Posterior Tibial Tendon Insufficiency Research Articles

Acquired Pes Planovalgus : Current Concepts - "From Adult Acquired Pes Planovalgus to Progressive Collapsing Foot Deformity".

The clinical disorder traditionally known as pes planovalgus due to posterior tibial tendon insufficiency or adult-acquired pes planovalgus has been the subject of several publications over the past two decades. Now, it is understood that the problem does not lie in the posterior tibial tendon per se and may even occur without tendon injury. Studies have brought new concepts and understanding that question the views on this subject, culminating in the replacement of existing classifications with one that is more assertive and discriminative of the potential presentation patterns of the deformity. In addition, a change in the name of the disorder to progressive collapsing foot deformity (PCFD) has been proposed. Regarding surgical treatment, the concept of an à la carte approach persists, emphasizing axis realignment through osteotomies, arthrodeses, and soft tissue balancing, which consists of tendon transpositions/repairs and reconstruction of ligament structures, especially the deltoid ligament complex and the spring ligament.

In-Office Posterior Tibial Needle Tendoscopy Is An Effective Treatment Strategy for Patients with Stage 1 Posterior Tibial Tendon Dysfunction: A Retrospective Review

Category: Arthroscopy; Other Introduction/Purpose: Posterior Tibial Tendon Insufficiency (PTTI) is a common pathology of the foot and ankle and the leading cause for adult-aquired flatfoot deformity. PTTI typically presents with loss of medial arch of the foot which may progress to hindfoot valgus, forefoot abduction, and development of midfoot osteoarthritis. Following failure of conservative management, tenosynovectomy is indicated in early stage PTTI. However, current tendoscopy techniques lead to significant soft tissue damage. Minimally invasive approaches to these arthroscopic procedures minimize damage to soft-tissue and allow for a much faster recovery. The purpose of this retrospective review is to evaluate the therapeutic and diagnostic potential of In-Office Posterior Tibial Needle Tendoscopy for PTTI. Methods: Chart review was conducted to identify patients who underwent In-Office Posterior Tibial Needle Tendoscopy with a minimum of 1-year follow-up. Data collected and assessed included: patient demographics, pathological characteristics, treatment characteristics, American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, visual analog scale (VAS) scores, return to sport (RTS), and failures. Results: Eleven patients were included at a mean follow-up of 17.4 ± 9.0 months and a mean age of 40.8 ± 14.64 years. Five patients (45.5%) were stage 1 PTTI, 5 patients were stage 2a PTTI and 1 patient was stage 2b PTTI. The mean AOFAS score improved from 45 ± 5.4 preoperatively to 70 ± 18.5 at final follow-up (p< 0.01). The mean VAS improved from 6 ± 0.7 preoperatively to 3.7 ± 1.6 at final follow-up (p< 0.01). The failure rate was 36.3%. All patients with stage 1 PTTI were asymptomatic at final follow-up. Four of the 6 patients (66.7%) with stage 2 PTTI warranted further surgical intervention. Conclusion: This retrospective study demonstrated there is therapeutic and diagnostic potential for In-Office Posterior Tibial Needle Tendoscopy. Patients with early stage PTTI had improved subjective clinical outcomes and rapid return to sport. For moderate to severe PTTI, in-office needle tendoscopy may be less beneficial. Further high quality studies are necessary to determine the optimal role of In-Office Posterior Tibial Needle Tendoscopy in the management of Posterior Tibial Tendon injury.

Can ChatGPT-4 Think Like an Orthopaedic Surgeon? Testing Clinical Judgement and Diagnostic Ability in Pathologies of the Foot and Ankle

Category: Other; Ankle Introduction/Purpose: Artificial intelligence chatbots have seen a notable rise in recent years, especially with the creation of ChatGPT, a chatbot that utilizes a language learning model with an ability to carry human-like conversation. While ChatGPT does not have any specific medicine-related training, prior studies have shown that its newest version, GPT-4, has been able to pass professional licensing examinations and perform comparably on question bank sets as surgical residents. The purpose of this study was to explore the diagnostic and decision-making capacities of ChatGPT-4 in clinical management specifically assessing for accuracy in identification and treatment of foot and ankle pathologies. Methods: This study presented 16 foot and ankle cases to ChatGPT-4. Each case was evaluated by 3 fellowship-trained foot and ankle orthopaedic surgeons. The scoring system included 5 criteria within a Likert scale, with 5 being the lowest score and 25 being the highest possible. The criteria included stating the correct diagnosis, stating the most appropriate procedure, identification of alternative treatments, providing comprehensive information beyond treatment, and not mentioning nonexisting therapies. ChatGPT-4 was referred to as “Dr. GPT”, using role prompting to encourage step-by-step processing and establish a peer dynamic so that the role of an orthopaedic surgeon was emulated by the chatbot. The 16 cases presented included the following: plantar fasciitis, Morton neuroma, ankle sprain, Achilles tendon rupture, Achilles tendonitis, metatarsalgia, peroneal tendon tear, posterior tibial tendon insufficiency, distal fibula fracture, 2nd metatarsal stress fracture, 5th metatarsal fracture, ankle arthritis, hallux rigidus, Lisfranc injury, midfoot arthritis, and hallux valgus. Results: The average score across all criteria for all 16 cases was 4.47, with an average sum score of 22.4. The plantar fasciitis case received the highest score, with an average sum score of 24.7. The lowest score was observed in the peroneal tendon tear case, with an average sum score of 16.3. Subgroup analyses of each of the 5 criterion using Friedman Rank Sum tests showed no statistically significant differences in surgeon grading. Criterion 5, lack of mention of nonexistent treatment options, and criterion 1, the ability for ChatGPT to correctly diagnose, received the highest subgroup scores of 4.88 and 4.77, respectively. The lowest criteria score was observed in criteria 4 (4.05), evaluating ChatGPT-4 providing comprehensive information beyond treatment options. Conclusion: This study demonstrates that ChatGPT-4 effectively diagnosed and provided reliable treatment for most foot and ankle cases presented, noting consistency amongst surgeon evaluators. The individual criterion assessment revealed that ChatGPT-4 was most effective in diagnosing pathologies. Additionally, the chatbot consistently did not suggest nonexistent treatment options, a common finding in prior studies evaluating ChatGPT-3.5 in which fabricated information was presented in a manner that was seemingly true. This resource could be useful for clinicians seeking patient education materials on diagnoses and treatment options without fear of incorrect information presentation, though comprehensive information beyond treatment may be limited.

Prevalence and classification of accessory navicular bone: a medical record review.

The accessory navicular bone (ANB) is one of the most common accessory bones in the foot. Certain pathologies, such as posterior tibial tendon insufficiency are associated with ANB, and should be differentiated from midfoot and hindfoot fractures such as navicular tuberosity avulsion fractures. There are few studies addressing the prevalence and types of ANB in Saudi Arabia. Determine the prevalence and morphological variations of ANB and its relation with age and sex in patients visiting foot and ankle clinics. Medical record review SETTING: Orthopedic foot and ankle clinic at a university hospital. The presence of ANB was retrospectively analyzed in radiographs from patients who presented to the orthopedic foot and ankle at our university hospital from February 2010 to December 2020. The patients were stratified according to sex, age, and diagnosis. For each ANB, recorded information included site, size, classification, subtypes, and symptomatology. Purposive sampling was used to select the patients for the study (non-probability sampling). Prevalence of ANB in patients attending a foot and ankle clinic. 117 patients and 194 feet. ANB was analyzed in 1006 radiographs from 503 patients. ANB was detected in 117 (23.3%) patients and 194 (19.3%) feet Prevalence was significantly higher in females (67.5%) than in males (32.5%) (Z=5.359, P<.001). The ages ranged from 19 to 86 years, with a mean age of 48.26 (14.5) years. The most common site was bilateral (77 patients, 65.8 %). Type I was the most common type, with a prevalence of 42.1%. There were no significant differences in types in relation to sex, but all types and subtypes differed significantly from each other. ANB was common among patients presenting to the foot and ankle clinic, with an overall prevalence of 23.3%. It should be considered among the differential diagnosis in chronic foot pain, and should be differentiated from midfoot and hindfoot fractures. Further studies with a larger, randomized sample are needed, for more accuracy and to confirm the reported results. Retrospective chart review, non-probability sampling, and use of plain radiographs. None.

Effectiveness of calcaneal osteotomy in surgical treatment of foot conditions: A Prisma statement guidelines compliant systematic review.

Calcaneal osteotomy is a commonly established method used to correct various foot malalignment surgery problems that produce varus and valgus hindfoot abnormality as well as Haglund's deformity, cavovarus foot reconstruction, flatfoot deformity, plantar fasciitis, posterior tibial tendon insufficiency and planovalgus foot. After decades, several procedures in orthopaedic foot surgery have been suggested for reducing the risk of wound and neurovascular complications. The goal of this Prisma statement guidelines compliant systematic review was to establish the effectiveness and safety of calcaneal osteotomy in foot surgery. We have performed a novel systematic review of the current published literature in order to evaluate the scientific evidence now available on this association, assigning predefined exclusion and inclusion criteria. Eight investigations were selected which had 191 cases. The adult flatfoot, tibialis posterior reconstruction and cavovarus foot deformity were treated with different procedures of calcaneal osteotomy techniques. The adequate level of effectiveness of calcaneal osteotomy is associated with the kind and location of the incision, with or without screw application, in each specific foot condition. There is a limited number of scientific investigations of the effectiveness and safety of the different kinds of calcaneal osteotomy in foot surgery, and there is the need to enhance outcome knowledge on this foot surgery technique.

Functional Outcomes and Deformity Correction of Double vs Triple Arthrodesis in Stage III Posterior Tibial Tendon Insufficiency. A Prospective Cohort Study

Category:HindfootIntroduction/Purpose:Posterior tibial tendon insufficiency (PTTI) remains the most important contributor to AAFD. When the deformity becomes rigid, management options are limited to arthrodesis. Triple arthrodesis is considered the gold standard for treating painful, rigid flatfoot deformities with proven long-term reliability of correction and favorable functional outcomes.However, the necessity of fusing an unaffected calcaneocuboid joint has been questioned, and double arthrodesis has been suggested as an alternative to triple arthrodesis. The double arthrodesis has been proven to restore function, provide a plantigrade foot, and protect against postoperative ankle valgus. This study aims to prospectively compare double and triple arthrodesis in terms of functional outcomes and deformity correction. To the best of our knowledge, this is the first prospective comparative study in the literature to date.Methods:This is a prospective comparative cohort study carried out between May 2017 and May 2019. The study was approved by the IRB at Assiut University and done according to the Helsinki declaration. Patients with AAFD stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year.Primary outcomes were union rates, AOFAS scores, and radiological parameters of deformity correction plain radiographs. Secondary outcomes were operative time, time to union, and complications. Twenty-three patients matched the inclusion criteria. Thirteen (all males) patients underwent double arthrodesis, while ten (nine males and one female) patients underwent triple arthrodesis. The mean age for double and triple arthrodesis was 20.15+-5.63 and 25.10+-8.36 years, respectively, and the mean follow-up lengths were 12.46 and 12.9 months, respectively, with no statistically significant differences in age, follow-up or gender between both groups.Results:All patients in both groups achieved union by four months. The mean time to union in the double and triple arthrodesis groups was 3.39+-0.65 vs. 3.31 +-0.6 months, respectively, with no statistically significant differences (P=0.77). The mean operative time in the double arthrodesis group than the triple arthrodesis group, 55.77+-15.18 vs. 91.6+-24.14 minutes (P<0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score postoperatively (71.46 +-7.77 vs. 88.38 +-3.66, P<0.001) and (66.9 +-7.69 vs. 85 +-5.83, P<0.001), respectively. Both double and triple arthrodesis groups had statistically significant improvement of preoperative Meary’s angle, calcaneal pitch, Cal-MT5 height, calc-MT1 angle, and TN coverage angle postoperatively. There were no statistically significant differences between double vs. triple arthrodesis groups in AOFAS score improvement or the magnitude of deformity correction.Conclusion:Double arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former. The authors recommend double arthrodesis if the calcaneocuboid joint is unaffected.

Hindfoot Double Arthrodesis in Adults Using Cannulated Screws: How We Do It?

Hindfoot arthrodesis is a common orthopedic surgical procedure indicated for reconstructive surgery in patients with advanced osteoarthritis, rheumatoid arthritis, posterior tibial tendon insufficiency (stages III and IV), severe cases of tarsal coalition, advanced stages of cavovarus foot (eg, Charcot-Marie-tooth disease), or type 2 Brodsky Charcot hindfoot arthropathy. Triple arthrodesis utilizing solid (noncannulated) screws is a technically demanding procedure because accurate placement of these screws is complex. Cannulated screws have become popular because of their easier insertion than solid screws and because of a lower chance of loss of reduction during insertion. The traditional triple hindfoot arthrodesis is performed using 2 separate incisions and also by the single medial approach with cannulated screws. Both procedures are described and illustrated in detail in this paper. We recommend inserting screws starting with the joint that has the greatest preoperative deformity and address soft tissue contractures if needed earlier during surgery. Appropriate placement of screws is very important for stable reconstruction and good postoperative outcomes. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Double versus triple arthrodesis for adult-acquired flatfoot deformity due to stage III posterior tibial tendon insufficiency: a prospective comparative study of two cohorts

PurposeThe study aims to prospectively compare double and triple arthrodesis in terms of functional outcomes and deformity correction. To the best of our knowledge, this is the first prospective comparative study in the literature to date.MethodsThis is a prospective comparative cohort study carried out between May 2017 and May 2019. The study was approved by the IRB at Assiut University and done according to the Helsinki declaration. Patients with AAFD stage III aged between 15 and 40 years old were assigned to double arthrodesis or triple arthrodesis. The groups were prospectively followed for one year. Primary outcomes were union rates, AOFAS scores, and radiological parameters of deformity correction on AP and lateral plain radiographs. Secondary outcomes were operative time, time to union, and complications. The double arthrodesis was done through the medial approach, while the triple arthrodesis was done through dual medial and lateral approaches. The post-operative protocol was standardized for both groups.ResultsA total of twenty-three patients matched the inclusion criteria and provided their consent to participate in the study. Thirteen (all males) patients underwent double arthrodesis, while ten (nine males and one female) patients underwent triple arthrodesis. The mean age for double and triple arthrodesis was 20.15 ± 5.63 and 25.10 ± 8.36 years, respectively, and the mean follow-up lengths were 12.46 and 12.9 months, respectively. There were no statistically significant differences between both groups in age, gender, laterality, or duration of follow-up. There were no statistically significant differences between both groups in AOFAS hindfoot scores or radiographic parameters. All patients were available for the final follow-up evaluation. All patients in both groups achieved union by four months post-operatively. The mean time to union in the double and triple arthrodesis groups was 3.39 ± 0.65 vs. 3.31 ± 0.6 months, respectively, with no statistically significant differences (p = 0.77). The mean operative time was significantly shorter in the double arthrodesis group than the triple arthrodesis group, 55.77 ± 15.18 vs. 91.6 ± 24.14 min (p < 0.001), respectively. Both double and triple arthrodesis groups had a statistically significant improvement of the mean AOFAS hindfoot score post-operatively (71.46 ± 7.77 vs. 88.38 ± 3.66, p < 0.001) and (66.9 ± 7.69 vs. 85 ± 5.83, p < 0.001), respectively. In the double arthrodesis group, the mean calcaneal pitch angle increased from 11.46° pre-operatively to 19.34° (MD = 8.45°, p < 0.001). The mean Meary’s angle improved from − 4.19 to 2.9° (MD = 7.32°, p < 0.001). Hibbs angle had a mean reduction of 6.45° post-operatively (p = 0.069). In the triple arthrodesis group, the mean calcaneal pitch angle improved from 10.06° pre-operatively to 17.49° post-operatively (MD = 7.12°, p < 0.001). The mean Meary’s angle improved from − 4.72 to 2.29° (MD = 7.09°, p < 0.001). The mean Hibbs angle decreased from 153.07 to 142.32° (MD = 10.54°, p < 0.001). The double vs. triple arthrodesis groups had no statistically significant differences in AOFAS hindfoot score improvement (16.92 vs. 19.1, p = 0.44), respectively. The two groups had no statistically significant differences in the magnitude of correction of all the radiographic parameters.ConclusionDouble arthrodesis is an equally reliable surgical option for AAFD stage III for achieving union, improving the functional outcomes, and deformity correction as triple arthrodesis with a significantly shorter operative time in the former. The authors recommend double arthrodesis if the calcaneocuboid joint is unaffected.

Adult-Acquired Flatfoot Deformity.

Adult-acquired flatfoot deformity (AAFD) comprises a wide spectrum of ligament and tendon failure that may result in significant deformity and disability. It is often associated with posterior tibial tendon deficiency (PTTD), which has been linked to multiple demographic factors, medical comorbidities, and genetic processes. AAFD is classified using stages I through IV. Nonoperative treatment modalities should always be attempted first and often provide resolution in stages I and II. Stage II, consisting of a wide range of flexible deformities, is typically treated operatively with a combination of soft tissue procedures and osteotomies. Stage III, which is characterized by a rigid flatfoot, typically warrants triple arthrodesis. Stage IV, where the flatfoot deformity involves the ankle joint, is treated with ankle arthrodesis or ankle arthroplasty with or without deltoid ligament reconstruction along with procedures to restore alignment of the foot. There is limited evidence as to the optimal procedure; thus, the surgical indications and techniques continue to be researched.

Medial displacement calcaneal osteotomy in treatment of stage II posterior tibial tendon deficiency

Background Medial displacement calcaneal osteotomy is indicated in individuals with stage 2 posterior tibial tendon deficiency (PTTD) with a supple hindfoot and the absence of clinical or radiographic arthritis. Patients and methods This prospective study evaluated the effects of medial displacement calcaneal osteotomy and flexor digitorum longus transfer to navicular bone on pedal realignment and function in 14 patients (15 feet) with a stage 2 PTTD. Results American College of Foot and Ankle Surgeons scoring scale module number 3 was measured before the reconstruction and at latest follow-up, and also patients’ satisfaction were reported, demonstrating a good realignment in short-term follow-up (15–18 months). The American College of Foot and Ankle Surgeons score improved postoperatively from average of 53.5 to 87.4 without progression of arthritis at adjacent joints. Conclusion This simple surgical procedure has an excellent effect on realignment and function of PTTD stage 2 without marked forefoot abduction.

Anatomical Study of the Neurovascular in Flexor Hallucis Longus Tendon Transfers

The transfer of the flexor hallucis longus tendon or flexor digitorum longus tendon is frequently used for the treatment of posterior tibial tendon insufficiency or chronic Achilles tendinopathy. According to several anatomical studies, harvesting the flexor hallucis longus (FHL) tendon may cause nerve injury. Sixty-eight embalmed feet were dissected and anatomically classified to define the relationship between Henry’s knot and the plantar nerves. Two different configurations were identified. In Pattern 1, which was observed in 64 specimens (94.1%), the distance between the medial plantar nerve and Henry’s knot was 5.96 mm (range, 3.34 to 7.84, SD = 1.12). In Pattern 2, which was observed in 4 specimens (5.9%), there was no distance between the medial plantar nerve (MPN) and Henry’s knot. No statistically significant difference was observed according to gender or side (p > 0.05). A retraction was performed to harvest the FHL through the posteromedial hindfoot incision using a single minimally invasive technique, and the medial and lateral plantar nerve lesions were scrupulously assessed. In conclusion, medial and lateral plantar nerve injuries did not occur more frequently, even after performing a single minimally invasive incision to harvest the FHL tendon, due to the large distance between the FHL tendon and the medial and lateral plantar nerves.

Treatment of 2nd stage posterior tibial tendon deficiency (PTTD)

In vitro and in vivo anti-leishmanial efficacy of copper salisylaldoxime (CuSAL), a transition metal complex, was evaluated and the underlying mechanism was studied. In vitro studies revealed that 30 μM of CuSAL causes 96% reduction in parasite burden in infected macrophages. CuSAL is least toxic in host cells. A dose of 5 mg/kg bodyweight per mice on alternate days (5 doses) gives ∼97% protection in both liver and spleen. Moreover, CuSAL potentially inhibits the catalytic activity of LdTOPILS and causes apoptosis of Leishmania parasites through induction of intracellular ROS generation and activation of caspase-like proteases. Interestingly, CuSAL does not inhibit the catalytic activity of human topoisomerase I. The present study illuminated that CuSAL, has potent anti-leishmanial activity, which selectively targets LdTOPILS; and is a safe for human. Therefore, this compound might be highly promising candidate to develop the rational approaches for chemotherapy of human leishmaniasis.

Remodeling of the Calcaneocuboid Joint in the Flatfoot

Category: Hindfoot Introduction/Purpose: Although the flatfoot has been successfully treated with a lateral column lengthening (LCL) for over half of a century, there has been controversy recently about whether the lateral column is actually short in a flatfoot, especially the acquired type. Some ask, “How can the normal, hard bones actually change and shorten?” And, if it is not short, perhaps the lengthening procedure is producing a non-physiologic state with abnormal anatomy. Would the flatfoot patient be better served with other procedures that don’t include a lateral column lengthening? Level of Evidence: Therapeutic Level IV. Methods: After observing a very dramatically changed calcaneocuboid (CC) joint when performing a double calcaneal osteotomy with a medial soft tissue reconstruction for a Johnson-Strom Stage II posterior tibial tendon insufficiency, it was decided to carefully observe, photograph, and record any changes in the CC joint at surgery in a consecutive series of 21 patients who were operated on who had this disorder(Figure 1). In total, there were fourteen double heel osteotomies, with medial soft tissue reconstructions for Johnson-Strom Stage II deformities, five triple arthrodeses for Stage III deformities, and two lateral column lengthenings with an ankle arthrodesis for a Stage IV deformity. All of the patients had a triple hemisection heel cord lengthening for hindfoot equinus. Results: Every patient studied had some changes to the CC joint which were generally related to the amount of deformity present. At a minimum, the calcaneal side of the joint drifted proximally, laterally and dorsally, with bone being laid down on the outside of the calcaneus, resulting in the joint being larger. There was drifting and abduction of the lateral portion of the articular surface of the joint. In some joints the lateral portion looked like a distinct but confluent facet. Often times, a marginal osteophyte was present laterally and dorsally in the widened area of the calcaneus and “kissing” osteophytes were seen on the cuboid. All of these remodeling changes resulted in the calcaneal side of the joint being short, and facing laterally and dorsally. Conclusion: These findings give evidence to the rationale for performing of a LCL proximal to the calcaneocuboid joint to treat the acquired flatfoot. When performing a LCL one should attempt to restore length to the calcaneal side of the joint, and to redirect it medially and plantarward. We do not remove the marginal spurs, rather they are maintained to provide an area to insert a retrograde fixation screw. If the patient has lateral column pain after the bone graft has incorporated, the screw and spurs are removed.

Adult-Acquired Flatfoot Deformity: Etiology, Diagnosis, and Management.

➢ Adult-acquired flatfoot deformity is a complex process attributed mainly to posterior tibial tendon insufficiency.➢ Thorough physical examination and radiographs of the foot and ankle are usually adequate to achieve diagnosis.➢ Nonoperative management is the first line of treatment and has a reported success rate ranging from 67% to 90%.➢ A multitude of surgical options are available, particularly for stage II, with no consensus on the best options.➢ Fusions are associated with poor outcomes; hence, there is a trend toward earlier reconstruction before arthritis ensues.

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon

BackgroundTo report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. MethodsWe evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. ResultsPostoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2–81.9 and 61.5–83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary’s angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. ConclusionsArthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

Comparison of preoperative MRI and intraoperative findings of posterior tibial tendon insufficiency.

BackgroundThe purpose of this study was to investigate the radiological and surgical correlation between preoperative magnetic resonance images (MRI) and the intraoperative findings in patients with acquired adult flatfoot.ResultsThe overall radiological–surgical correlation between preoperative MRI and the intraoperative findings for posterior tibial tendon insufficiency was only slight to fair in our patient’s series. Comparing the most commonly used posterior tibial tendon classification systems, the classification of Rosenberg et al. and Kong et al. showed higher interobserver agreement than our modified classification system and the classification system of Conti et al.ConclusionFurther prospective studies are needed to evaluate the importance of preoperative MRI before surgical repair of posterior tibial tendon dysfunction.

Adult Flexible Flatfoot Due to Insufficiency of Posterior Tibial Tendon

Category: Hindfoot Introduction/Purpose: We postulated that in a flexible adult flatfoot, calcaneo-stop procedure combined with medial tensioning of posterior tibial tendon allowed the resolution of symptoms by correcting the pattern of the gait and avoiding the evolution to a subsequent stage. The purpose of this study was to determine functional, biomechanic, and radiographic results in patients who underwent surgery for flexible flatfoot without osteotomies or arthrodesis. Methods: We evaluated clinically and radiographically 29 patients surgically treated for adult flatfoot grade IIa according to Myerson, with a mean age of 46.4 years. Mean follow-up was 34.15 months. For clinical evaluation the AOFAS hindfoot and VAS- FA scores were used. In 10 patients, pre and post-operatively gait analisys was performed. Results: Postoperative results showed a significant increase of AOFAS and VAS-FA scores, from 54.7 (range 34 to 78) to 83.1 (range 66-100) and 60.5 (range 35-86) 85 (range 64-100) points, respectively. For the X-ray parameters, in the AP projection, we observed a significant variation of Kite's angle, from 24.2° in the pre-op to 19.2° in the post-op. In lateral view Costa-Bertani angle showed changes from 146.8° to 140.5°. The Meary's angle, showed an average at the post-op of 4.3°. Postoperative satisfaction was excellent-good for 25 patients (86.2%). Postoperative gait analysis showed an improved pattern of the gait. Conclusion: The technique of arthroereisis with medial tensioning of PTT is a valid technique for the young adult, up to 50 years and with no signs of osteoarthritis of the midfoot and hindfoot.

Osteoarthritis of Lateral Lisfranc Joint After Lateral Column Lengthening in Flatfoot

Category: Lesser Toes Introduction/Purpose: Lateral column lengthening (LCL) procedure is commonly optional treatment as one of reconstruction surgery for the adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon insufficiency in stage II. However, it had been confirmed that lateral forefoot pressures increase after LCL in previous studies. We may occasionally encounter some cases who have pain in the lateral aspect of the foot associated with osteoarthritis of Lisfranc joint after the surgery (Fig.). In this study, we retrospectively assessed lateral Lisfranc arthritis as postoperative complications after LCL. Methods: 17 feet in 15 patients who underwent operation including LCL for AAFD due to posterior tibial tendon insufficiency in stage II (two patients male and 13 were female). The mean age at the time of surgery was 64.2 years (52-80). All cases had LCL by calcaneocuboid distraction arthrodesis. The amounts of LCL achieved were 12.7 mm on average (8.0-15.0). The average duration of follow-up after the surgery was 21.8 months (4-97). We divided the subjects up into two groups: (1) pain group (n=7), were experiencing pain in the plantar-lateral aspect of the foot and/or tenderness at fourth and/or fifth tarsometatarsal (TMT) joint postoperatively; and (2) no-pain group (n=10), did not have that pain nor tenderness until the latest follow-up. Two groups were compared in age, body mass index (BMI), the American Orthopaedic Foot and Ankle Society (AOFAS) score, the amounts of LCL and several parameters on the radiograph. Results: In the pain group, all cases had osteoarthritic changes of the lateral Lisfranc joint (41.2%) on radiographs (grade II or more on the Kellgren-Lawrence grading scale). In overall subjects, 11 feet (65%) were revealed lateral Lisfranc arthritis. There were no significant differences in age, BMI, AOFAS scale, the LCL amounts between both groups. The medial column height was lower than lateral preoperatively, it became higher postoperatively by the reconstruction. In the pain group, the postoperative differences between medial and lateral tend to be greater than in no-pain group (P = 0.17). Patients with pain had significantly lower postoperative first talometatarsal angle (p &lt; 0.05). However, no significant differences were found in terms of the other radiographic parameters such as calcaneal pitch angle, talonavicular coverage angle and hindfoot alignment by Cobey’s view. Conclusion: This study indicated a high possibility of Lisfranc arthritis in patients who have pain of the lateral aspect of the foot after LCL. We suggest that this osteoarthritic change is one of the causes of such pain, and attribute the arthritis to increased lateral column pressures by excess calcaneocuboid distraction. As a preventive measure had reported previously, we may have to keep LCL within less than 10 mm, and may have to add the stabilization of medial column such as the first TMT fusion or Cotton osteotomy.

Adult flexible flatfoot due to insufficiency of posterior tibial tendon: Calcaneo-stop and tensioni

Adult flexible flatfoot due to insufficiency of posterior tibial tendon: Calcaneo-stop and tensioni

Endoscopic Repair of the Superficial Deltoid Ligament and Spring Ligament

The plantar calcaneonavicular ligament, also known as the spring ligament, is an important static stabilizer of the medial longitudinal foot arch. Compromise of this ligament is a primary causative factor of peritalar subluxation, and it should be repaired in addition to treatment of tibialis posterior tendon abnormalities. Open repair of the ligament requires extensive soft-tissue dissection. The development of the high distal portal for posterior tibial tendoscopy allows repair of the ligament endoscopically. This, together with endoscopically assisted reconstruction of the tibialis posterior tendon, allows complete endoscopic treatment of stage 2 posterior tibial tendon deficiency. The major structure at risk is the medial plantar nerve. This technique is technically demanding and should be reserved for experienced foot and ankle arthroscopists.