis were included. Study appraisal and synthesis methods: Two blinded reviewers performed screening, data extraction, and methodological quality assessments using the QUADAS-2. Results: A total of 15 observational studies were included in the review. Assessment methods included were verbal assessments, physical examinations, and imaging (magnetic resonance imaging (MRI), ultrasound (US), and radiographs). The single-heel rise test was a commonly mentioned physical examination, showing reliability in one study but contradicting in another. MRI was frequently described as the “gold standard”. However, US showed both comparable accuracy and advantages compared to MRI, such as cost-effectiveness and real-time examinations. Conclusions: There are many assessment methods described in the literature and, due to the lack of accuracy of the tests, a mixture of tests should be used to assess PTTD. The parameters from the tests can provide a diagnosis of PTTD, but do not offer detail on how they assist the non-surgical treatment of the condition.

Lower limbs biomechanical deficits associated with stage 1 and 2 posterior tibialis tendon dysfunction during walking

BackgroundPosterior tibialis tendon dysfunction (PTTD) is a chronic degenerative musculoskeletal disorder causing a progressive ankle complex and arch collapse altering lower limb biomechanics. However, biomechanical changes associated with stage 1 and 2 PTTD need to be better characterized during walking to guide clinical recommendations and improve non-operative treatments. Research questionWhat are the lower limb kinematic and kinetic differences between individuals with stage 1 (PTTD1), individuals with stage 2 PTTD (PTTD2) and healthy counterparts during gait? MethodsSixteen PTTD1, 11 PTTD2 and 20 healthy controls were included in this multicentric case-control study to compare their lower limb gait biomechanics. Kinematic and kinetic data were recorded using a three-dimensional motion capture system and a force plate. One-dimensional statistical parametric mapping was used to compare lower limb joint motion and moments between groups during the stance phase. ResultsPTTD1 had minimal biomechanical differences compared with the control group. In contrast, PTTD2 presented significant differences compared with controls and PTTD1. At the ankle, PTTD2 exhibited greater plantarflexion and eversion angles and midfoot dorsiflexion and inversion angles throughout stance compared with controls and PTTD1. PTTD2 presented lower midfoot abduction moments compared with controls. These changes led PTTD2 to exhibit knee and hip adaptative biomechanical mechanisms in the frontal and transverse planes in late stance. PTTD2 had greater knee internal rotation angles and smaller knee external rotation moments compared to controls. PTTD2 had smaller hip internal rotation angles compared with PTTD1 and smaller hip adduction moments compared with controls. SignificancePTTD1 showed minimal biomechanical differences compared to controls and important differences compared to PTTD2. The lower limb biomechanical deficits accentuate as the pathology advances from stage 1 to stage 2. PTTD is a progressive condition needing early clinical management at stage 1 to avoid successive biomechanical changes associated with stage 2.

An Emphasis on the Role of Peroneus Brevis to Peroneus Longus Transfer in Progressive Collapsing Flatfoot Deformity

The role of the peroneal tendons in progressive collapsing flatfoot deformity (PCFD), also traditionally known as posterior tibial tendon dysfunction, is likely overlooked and almost certainly understudied. We explored the impact of peroneus brevis (PB) to peroneus longus (PL) transfer in the adult population with flexible PCFD deformities class A1 (flexible hindfoot valgus), B1 (flexible midfoot abduction), and C1 (flexible forefoot varus) as an augmentative measure combined with various bony procedures with proper assessment functionally, clinically, and radiologically. PB to PL tendon transfer poses a simple procedure dealing with muscle imbalance between the medial and lateral columns of the foot. It deals with the new understanding of the PCFD complex as a three-dimensional deformity. It works mainly on the axial plane to limit midfoot abduction and strongly augments the PL acting on the sagittal plane to address the forefoot varus. Finally, to a lesser extent, it deals with the coronal plane of hindfoot valgus, eliminating the primary evertor of the foot (PB) while simultaneously strengthening the PL, which contributes to the medial longitudinal and transverse arches of the foot, therefore decreasing the possibility of lateral column overload commonly caused by the Evans osteotomy through reducing pressure across the calcaneocuboid joint. This procedure is preferably indicated for flexible PCFD deformities class (A1, B1, and C1), yet is contraindicated in neuromuscular deformities with peroneal nerve palsy. Level of Evidence: Level IV.

Qualitative pilot study on the orthotic management of tibialis posterior tendon dysfunction by foot and ankle health professionals

Qualitative pilot study on the orthotic management of tibialis posterior tendon dysfunction by foot and ankle health professionals

Occurrence of adult acquired flat foot among diabetic patients in Rawalpindi and Islamabad: a cross-sectional descriptive study

Human foot is a biological masterpiece, which is strong enough to support the body weight and flexible enough to adjust to various surfaces. Foot postural deviation can alter the alignment of the entire body. The collapse of the medial longitudinal arch of the foot causes one of the most prevalent deformities i.e. flat foot. Diabetic patients are more prone to have flat foot due to degeneration of posterior tibial tendon over the course of their disease. The aim of this study was to determine the occurrence of adult acquired flat foot and assess the disability of flat foot among diabetic population in Rawalpindi and Islamabad, Pakistan. In this cross-sectional descriptive study, 384 diabetic patients aged 35-60 year were enrolled after obtaining informed consent. Non-probability convenience sampling technique was employed. The data was gathered by performing navicular drop test to determine the presence of flat foot, assessment of posterior tibial tendon dysfunction through single heel rise test and by using foot function index questionnaire to assess pain, disability and activity limitation. Based on results of the study, posterior tibial tendon dysfunction was observed to cause the appearance of low navicular height leading to flat foot in 58.33% of the population. Moreover, there is a moderate tendency of occurrence of flat foot among diabetic population in the absence of other risk factors such as hypertension, obesity, steroids use and previous foot trauma etc. With regard to the functionality measured by foot function index, it was implied that the functional status of the patient was reduced because of the pain, disability and activity restriction in the presence of flat foot.

"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.

The role of different physiotherapy methods in tibialis posterior muscle insufficiency – a literature review

Introduction. Dysfunction or rupture of the posterior tibial tendon (PTT) is a fairly common cause of acquired adult flatfoot. Conservative and surgical treatments are used to correct PTT dysfunction. Objective. The aim of this study was to present the characteristic features of PTT dysfunction and evaluate the application and effectiveness of selected physiotherapeutic methods in the treatment of posterior tibial muscle insufficiency. Materials and Methods. Available literature was analyzed based on English-language databases such as PubMed, Scopus, ScienceDirect, Medline, and others, using the Google Scholar search engine. A total of 20 articles were analyzed out of 52 identified through the aforementioned method. Publications no older than 10 years were included as search criteria, using the following keywords: posterior tibial muscle insufficiency, orthoses, orthopedic insoles, flatfoot, physiotherapy. Results. It was not possible to specify which method of treating posterior tibial muscle insufficiency is the most effective. Conclusions. Contemporary research suggests that conservative treatment methods appear to be effective in treating posterior tibial muscle insufficiency. Although opinions on the effectiveness of orthoses are divided, the majority acknowledges that orthoses

Republication of "Preliminary Experience Using Bioactive Glass Wedges for Cotton Osteotomy".

Medial cuneiform dorsal opening wedge (Cotton) osteotomy is often used for treating forefoot varus in patients undergoing surgery for stage II posterior tibialis tendon dysfunction. The goal of this study was to examine the radiographic outcomes of Cotton osteotomy with bioactive glass wedge to assess for both maintenance of correction and clinical results and complications. We hypothesized that bioactive glass wedges would maintain correction of the osteotomy with low complication rates. Between December 2015 and June 2016, the charts of 17 patients (10 female and 7 male) who underwent Cotton osteotomy using bioactive glass wedges were retrospectively reviewed. Patient age averaged 56.8 years (range, 16-84). The average follow-up was 6.5 months. Radiographs were reviewed to assess for initial correction and maintenance of correction of medial column sag as well as for union. Charts were reviewed for complications. The medial column sag correction averaged 15.6% on the final postoperative lateral radiograph. Meary angle averaged 19 degrees (3.14-42.8 degrees) preoperatively and 5.5 degrees (0.4-20.7 degrees) at final follow-up. All patients achieved clinical and radiographic union. One patient developed neuropathic midfoot pain and was managed with sympathetic blocks. One patient had a delayed union that healed at 6 months without surgical intervention. No patients required the use of custom orthotics or subsequent surgical procedures. Cotton osteotomy with bioactive glass wedges produced consistent correction of the medial column with low risk. Level IV, case series.

Prevalence of Posterior Tibialis Tendon Dysfunction in Individuals with Flatfeet

Posterior Tibialis Tendon Dysfunction is a progressive condition usually associated with an overpronated foot (flatfoot). It can be a debilitating condition in its later chronic stages severely affecting the ADL’s of an individual if not identified in its earliest stages.As an earlier detection may help prevent or halt the progression of PTTD in its advanced severe stages in younger individuals with age 18 to 25 years with flatfeet. The assessment of the individuals for PTTD was done using the Johnson and Strom criteria which is a widely used classification for clinical diagnosis of this dysfunction.

Tibial Retro-Malleolar Groove Morphology in Patients With Posterior Tibialis Tendon Dysfunction

The posterior tibial tendon is a gliding tendon which courses around the medial malleolus and fails in posterior tibialis tendon dysfunction (PTTD) leading to a flat foot deformity. Distal tibial bone spurs have been identified as a secondary sign of PTTD although they have not been quantified in detail. The aim of this study was to assess the association of tendon dysfunction with the bony morphology of the tibial retro-malleolar groove. We performed a retrospective review of the clinical presentation, plain radiographs, and 103 magnetic resonance imaging (MRI) scans in 82 consecutive patients with PTTD compared with a non-PTTD group. We carried out a quantitative and qualitative assessment of the presence of plain radiographic bone spurs, stage of PTTD and MRI imaging of the morphology of the tibial bony malleolar groove. Plain radiographic bone spurs, as a secondary sign of PTTD, were present in 21.3% of ankle radiographs. MRI bone spurs were identified in 26/41 (63.4%) for all high-grade partial and complete tears and 7/41 (17.1%) for isolated complete tears compared with only 3.9% of the non-PTTD group. There was a significant association between the presence of bone spurs on MRI imaging and high-grade partial and complete tibialis posterior tears (p < .001; odds ratio of 4.98). Eleven of 103 (10.7%) of spurs were large and in 4/103 (3.9%) were substantial enough to create a tunnel-like hypertrophic groove not previously reported. There is variation in the bony structure of the malleolar groove in PTTD not observed in the non-PTTD group. Further investigation over time may elucidate whether the groove morphology may lead to mechanical attrition of the tibialis posterior tendon and contribute to failure of healing and progressive tendon degeneration.

Living with foot and ankle disorders in rheumatic and musculoskeletal diseases: A systematic review of qualitative studies to inform the work of the OMERACT Foot and Ankle Working Group

ObjectivesThis study aimed to determine outcome domains of importance to patients living with foot and ankle disorders in rheumatic and musculoskeletal diseases (RMDs), by exploring the symptoms and impact of these disorders reported in existing qualitative studies. MethodsSix databases were searched from inception to March 2022. Studies were included if they used qualitative interview or focus group methods, were published in English, and involved participants living with RMDs (inflammatory arthritis, osteoarthritis, crystal arthropathies, connective tissue diseases, and musculoskeletal conditions in the absence of systemic disease) who had experienced foot and ankle problems. Quality was assessed using the Critical Appraisal Skills Programme qualitative tool and confidence in the findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. All data from the results section of included studies were extracted, coded and synthesised to develop themes. ResultsOf 1,443 records screened, 34 studies were included, with a total of 503 participants. Studies included participants with rheumatoid arthritis (n = 18), osteoarthritis (n = 5), gout (n = 3), psoriatic arthritis (n = 1), lupus (n = 1), posterior tibial tendon dysfunction (n = 1), plantar heel pain (n = 1), Achilles tendonitis (n = 1), and a mixed population (n = 3), who live with foot and ankle disorders. Seven descriptive themes were generated from the thematic synthesis: pain, change in appearance, activity limitations, social isolation, work disruption, financial burden and emotional impact. Descriptive themes were inductively analysed further to construct analytical themes relating to potential outcome domains of importance to patients. Foot or ankle pain was the predominant symptom experienced by patients across all RMDs explored in this review. Based on grading of the evidence, we had moderate confidence that most of the review findings represented the experiences of patients with foot and ankle disorders in RMDs. ConclusionsFindings indicate that foot and ankle disorders impact on multiple areas of patients’ lives, and patients’ experiences are similar regardless of the RMD. This study will inform the development of a core domain set for future foot and ankle research and are also useful for clinicians, helping to focus clinical appointments and measurement of outcomes within clinical practice.

P041 Living with foot and ankle disorders in rheumatic and musculoskeletal diseases: a thematic synthesis of qualitative studies to inform the work of the Outcome Measures in Rheumatology (OMERACT) Foot and Ankle Working Group

Abstract Background/Aims Foot and ankle involvement is common in rheumatic and musculoskeletal diseases (RMDs), but high-quality evidence is lacking to determine the effectiveness of foot and ankle treatments. Heterogeneity in the outcomes used across clinical trials in this area hinders the ability to compare study findings, and some outcomes are not always meaningful to patients. This study aimed to determine what outcomes are important to patients by exploring and synthesising qualitative data relating to the symptoms and impact of living with foot and ankle disorders in RMDs. Methods Six databases (CINAHL; Ovid Embase; Ovid MEDLINE; Psycinfo; Cochrane Database of Systematic Reviews; CENTRAL) were searched from inception to March 2022. Qualitative interview or focus group studies published in English and involving participants living with foot or ankle disorders in RMDs (inflammatory arthritis, osteoarthritis, crystal arthropathies, connective tissue diseases, and musculoskeletal conditions in the absence of systemic disease) were included. Quality was assessed using the Critical Appraisal Skills Programme qualitative tool. All data from the results section of included studies were extracted, coded and synthesised to develop themes. Patient and public involvement contributors were involved throughout the review, from design of the study to interpretation of the results and discussions about the findings. Results Of 1,440 database records screened, 34 studies were included, with a total of 581 participants. Studies focused on living with foot or ankle disorders in rheumatoid arthritis (n = 18), osteoarthritis (n = 5), gout (n = 3), psoriatic arthritis (n = 1), lupus (n = 1), posterior tibial tendon dysfunction (n = 1), plantar heel pain (n = 1), Achilles tendonitis (n = 1), and mixed population (n = 3) patients. Six themes were generated from the thematic synthesis: pain, change in appearance, activity limitations, social isolation, limited work ability and emotional impact. Foot or ankle pain was the predominant symptom experienced by patients in all included studies and was closely linked to other themes. Both pain and change in appearance of the feet or ankles (deformity), and subsequent limitations in footwear and clothing choices, led to restrictions in physical activities, social participation and work. Emotional distress, including anxiety, anger and embarrassment, was common among patients with foot and ankle disorders across all of the RMDs explored in this review. Conclusion This is the first study to synthesise findings of qualitative research exploring the lived experience of patients with foot and ankle disorders in RMDs. Findings indicate that these disorders impact on multiple areas of patients’ lives, both physically and psychologically. Patients’ experiences of foot and ankle disorders are similar across different RMDs, although there are a limited number of qualitative studies focusing on conditions other than rheumatoid arthritis. These findings will inform a future consensus study prioritising the outcomes that should be measured in future research studies and clinical practice. Disclosure L.S. Chapman: None. C. Flurey: None. A.C. Redmond: None. P. Richards: None. C. Hofstetter: None. B. Tapster: None. J. Emmel: None. P.S. Helliwell: None. H.B. Menz: None. M.T. Hannan: None. B. Shea: None. H.J. Siddle: None.

Clinical outcomes of posterior tibial tendon sheath ultrasound-guided corticosteroid injections.

The purpose of this study was to assess the safety of ultrasound-guided corticosteroid injections into the posterior tibial tendon sheath for posterior tibialis tendinopathy. Secondary outcomes include duration of pain relief, amount of pain relief, need for repeat injections and progression to surgery. We retrospectively reviewed all patients in our electronic medical record who underwent a posterior tibial tendon sheath (PTTS) steroid injection between 2015 and 2020 for the diagnosis of posterior tibial tendon dysfunction and/or posterior tibialis tendon insufficiency, and/or ankle pain. Demographic information was obtained from the patient record in addition to MRI data, clinical response to injection based on follow-up visits, number of total injections and progression to surgery. Thirty-eight posterior tibial tendon sheath ultrasound-guided injections were administered in 33 patients who met inclusion criteria during the 5-year study period. Thirty-three patients were included in the study with a total of 38 injections performed. Eighteen of 38 (47%) injections yielded good or better pain relief. Seven of 33 patients (21%) progressed to surgery. There were no reported complications with the 38 performed injections. Ultrasound-guided corticosteroid injection into the posterior tibial tendon sheath is a safe nonoperative treatment modality for progressive collapsing foot deformity. The efficacy of the injection appears highly variable with 47% of injections yielding 'good' or better clinical results. When evaluating body mass index (BMI), obese patients (BMI ≥30.0) were found to have a more sustained response to injection (P=0.029) and more pain relief (P=0.049) than non-obese patients.

Supination resistance variations in foot and ankle musculoskeletal disorders: implications for diagnosis and customised interventions with wedged insoles

BackgroundSupination resistance is a clinical outcome that estimates the amount of external force required to supinate the foot. A greater supination resistance may indicate greater loads on structures responsible for generating internal supination moments across the subtalar joint during static and dynamic tasks. As such, greater supination resistance may be an expected finding in medial foot and ankle musculoskeletal disorders, such as plantar fasciopathy (PF) and posterior tibial tendon dysfunction (PTTD), whereas reduced supination resistance may be present in lateral ankle disorders, such as chronic ankle instability (CAI). However, no studies have yet investigated the changes in supination resistance across these foot and ankle musculoskeletal disorders. This study aimed to quantify supination resistance in individuals with PF, PTTD and CAI compared to healthy controls. Additionally, this study aimed to explore the changes in supination resistance following the simulation of varus and valgus wedges, which are commonly used interventions for these disorders.MethodsFourteen participants with PF, fourteen with PTTD, fourteen with CAI and fourteen healthy controls were recruited. Supination resistance was quantified on a level surface and on a 10-degree inclined surface with varus and valgus positions.ResultsSupination resistance was lower for the injured foot for CAI (p < 0.001) and greater for PTTD (p < 0.001) compared to the healthy foot. There was no significant between-foot difference observed for PF (p = 0.275) and controls (p = 0.970). In the injured foot, CAI exhibited lower supination resistance compared to controls (p < 0.001), PF (p = 0.012) and PTTD (p = 0.014). Regardless of the groups, supination resistance increased when tested on a surface with valgus inclination (p < 0.001) and decreased when tested on a surface with varus inclination (p < 0.001).ConclusionsVarus and valgus inclinations to the surface were effective in modifying supination resistance in PTTD and CAI, respectively. Supination resistance seemed unchanged in PF, and thus inclining the standing surface leads to greater between-feet asymmetries. This study also highlights the potential of wedged insoles as a mean to customise treatments and modify tissue stresses in these disorders. The findings contribute to the understanding of foot and ankle biomechanics and may aid in the development of more effective management and rehabilitation strategies.

Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review.

Background and Objectives: Tibialis posterior tendon pathologies have been traditionally categorized into different stages of posterior tibial tendon dysfunction (PTTD), or adult acquired flatfoot deformity (AAFD), and more recently to progressive collapsing foot deformity (PCFD). The purpose of this scoping review is to synthesize and characterize literature on early stages of PTTD (previously known as Stage I and II), which we will describe as tibialis posterior tendinopathy (TPT). We aim to identify what is known about TPT, identify gaps in knowledge on the topics of TPT, and propose future research direction. Materials and Methods: We included 44 studies and categorized them into epidemiology, diagnosis, evaluation, biomechanics outcome measure, imaging, and nonsurgical treatment. Results: A majority of studies (86.4%, 38 of 44 studies) recruited patients with mean or median ages greater than 40. For studies that reported body mass index (BMI) of the patients, 81.5% had mean or median BMI meeting criteria for being overweight. All but two papers described study populations as predominantly or entirely female gender. Biomechanical studies characterized findings associated with TPT to include increased forefoot abduction and rearfoot eversion during gait cycle, weak hip and ankle performance, and poor balance. Research on non-surgical treatment focused on orthotics with evidence mostly limited to observational studies. The optimal exercise regimen for the management of TPT remains unclear due to the limited number of high-quality studies. Conclusions: More epidemiological studies from diverse patient populations are necessary to better understand prevalence, incidence, and risk factors for TPT. The lack of high-quality studies investigating nonsurgical treatment options is concerning because, regardless of coexisting foot deformity, the initial treatment for TPT is typically conservative. Additional studies comparing various exercise programs may help identify optimal exercise therapy, and investigation into further nonsurgical treatments is needed to optimize the management for TPT.

Foot &amp; Ankle

The December 2022 Foot &amp; Ankle Roundup360 looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle.

Are Complications and Survival of Total Ankle Arthroplasty Influenced by Hospital Setting? An Analysis of 189 Cases Performed in Community and County Hospitals

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Total ankle arthroplasty is a notoriously challenging operation typically reserved for well-resourced academic tertiary care facilities. Limited studies support its safety in a community hospital setting, while outcomes in a county hospital setting have not been previously described. Demonstrating that TAA can be performed effectively and safely in broader hospital settings is critical given the importance of access to care, the prevalence of tibiotalar arthritis, and known efficacy of TAA for pain management, ankle stability, and preservation of functional ambulation. The purpose of this study was to investigate the differences in post-operative complications, revision rates, and implant survival of TAA performed in the community versus county hospital setting. Methods: A total of 189 patients that underwent TAA between January 2014 and May 2021 were retrospectively evaluated. 149 cases (79%) were performed in a community hospital setting, and 40 cases (21%) were performed in a county hospital setting. Surgeries were completed by a single fellowship-trained surgeon utilizing the same Stryker STAR implant for all cases. Patient demographics, postoperative complications, and revision surgery profiles were collected with a mean follow-up of 22.3 +- 21.1 months. Logistic regression was used to analyze the relationships between complications and osteoarthritis etiology, age, smoking history, diabetes, obesity, and hospital setting. Categorical variables were compared with Chi-square tests, means were compared with a two-tailed Student's t-test, and implant survival was assessed with a Kaplan-Meier analysis. Significance was defined as p&lt;.05 for all statistical analyses. Results: Controlling for osteoarthritis etiology and patient demographics, TAA performed in the county setting was a significant predictor of aseptic loosening (b=2.25, SE=1.01, p=.025; OR=9.5, 95% CI: 1.3-68.1) and posterior tibial tendon (PTT) dysfunction (b=2.76, SE=1.3, p=.034; OR=16, 95% CI: 1.2-204). Rate of aseptic loosening was significantly higher in the county as compared to the community setting (10% vs. 1.3%) (p=.006), as was PTT dysfunction (10% vs. 0.7%) (p=.001). All other complications were comparable between settings (p&gt;.05) (Figure 1). At 7 years, TAA survival with any reoperation as an endpoint was comparable between community (88.6%) and county (87.5%) settings (p=.872), with no difference in mean time to reoperation between community (11.2 months) and county (22.3 months) settings (p=.25). With explant surgery as an endpoint, survival was similarly comparable between community (97.3%) and county (95%) settings (p=.677). Overall mean time to explant surgery was 24.4 months with no difference between settings (p=.10). Conclusion: Total ankle arthroplasty has a similar reoperation rate and implant survival in community and county hospital settings. Our mid-term results compare favorably with outcomes reported from academic tertiary care facilities and suggest that total ankle arthroplasty is an effective intervention across hospital settings when performed by an experienced surgeon. However, certain complications, including symptomatic aseptic loosening and PTT dysfunction, were found to be more common when performed in the county hospital setting. Future studies are necessary to investigate the impact of the increased complication rate on long-term outcomes of total ankle arthroplasty in the county hospital setting.

Patient Outcomes Following Flatfoot Reconstruction with the Use of a Spring Ligament Fibertape Device

Category: Hindfoot; Arthroscopy; Sports; Trauma Introduction/Purpose: Flatfoot deformities are chronic debilitations that involve multiple ligament complexes that stabilize the hindfoot. No study has clearly evaluated the efficacy of utilizing the spring ligament internal-brace fibertape device as an adjunct through clinical and radiographic measures. The purpose of this study is to explore the diagnostic efficacy of 3T MRI to evaluate the spring ligament, and to compare operative failures, complications, and radiographic outcomes of patients who underwent procedures for posterior tibial tendon dysfunction (PTTD) that employed the internal-brace fibertape (IB) and those that did not in the non-internal-brace (NIB) group. Methods: Following IRB approval, patients that underwent flatfoot reconstruction by four surgeons at a single institution between 2015 and 2018 were queried from an institutional radiology database. A total of 44 cases were identified with procedures that utilized the IB, and those that underwent MRI preoperatively had spring ligament integrity compared to intraoperative findings. These 44 cases that utilized the IB were subsequently match paired 1:2 with an NIB group. Data was collected retrospectively for both clinical and radiographic outcomes. Clinical outcomes included failures leading to reoperation, complications, and additional procedures. Radiographic parameters involved pre- and post-operative comparisons. Inadvertent reoperations that implicated malunion or the need for a triple arthrodesis within 13 months of the initial procedure were compared. Patient complications were compared. Statistical analysis was performed to evaluate the relationship between the clinical outcomes of these patients and use of the IB as an additional source of stabilization. Results: A total of 132 cases were analyzed with 44 that employed the IB and 88 NIB. The average ages for each group were 46.7 and 46.5 years for the IB and NIB group respectively. Of the 44 IB patients, 0 out of the 10 (0.0%) who had received a preoperative MRI were correctly identified as having an attenuated or frankly torn spring ligament as determined intraoperatively. There were significant differences in failure rates between groups with 0.0% of IB procedures and 4.5% of NIB procedures resulting in failure (p=0.022). There were no significant differences among complications between groups. There were significant improvements between all pre- and post-operative radiographic measurements within each group. However, the improvements were not found to be significant between groups. Conclusion: The results of this systematic retrospective chart review demonstrate that the spring ligament internal-brace device may serve as an effective adjunct in PTTD procedures and suggest considering it when planning irrespective of preoperative MRI findings. The data suggest that failure rates may be reduced without increasing complications. Both methods of fixation can provide significant improvements in reconstructing the arch. However, the internal-brace may reduce the prevalence of post- operative malunion or the need for a triple arthrodesis.