Posterior Tibial Tendon Research Articles

Etiology, pathogenesis, clinical features, diagnostics and conservative treatment of adult flatfoot

On average, one in six adults is affected by an acquired flatfoot. This foot deformity is characterized by its progression of stages and in 10% of cases causes complaints that require treatment. Untreated, the loss of walking ability may result in the final stage. Correct staging is crucial to being able to offer aspecific course of therapy including awide spectrum of conservative and operative treatments. This review is based on pertinent publications retrieved from aselective search in PubMed and Medline and on the authors' clinical experience. The loss of function of static (spring ligament complex) and dynamic (tibialis posterior tendon) stabilizers causes the characteristic deformity with loss of the medial arch, hind foot valgus and forefoot abduction. In the late stage, severe secondary osteoarthritis in upper and lower ankle joints occurs and impedes walking ability. The essential physical examination is supplemented by weight-bearing dorsoplantar and lateral radiographs, which provide further information about axial malalignment (Meary's angle, Kite's angle). The long axis hind foot view allows analysis of the hindfoot valgus. MRI provides further information about the integrity of the tibialis posterior tendon, spring ligament complex and cartilage damage. The therapy aims to reduce pain, regain function and avoid development of secondary osteoarthritis and degenerative tendon disorders. Progress of the deformity should be stopped. Therefore, the main aspects of the deformity-loss of medial arch, hindfoot valgus and forefoot abduction should be addressed and corrected. In the acute phase, tendovaginitis of the tibialis posterior tendon can be treated sufficiently by anti-inflammatory measures, relieving mechanical loads on the tendon and muscle and physiotherapy.

To Compare the Effectiveness of Taping and Arch Support on the Flexible Flat Foot on a Random Population

Background: Flat foot is also known as Pes planus caused by injury, prolonged stress on the foot, obesity,and faulty biomechanics. This will cause the posterior tibial tendon dysfunction, collapse of the foot archand developed flat foot (Pes planus).Objective: Many of the research studies show the prevalence of flexible flat foot is on raise in recent timesdue to any number of factors. The majority of researchers focused independently on the effectiveness ofKinesio taping and arch support. So we aim to compare the effectiveness of Kinesio taping and medial archsupport.Method: The study design is an experimental study. The study will be conducted at Aimst University, Kedah,Malaysia. Total of 30 participants of both the gender, age between 18 to 30 years, who have a limitation ofROM and pain while performing dorsiflexion and plantar flexion, will be recruited. Each participant willundergo pre-test and post-test screening for an assessment of Body Mass Index (BMI), ROM, pain, physicalexamination, and Staheli Arch Index. Later the participants will be divided into two groups by a convenientsampling method. Group A participants will undergo exercises related to strengthening of foot musclesalong with non-allergic taping technique while Group B participants will undergo exercises related to thestrengthening of foot muscles along with medial arch support.Data Analysis: Data collected is using IBM SPSS Statistics 23 for analyzing the data. For statistical analysisof the range of motion, VAS scale and Staheli Arch Index, Wilcoxon Signed Ranks Test was used. Tocompare the outcome of Kinesio Taping and Medial Arch Support, Mann-Whitney U test was used.Result: After statistical analysis, a significant improvement was found in the range of motion and VASScale. The level of improvement (p<0.05) was significantly high with Kinesio Taping in flat foot.Conclusion: The present study concluded that the application of Kinesio tape to flat feet was an effectiveintervention method for immediately reducing abnormally increased foot pressure and tone and stiffness inthe lower extremities muscles and considered to be the most effective intervention for subjects with flat foot.

A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand.

Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections. This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed. Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function. Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.

Combined Suspensory and Aperture Fixation of Posterior Tibialis Tendon Anterior Transfer for Dropfoot

Category:Other; TraumaIntroduction/Purpose:Anterior transfer of the tibialis posterior tendon (TPT) can restore ankle dorsiflexion in patients with foot drop. A limitation of this procedure is the need for postoperative ankle immobilisation. We present the results of a novel dual method of TPT docking which infers immediate stability, allowing early weightbearing.Methods:8 patients underwent 9 tendon transfers,age range of 28-52 years. 3 patients had dropfoot from common peroneal nerve injury, 6 cases were part of a complex cavovarus or spastic equinovarus correction. The TPT is passed to the dorsum of the foot through the interosseous membrane. The docking site is prepared with a bicortical pilot hole followed by unicortical overreaming. The TPT is whipstitched and an Arthrex biceps button is threaded to the sutures. The button is passed bicortical and flipped using a tension slide technique give stable suspensory fixation. Additional stability is conferred by overpassing an Arthrex biotenodesis screw giving aperture fixation. Patients are immobilised in a boot and allowed to weightbear immediately.Results:Follow up was 6 months. There was difficulty in docking of suspensory fixation in two of the early cases. These patients had aperture fixation and were immobilised non weightbearing in a cast for 6 weeks. With technical modifications, all subsequent patients had dual fixation. At 6 months there were no radiological or clinical failures of fixation. Patients without other underlying issues were able to mobilise splint free at 6 months. All patients were satisfied with their procedure.Conclusion:Aperture fixation with an interference screw has become the gold standard for TPT transfer, however, patients still need a prolonged period of immobilisation. Combined suspensory and aperture fixation is technically straightforward and seems to give more initial stability allowing early weightbearing. Further prospective studies and biomechanical studies are needed to validate this technique.

Medial Displacement Calcaneal Osteotomy as a Novel Treatment for Recurrent Pain after Kidner Procedure for Accessory Navicular Syndrome

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:The accessory navicular is often considered to be related to flatfoot deformity. While the Kidner procedure is commonly utilized in treating painful accessory navicular, its ability to correct flatfoot deformity is debated. Patients may also have recurrent pain due to increased tension of the posterior tibial tendon (PTT) in the setting of an uncorrected flatfoot. In the literature, both PTT lengthening and tendon transfer are techniques described to address this issue with varying success and outcomes. Because medial displacement calcaneal osteotomy (MDCO) is a powerful procedure capable of reducing tension of the medial column and correcting hindfoot valgus deformity, we investigated its use in addressing these symptoms. We report outcomes of a novel use of MDCO in treating patients with recurrent pain following Kidner procedure.Methods:We retrospectively identified 21 patients who underwent MDCO for recurrent pain after Kidner procedure at our institution. MDCO was indicated when patients failed to perform single heel raise due to pain at the PTT attachment site at minimum 6 months following index surgery. Pre- and postoperative radiographic parameters were measured: lateral talo-1st metatarsal angle (Meary’s), talonavicular coverage angle (TNC), calcaneal pitch (CP), and hindfoot moment arm (HMA). Using previously validated cut-offs in describing flatfoot deformity, a Meary’s angle less than -4 degrees was considered a flattened arch, and a HMA more than 3.2mm was considered a valgus heel deformity. Measurements were also performed in x-rays of the contralateral foot to determine whether foot deformity in the involved foot was attributed to Kidner procedure or a preexisting deformity. Pre- and postoperative visual analogue scale (VAS) and FAOS outcome scores were compared to assess for improvement in patient-reported outcomes.Results:The mean age was 25.7 years (range, 21-49) and the mean follow-up was 20.1 months (range, 14-26). The average time from the index surgery was 7.3 months (range, 6-10). Average size of the accessory navicular before excision was 11 mm (range, 4.6-18.3). Concomitant procedures included medial head gastrocnemius recession (n=11), plantarflexion osteotomy of first metatarsal bone (n=1), and talocalcaneal coalition excision (n=1). Radiographically, 12 patients (57%) had a flattened arch and all patients (100%) had heel valgus deformity. All radiographic parameters except Meary’s angle (p=0.885) improved postoperatively. Contralateral radiographs revealed that fifteen patients (71%) had a flattened arch, and 19 patients (90%) had heel valgus deformity. There were no differences between both sides. VAS and FAOS improved significantly (p <0.001).Conclusion:Our data suggest that recurrent pain after Kidner procedure may be related to unaddressed preexisting hindfoot valgus deformity. MDCO provided satisfactory outcomes in relieving this symptom without performing surgery to the PTT. Therefore, MDCO can be a viable option for treatment of recurrent pain following Kidner procedure while potentially avoiding loss of inversion power and donor-site comorbidities associated with PTT lengthening and tendon transfer.

Lateral Column Lengthening Versus Medial Displacement Calcaneal Osteotomy in Stage II Tibialis Posterior Tendon Dysfunction: Randomized Controlled Trial

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Adult acquired flatfoot deformity is a complex deformity associated with the collapse of the medial longitudinal arch. Several factors have been proposed in the etiology of adult acquired flatfoot deformity including arthritic, neuromuscular, and traumatic conditions; however, posterior tibial tendon dysfunction remains the most common etiology. A spectrum of conditions affecting the posterior tibial tendon has been identified, with tendinitis occurring early in the disease process and tendon rupture occurring at the more advanced stages. Adult-acquired flatfoot deformity requires a complex operative plan that often utilizes several procedures to correct deformity, at both the hindfoot and midfoot. The objective of this study was to compare the efficacy of two different osteotomies commonly used to correct flexible flat feet.Methods:42 Patients (21 males and 21 females) with stage II PTTD acquired flexible flatfeet were included with a mean age of 49.62 +- 6.2. Twinty-two patients had medial displacement calcaneal osteotomy (MDCO) while 20 cases had latercal column lenghtening (LCL). Strayer procedure, spring ligament plication and FDL transfer were done in all patients. Pre- and Post-operative clinical assessment was done using AOFAS and FFI questionaire. Six radiographic parameters were analyzed, two in the anteroposterior view ( talo-navicular coverage and talo-calcaneal angle), three in lateral view ( talo- first metatarsus angle, talo- calcaneal angle and calcaneal inclination angle) and tibio-calcanal angle in axial view.Results:At a mean follow up of 12 months, significant improvement in AOFAS and FFI scores in MDCO and LCL groups with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups. LCL group showed significant better correction in TNC and calcaneal inclination angles when compared to MDCO group. However, MDCO procedure showed significantly better correction in axial tibial calcaneal angle. Both techniques correct the deformity, however cases received LCL has better correction than MDCO cases and less reoperation rate.Conclusion:Reconstructions performed with LCL produced a greater change in the realignment of adult acquired flatfoot, maintained more of their initial correction over time, and were associated with a lower incidence of additional surgery than reconstructions with a MDCO of the calcaneus. However, a higher incidence of degenerative change in the hindfoot was observed in the LCL group. The ability of LCL to correct the deformity in anteroposterior and lateral plan and MDCO in lateral and axial plan suggests that proper osteotomy should be planned according to the existing deformity. Combination of both techniques may be required in certain cases.

Long-Term Patient Reported Outcomes after Correction of Traumatic Foot Drop

Category:Trauma; AnkleIntroduction/Purpose:There is limited literature on patient reported outcomes after tendon transfer for traumatic foot drop. The purpose of this study was to determine long-term patient reported functional outcomes after posterior tibialis tendon (PTT) transfer in patients with foot drop resulting from a traumatic common peroneal nerve injury.Methods:Between August 2006 to January 2019, 31 patients underwent PTT transfer for foot drop secondary to a traumatic injury to their common peroneal nerve at our institution. The average follow-up was 14 months. A retrospective chart review was performed to document physical exam measures and to review postoperative radiographs for changes in foot alignment. There were 17 out of the initial 31 patients available at a mean follow-up of 5.9 years who responded to a phone questionnaire, including the Foot and Ankle Ability Measure (FAAM) questionnaire, and questions on brace and assistive device use, activity level, and satisfaction with surgery.Results:Preoperatively, all patients had an equinus contracture with no dorsiflexion strength, abnormal gait, and used an ankle- foot orthosis (AFO) or pneumatic boot for ambulation. Postoperatively, the average ankle dorsiflexion strength was 4/5 with 28/31 patients reporting a normal gait and 26/31 not using a brace for ambulation. Postoperative radiographs did not show changes in alignment or progression to flatfoot deformity. For the subset of 17 patients who responded to the phone questionnaire, the mean FAAM ADL subscale score was 68.1 and the Sport subscale score was 52.1 at an average of 5.9 years after surgery. The majority of patients (76%) were very or quite satisfied with the outcome of surgery and 15/17 (88%) patients reported they would undergo the PTT transfer procedure again.Conclusion:Posterior tibialis tendon transfer for patients with foot drop secondary to a traumatic injury to their common peroneal nerve showed a high satisfaction rate and improvement in function after surgery without the need for brace or assistive device use at long-term follow-up at an average of 6 years. Additionally, there was no progression to flatfoot deformity after posterior tibialis tendon transfer at 1 year postoperatively.

Pre-Operative Radiographic Parameters of Arch Collapse Do Not Predict Future Treatment Failure in Patients with Stage IIb Pes Planus

Category:Ankle; Hindfoot; Midfoot/ForefootIntroduction/Purpose:Adult-acquired flatfoot deformity (AAFD) is a complex pathology of the foot that often results from dysfunction of the posterior tibial tendon (PTTD) and encompasses a wide spectrum of deformity. A high-degree of continued morbidity following flatfoot reconstruction exists for which prognostic indicators of future poor outcomes are uncertain. AP and lateral weight-bearing radiographs are commonly utilized to assess the severity of deformity including forefoot abduction, medial arch collapse, and hindfoot valgus. However, the relationship between pre-operative radiographic severity of deformity and predilection for future surgical treatment failure remains uncertain. The purpose of this study was to perform pre-operative radiographic measurements of patients with stage IIb PTTD and determine which preoperative radiographic parameters, if any, predict future surgical treatment failure.Methods:Following IRB approval, an institutional electronic medical record database was queried from January 2000-2014 to identify all patients undergoing surgical correction for stage IIb PTTD. 256 patients with stage IIb PTTD underwent medial displacement calcaneal osteotomy and flexor digitorum longus transfer, with possible spring ligament repair and/or Achilles lengthening. Patients undergoing concomitant lateral column lengthening or midfoot fusion, patients with previous hardware, and patients with incomplete medical records were excluded. Preoperative radiographs were retrospectively analyzed to assess preoperative deformity. Talonavicular coverage angle was measured using AP radiographs. Lateral radiographs were used to measure talar-1st metatarsal angle (Meary’s) angle, calcaneal pitch and medial cuneiform-floor height. Patient charts were also reviewed to determine whether patients experienced treatment failure, defined as return to the operating room for unplanned revision surgery (e.g. broken/painful hardware, nonunion, residual deformity, infection, nerve damage, blood clot/DVT). The degree of pre-operative deformity was compared between treatment failure and non-failure groups.Results:Out of the 256 patient cohort, a total of 58 patients (22.7%) experienced treatment failure indicated by the need for an unplanned revision surgery, while 198 patients (77.3%) did not experience failure. There were no significant differences in the severity of pre-operative radiographic deformity between the treatment failure and non-failure groups including Meary’s angle (p = 0.93), calcaneal pitch (p = 0.70), talonavicular coverage angle (p = 0.99), and medial cuneiform height (p = 0.52, Table 1).Conclusion:The results of this study show that there is no significant difference in pre-operative radiographic deformity between patients who experienced failure versus non-failure following surgical flatfoot correction suggesting that the degree of pre- operative deformity is not significantly associated with an increased risk for future surgical failure. The analysis of these results, may underscore the relative importance of the physical exam in the evaluation of patients with symptomatic stage IIb PTTD and a relative lack of prognostic value in radiographic parameters commonly used to describe patients’ deformity.

POSTERIOR TIBIAL TENDON INJURY - IS MISSED DIAGNOSIS, A POSSIBILITY? SHOULD IT BE SUSPECTED IN ALLANKLE EVERSION SPRAINS? - A CASE REPORT

Ankle sprains are one of the most common injuries that occur among people of all ages and accounts for 75% of ankle injuries and for 10 to 30 percent of sports-related injuries in young athletes. Inversion sprain is more common than eversion ankle sprain, to result in injury to the lateral ligament complex. Though injury to the posterior tibial tendon is not a very common injury associated with eversion ankle sprain, it often can be overlooked and missed in the initial physical examination. We present a case of a college student who sustained a twisting injury to his left ankle while playing football. After initial history, physical examination and plain radiographic evaluation, a diagnosis of eversion ankle sprain was made by a general practitioner and treated conservatively. Due to persistent symptoms and local signs, subsequent evaluation with an MRI study revealed tibialis posterior (TP) tendon strain with diffuse soft tissue swelling extending up to lower third of the leg and associated Grade I osteochondral injury to the posterolateral aspect of talus. The injury was successfully treated with medial arch support ankle brace, analgesics, guarded weight bearing and physiotherapy with full functional recovery in 12 weeks.

Predictors of Spring Ligament Degeneration and Outcomes of Reconstruction during Correction of Adult Acquired Flatfoot Deformity

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:It is currently unclear how injury to the spring ligament (SL) affects the preoperative presentation of adult acquired flatfoot deformity (AAFD). The purposes of this study were to retrospectively identify shared factors that could be used to preoperatively predict SL damage in patients undergoing AAFD correction as well as compare outcomes of patients undergoing SL reconstruction to those not undergoing reconstruction during AAFD correction.Methods:All patients undergoing operative correction of grade 2B AAFD secondary to tibialis posterior tendon dysfunction by a single fellowship-trained foot and ankle orthopaedic surgeon from 2011 to 2017 were reviewed. Operative reports were reviewed for the surgeon’s evaluation of the competency of the SL and to determine whether SL reconstruction was performed. Patient charts were reviewed for demographic information, preoperative Visual Analog Scale (VAS) pain level, and their Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and -Sports subscales. Preoperative radiographic parameters were assessed by a surgeon blinded to the intraoperative findings. Patient outcomes of VAS pain, FAAM-ADL, and FAAM-Sports were collected at a minimum of 24 months postoperatively. Multiple logistic regression analysis was performed to determine significant independent predictors of spring ligament tears.Results:The study included 115 feet undergoing corrective reconstruction, with 47 feet having a spring ligament tear (40.9%). Patients with tears were significantly older (p<0.001), with higher preoperative reported pain (p=0.01), and lower preoperative FAAM-ADL (p=0.04) and -Sports (p=0.006) scores than those without SL tears. Patients with a SLT demonstrated significant differences in AP talo-1st MT angle (p=.003), talonavicular uncoverage percentage (p<0.001), talonavicular angle (p=0.017), and Meary`s talo-1st MT angle (p=0.001). Based on multiple logistical regression analysis (odds ratio [95% confidence interval]), patient age (1.10 [1.03, 1.18]; p=0.003), talonavicular uncoverage percentage (1.35 [1.13, 1.60]; p<0.001), and talonavicular angle (0.82 [0.71, 0.96]; p=0.0133) were independently predictive of ligament degeneration. Patients undergoing SL reconstruction did not differ significantly in functional score improvements compared to those without reconstruction.Conclusion:Our findings suggest that a SLT is associated with more advanced flexible pes planovalgus, measured both by radiographic parameters as well as its impact on patient function. Increasing patient age, increasing talonavicular uncoverage percentage, and decreasing talonavicular angle are all independently associated with increased likelihood of patients with AAFD having a SLT. AAFD correction with concomitant SL reconstruction does not appear to influence absolute or changes in patient pain and function.

Minimally Invasive Surgery for Correction of Adult Acquired Flat Foot Deformity: An Anatomic Study

Category:Midfoot/Forefoot; HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is a complex and chronic debilitating condition characterized by a decrease in the medial arch height and, in advanced stages, a decrease in the talonavicular coverage angle as the forefoot drifts into pronation and abduction. Operative treatment of stage II deformity has changed significantly over the past few decades. Joint sparing procedures which aim to realign the hindfoot and augment the diseased tibialis posterior tendon with the flexor digitorum longus transfer are commonly performed. The introduction of minimally invasive surgery (MIS) has been associated with smaller incisions, less blood loss, and quicker recovery times. The purpose of this study was to qualitatively and quantitatively observe the tendinous and neurovascular structures at risk with MIS AAFD osteotomy procedures in cadaveric feet.Methods:MIS technique was used to perform medial displacement calcaneal, Evans, and Cotton osteotomies on nine cadaveric feet under fluoroscopic guidance. The sural nerve, superficial peroneal nerve and its branches, deep peroneal nerve, dorsalis pedis artery, saphenous vein, and peroneal and extensor hallucis longus tendons were carefully dissected from each cadaveric foot and evaluated for injuries following the MIS osteotomy cuts. The distance from the osteotomy cuts and these anatomic structures were measured and recorded.Results:On average, the sural nerve was 8.4 mm and 9 mm from the calcaneal and Evans osteotomy sites, respectively. The intermediate dorsal cutaneous nerve was on average 68.3 mm and 41.1 mm from the calcaneal and Evans osteotomy sites, respectively. The peroneal tendons were on average 16.7 mm and 0 mm from the calcaneal and Evans osteotomy sites, respectively. The extensor hallucis was an average of 1 mm from the Cotton osteotomy site. There was a partial tear injury to the peroneus brevis in four of the cadaveric specimens at the Evans osteotomy site without complete laceration. There was no injury to the sural nerve, superficial peroneal nerve and its branches, saphenous vein, deep peroneal nerve, dorsalis pedis artery, or extensor hallucis longus tendon.Conclusion:Tendinous and neurovascular structures are at risk with MIS AAFD osteotomy procedures. Care should be taken with soft tissue handling and blunt dissection to decrease iatrogenic injuries to these structures. Specifically, extra care and recognition of the peroneal tendons during the Evans osteotomy may prevent damage, as this structure was at greatest risk among the three osteotomy cuts. Future research studies evaluating this technique and the functional outcomes in patients in a clinical setting is warranted. Surgical technique studies are underway to implement smaller, yet appropriate bone grafts through mini incisions.

Medial Displacement Calcaneal Osteotomy: Loss of Correction with Varying Drilling Techniques

Category:HindfootIntroduction/Purpose:Surgical correction of Stage 2 posterior tibial tendon dysfunction typically involves a combination of soft tissue and bony corrections, often including a medial displacement calcaneal osteotomy (MDCO). This osteotomy is often fixated utilizing two parallel screws; however, it remains unknown how much correction is lost based on various accepted drilling techniques for common fixation of this osteotomy. Our cadaveric study compares three different surgical drilling techniques, using two parallel cannulated screws for fixation, to best maintain desired translation of the MDCO.Methods:Fifteen above knee, fresh-frozen, matched pair cadaveric specimens (30 limbs) were randomized equally into three groups. Calcanealosteotomies were performed, followed by manual 10 mm medial translation of the tuberosity. Two parallel 2.5mm guide wires were advanced across the osteotomy site under fluoroscopy. The first group involved a ‘staggered’ drilling technique in which one guide wire was over drilled to the osteotomy site with a 4.5mm cannulated drill and then a 7.0 mm cannulated screw was placed across the osteotomy, followed by a second screw in similar fashion. The second, ‘simultaneous’ group consisted of over drilling both guide wires sequentially followed by placement of both screws. The third control group involved simultaneously over drilling only the near cortex, followed by placement of the 2 screws. Following screw fixation, the calcaneal tuberosity was manually translated in a lateral direction. The loss of correction was then marked and measured in millimeters.Results:All thirty cadaveric specimens underwent standard medializing calcaneal displacement osteotomy without significant variation, or complication. Loss of medialization was measured in millimeters following a manual lateral displacing force after the screw fixation of the osteotomy. The ‘simultaneous’ drilling group experienced the greatest loss of medial displacement with the mean loss of correction being 2.6 mm (range 1.37 - 3.48 mm) following manual lateral translation. The ‘staggered’ group showed an average loss of 1.16 mm (range 0.36 - 2.67 mm). The control group, that simply involved drilling of the near cortex, demonstrated the greatest maintenance of medial displacement with a mean loss of only 0.036 mm (range 0.01 - 0.06 mm).Conclusion:Our cadaveric study comparing three different drilling techniques for maintaining the intended correction following MDCO demonstrates that simultaneous over drilling of only the tuberosity near cortex prior to screw fixation was the most resistant to loss of medial displacement; whereas mean loss of correction with simultaneous drilling of both wires to the osteotomy resulted in the greatest loss of correction at an average of 26%.

Outcomes of Flexible Flatfoot Deformity Reconstruction in the Young Patient

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Surgical correction of the collapsing flatfoot deformity has been well studied in the literature, with the average patient being a female in her 50s. While reconstruction of the flexible, symptomatic flatfoot in children and adolescents has been described, assessment of outcomes across age groups is limited. Therefore, the purpose of our study is to compare the clinical and radiographic outcomes in younger patients 30 years or less undergoing flatfoot reconstruction with that of older patients. In addition, the procedures performed for reconstruction and the incidence of subsequent reoperations were compared between the two groups.Methods:Ninety-four feet (51 left, 43 right) in 87 patients who underwent reconstruction for flexible collapsing flatfoot deformity were divided into 2 groups based on age: <= 30 years (n=22), and >30 years (n=72). Exclusion criteria included tarsal coalition or neuromuscular disease. Average age and BMI was 20.8 years (range, 13 to 30) and 26.8 (range, 18 to 38) in the younger cohort, and 57.5 years (range, 35 to 81) and 29.8 (range, 18 to 46) in the older cohort. Preoperative and minimum 2-year postoperative PROMIS scores were compared. Average follow-up was 30.6 and 27 months in the younger and older cohorts, respectively. We assessed five radiographic parameters both preoperatively and postoperatively, including talonavicular (TN) coverage angle, lateral talo-first metatarsal angle (Meary’s), lateral talocalcaneal angle, calcaneal pitch, and hindfoot moment arm (HMA). Operative reports and hospital records were reviewed to compare procedures performed for reconstruction as well as subsequent reoperations.Results:Younger patients demonstrated significant preoperative to postoperative improvements in Physical Function (p=0.01), Pain Interference (p<0.01), and Pain Intensity (p<0.01), with significantly greater improvement in Physical Function by 4.2 points (95% CI = 0.9 to 7.6, p=0.01) compared to the older cohort. All radiographic parameters demonstrated significant improvement (p<0.01) with no differences between the two groups. Younger patients were more likely to undergo Cotton osteotomy and deltoid ligament repair (p=0.01), and less likely to undergo flexor digitorum longus transfer, first tarsometatarsal fusion, spring ligament repair, and posterior tibial tendon repair (p<0.01). There were 8 (36.4%) reoperations in the younger group with painful hardware removal (ROH), and 27 (37.5%) in the older group (1 conversion to triple arthrodesis, 3 non-unions, 4 repeat medializing calcaneal osteotomies, 19 ROH).Conclusion:While the approach to surgical correction of younger patients with symptomatic, collapsing flatfoot deformity is similar to that of older adult patients, our data suggest that age may play a role in clinical outcomes, procedures indicated, and subsequent corrective reoperations. These findings point towards the efficacy of surgical correction in addressing this symptomatic pathology at a younger age.

Morphologic Characteristics of the Medial Malleolar Fragment based on CT Scan in Ankle Fractures

Category:Ankle; TraumaIntroduction/Purpose:The aim of this study was to describe and evaluate the morphologic characteristics of the medial malleolar fragment in ankle fractures and suggest the guideline for proper fixation of the fragmentMethods:From August 2011 to June 2018, 172 cases were enrolled. There were performed the operation in ankle fractures with a medial malleolar fragment. All cases were divided into three types, based on the transverse fracture line of the medial malleolar by the CT (computed tomography) scan; type 1 was involved in the anterior colliculus, type 2 was the intercollicular groove and type 3 was the posterior colliculus. All cases were classified by Lauge-Hansen classification and compared with the groups statistically. The fixation methods by the groups were reviewed and compared. All cases were analyzed by SPSS 19.0, the p-value was less than 0.05.Results:According to the CT scan, type 1 was 14 cases (8.1%), type 2 was 48 cases (27.9%) and type 3 was 110 cases (63.9%). Based on the Lauge-Hansen classification, SER (supination-external rotation) type was 136 cases(76.4%), PER (pronation-external rotation) was 30 cases(17.4%) and PA(pronation abduction) was 8 cases(4.7%).In SER type, type 1 was 6 cases(4.4%), 2 was 42 cases(30.9%) and 3 was 86 cases(63.2%). In PER type, 1 was 6 cases (20%), 2 was 4 cases (13.3%) and 3 was 20 cases (18.9%). In PA type, 1 was 2 cases (25%), 2 was2 cases (25%) and 3 was 4 cases (50%). The fixation methods were various, such as a tension band wiring, 4.0 cannulated screw, hook plate.Conclusion:The morphology of a medial malleolar fragment based on CT scan in ankle fractures were 3 types. There was common a morphology involved the posterior colliculus, Type 3. We suggest that the operators should choose the proper fixation method by the morphology of the fragment and should be careful to avoid the injury of the posterior tibialis tendon.

Comparative Study of Flexor Hallicus Longus Tendon Length through Single Incision or Accessory Plantar Medial Incision: A Cadaver Study

Category:Ankle; HindfootIntroduction/Purpose:Flexor Hallucis Longus (FHL) tendon transfer to the calcaneus is a common adjuvant procedure in the treatment of Achilles pathology. The FHL tendon can be harvested using a posterior incision where the tendon is dissected along its course into the fibroosseous tunnel. Alternatively, the FHL may be harvested through a separate plantar medial incision as it crosses the flexor digitorium longus at the Knot of Henry. This study aims to quantify FHL tendon lengths achieved through the two common approaches utilizing pair matched cadavers.Methods:Seven pair matched fresh-frozen cadaver legs without signs of musculoskeletal abnormalities were used for this assessment. One leg in each pairing underwent a single incision harvest while the contralateral leg underwent an accessory medial plantar harvest. After dissecting the tendon, a calcaneus tunnel was prepared from dorsal to plantar in both calcanei in standard fashion. Two measurements were obtained. The first measurement was taken from the distal aspect of the muscle belly to the distal end of the tendon. The tendon was then pulled through the calcaneus, and the foot was held in tension at 20 degrees of plantar flexion. The second measurement was taken from site where tendon entered the calcaneous to the distal end of the tendon graft. The measurements were analyzed using Wilcoxon Signed Ranks Test and Fischer Exact Test.Results:Using a posterior incision, the mean tendon measurement from calcaneous tunnel to the distal end of the tendon was 4.0 cm. Using an accessory plantar medial incision, the mean tendon measurement from the calcaneous tunnel to the distal end of the tendon was 7.2 cm. The average tunnel length obtained using an accessory medial incision was significantly greater than the length obtained using the single incision approach (p= 0.0003, p=0.0022, and p=0.0016). The accessory plantar medial incision obtained an FHL tendon tunnel length that was an average of 2.9 cm greater than the posterior incision.Conclusion:The single incision approach provided sufficient length to safely anchor the FHL into the calcaneus which suggests that the accessory plantar medial approach is not necessary for routine FHL transfers to the calcaneus with interference screw fixation. However, if additional length is needed for other applications such as posterior tibialis tendon dysfunction or peritoneal tendon tears, the accessory incision does provide an average of 2.9 cm of additional length.

Minimally invasive components of the treatment of tibialis posterior insufficiency in adults : Tendoscopy of the Achilles tendon, minimally invasive calcaneus displacement osteotomy and the sinus tarsi spacer

Minimally invasive medializing calcaneal osteotomy, the implantation of atarsi spacer and the tendoscopy of the posterior tibial tendon have been established as treatment options for tibialis posterior insufficiency gradeII. The minimally invasive medializing calcaneal osteotomy allows acorrection of the hindfoot valgus like an open procedure with asignificantly lower risk of wound healing problems. It has gained increasing popularity within recent years. There is also good evidence for arthroereisis, with the use of the sinus tarsi spacer being primarily an addition to calcaneus sliding osteotomy. The possibilities for tendoscopy of the posterior tibial tendon are limited to debridement and synovectomy. Various papers report minimally invasive alternatives to the strayer procedure for ashortened gastrocnemius muscle. The proximal lengthening of the medial head of the gastrocnemius muscle is particularly popular as asoft tissue-sparing, less traumatic procedure. So far, no reports of aminimally invasive cotton osteotomy have been found in the literature.

Do Not Judge an Ossicle by Its Size: Type 1 Ossicles Associated With Posterior Tibial Tendon Dysfunction.

Patients with type II navicular ossicles have traditionally been considered to be symptomatic, whereas patients with type I and III bones are considered asymptomatic without additional relevant imaging findings. The main objective of this study is to investigate the association of type I os naviculare with clinical symptomology and magnetic resonance imaging findings in comparison to types II and III ossicles. Three hundred nine subjects with accessory navicular bone types were identified, and their associations with focal navicular pain, pes planus alignment, ossicle or proximal navicular bone marrow edema pattern presence (BMEP), and posterior tibial tendon (PTT) sheath fluid distension were assessed. Fisher's exact test was used for categorical data and unpaired t tests for continuous data. Intraobserver and interobserver agreement was calculated. Overall, 28% (85/309) of type I, 57% (176/309) of type II, and 16% (48/309) of type III accessory bones had focal navicular pain (type I vs type II, P = 0.17; type III vs type II, P = 0.001). Thirty-two percent of type I, 38% type II, and 8% type III accessory bones had pes planus (type I vs II, P = 0.3; type III vs type II, P = 0.001). Nine percent of type I, 48% of type II, and 6% of type III accessory bones had BMEP (type I vs II, P < 0.0001; type III vs type II, P = 0.001). Thirty-three percent of type I, 42% of type II, and 6% of type III accessory bones had PTT intrasheath fluid (type I vs II, P = 0.16; type III vs type II, P = 0.001). Symptomatic type I navicular ossicle patients demonstrate an increased tendency to present with early findings of PTT dysfunction and morphologic pes planus to a greater degree than previously recognized. 3.

Characteristic of Posterior Tibialis Tendon Dysfunction and Adult Acquired Flatfoot Deformity in Professional Athletes

Flatfoot cause several complications such as foot pain, knee pain, back pain, and postural disturbance. These pain rarely occur on babies and children, but the main cause of pain on runners and increase of sport injury. The purpose of this study was to identify characteristic posterior tibialis tendon dysfunction and adult acquired flatfoot deformity in professional athletes at East Java Indonesia. The sample consisted of 112 sample from 56 athletes (n=112) with complain such as foot pain, and knee pain underwent foot ultrasound and radiographic examination in Radiology Department of Soetomo General Academic Hospital Surabaya. Flatfoot was found in 79 sample (70,5%) while the other 33 sample (29,5%). Tenosynovitis that diagnosed from thickening of posterior tibialis tendon sheath was found in 69 sample (61,6%) and normal posterior tibialis tendon in 37 sample (38,4%). Partial tear in posterior tibialis tendon was found in 7 sample (6,3%), while the other 105 sample (93,7%) are without tear. Type of sport that has the largest percentage of flatfoot was wrestling 24 (21,4%) from all the sample. Most of the samples had bilateral flatfoot deformity (92,8%) and bilateral posterior tibialis tendon dysfunction (88,6%). In this study, amongst the athletes, the practitioners of wrestling and fencing had the largest number of flatfoot and tenosynovitis, whereas the largest percentage is gymnastics. The practitioners of wushu had the largest number and percentage of normal pedis radiographic x-ray and posterior tibialis tendon ultrasound. Majority of athletes had flatfoot deformity and posterior tibialis tendon dysfunction, however only a few that had partial tear in posterior tibialis tendon.

Relationship Between Recurrent Adductus Deformity of the Forefoot and Achilles Tendon Elongation Following Ponseti Treatment in Children with Idiopathic Clubfoot.

Many authors have highlighted the role of muscle strength imbalance around the ankle in the development of recurrent clubfoot following Ponseti treatment. However, this possible underlying mechanism behind recurrence has not been investigated sufficiently to date. This study aimed to explore whether there is a relationship between Achilles tendon elongation and recurrent metatarsus adductus deformity in children with unilateral clubfeet treated by the Ponseti method. A retrospective chart review was performed on 20 children (14 boys and six girls; mean age, 7 years; age range, 5-9 years) with a recurrent metatarsus adductus deformity treated by the Ponseti method for unilateral idiopathic clubfoot. At the final follow-up, isometric muscle strength was measured using a portable, hand-held dynamometer in reciprocal muscle groups of the ankle. The length of the tendons around the ankle was measured ultrasonographically. The plantarflexion-to-dorsiflexion ratio was lower on the involved side (P = .001). No significant differences in the strength ratio of inversion to eversion were found (P = .4). No difference was observed in lengths of tibialis anterior and posterior tendons (P = .1), but the Achilles tendon was longer on the involved side (P = .001; P < .01). A significant negative correlation was discovered between involved-to-uninvolved Achilles tendon length ratios and involved-to-uninvolved plantarflexion strength ratios (r = -0.524; P = .02) Conclusions: Achilles tendon elongation may be a contributor to the muscle imbalance in clubfeet with relapsed forefoot adduction treated by the Ponseti technique.

The predictive role of the posterior tibial tendon cross-sectional area in early diagnosing posterior tibial tendon dysfunction.

A hypertrophied posterior tibial tendon (PTT) has been considered to be an important morphologic parameter of PTT dysfunction (PTTD). Previous research has demonstrated that the PTT thickness (PTTT) is correlated with early signs of PTTD. However, the thickness is different from hypertrophy. Thus, we devised the PTT cross-sectional area (PTTCSA) as a new predictive parameter for diagnosing the PTTD.The PTT data were acquired from 14 patients with PTTD and from 20 normal individuals who underwent ankle magnetic resonance imaging. We measured the PTTT and PTTCSA at the PTT on the ankle magnetic resonance imaging.The mean PTTT was 2.43 ± 0.39 mm in the normal group and 3.40 ± 0.42 mm in the PTTD group. The average PTTCSA was 16.10 ± 4.27 mm2 in the normal group and 26.93 ± 4.38 mm2 in the PTTD group. The receiver operator characteristic analysis curve demonstrated that the highest predictive value of the PTTT was 3.07 mm, with 85.7% sensitivity, 85.0% specificity. The highest predictive value of the PTTCSA was 22.54 mm2, with 92.9% sensitivity, 90.0% specificity.Our findings suggest that the PTTCSA was a more valid predictor of PTTD, even though the PTTT and PTTCSA were both significantly associated with PTTD.