Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

2018 ◽  
Vol 39 (4) ◽  
pp. 433-442 ◽  
Author(s):  
Alessio Bernasconi ◽  
Francesco Sadile ◽  
Matthew Welck ◽  
Nazim Mehdi ◽  
Julien Laborde ◽  
...  
Keyword(s):  
Invasive Surgery ◽  
Stage Ii ◽  
Preoperative Imaging ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Sf 36

Background: Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data. Methods: We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated. Results: At a mean of 25.6 months’ follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament. Conclusions: Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description. Level of Evidence: Level IV, therapeutic study, case series.

Posterior Tibial Tendon Excision and Postoperative Pain in Adult Flatfoot Reconstruction: A Preliminary Report

2013 ◽  
Vol 3 (1) ◽  
pp. 20-24
Author(s):  
James K DeOrio ◽  
James A Nunley ◽  
Constantine A Demetracopoulos
Keyword(s):  
Surgical Treatment ◽  
Preliminary Report ◽  
Stage Ii ◽  
Posterior Tibial Tendon ◽  
Resection Group ◽  
First Metatarsal ◽  
Posterior Tibial ◽  
Metatarsal Angle

ABSTRACT Background Posterior tibial tendon insufficiency plays a large role in the pathogenesis of adult acquired flatfoot deformity (AAFD) in select patients. Transfer of the flexor digitorum longus is indicated to compensate for the loss of posterior tibial tendon function; however the role of resection of the degenerated posterior tibial tendon remains unclear. The aim of this study was to determine the effect of posterior tibial tendon resection on pain relief following surgical treatment of stage II AAFD. Methods All patients who underwent surgical treatment for stage II AAFD and posterior tibial tendon insufficiency were retrospectively reviewed. Patients were divided into two groups based on whether the degenerated posterior tibial tendon was resected or left in situ. Twenty-seven patients with a mean follow-up of 13.3 months were included in the study. A visual analog scale (VAS) score for pain was recorded for each patient pre-operatively and at final follow-up. Concomitant surgical procedures and the incidence of postoperative medial arch pain were also reported. Preoperative deformity and postoperative deformity correction were assessed by measuring the anteroposterior talar-first metatarsal angle, the talonavicular (TN) coverage angle, the lateral talar-first metatarsal angle, and the calcaneal pitch onstandard weight bearing radiographs. Results Eleven patients underwent FDL transfer and resection of the posterior tibial tendon (PTT resection group), and 16 patients underwent FDL transfer without resection of the posterior tibial tendon (PTT in situ group). A greater percentage of patients in the PTT resection group underwent lateral column lengthening (100 vs 18.8%, p < 0.001), and a greater percentage of patients in the PTT in situ group had a medial displacement calcaneal osteotomy performed (93.8 vs 18.2%, p < 0.001). There was no difference in preoperative VAS pain scores between groups, and all patients demonstrated excellent pain relief postoperatively. No patient in either group reported medial arch pain postoperatively. Radiographic assessment revealed similar deformity preoperatively in both groups, and patients in the PTT resection group demonstrated a greater correction of the TN coverage angle (9.8 ± 4.6 vs 6.0 ± 4.1 degrees, p = 0.041). Conclusion Resection of the PTT did not significantly affect postoperative VAS scores at final follow-up. It did however, correlate with a slightly greater correction of the TN coverage angle. There were no instances of pain along the medial ankle or medial arch of the foot in either group postoperatively. Future prospective studies are needed to determine whether resection of the PTT is necessary at the time of surgery for stage II AAFD. Demetracopoulos CA, DeOrio JK, Nunley JA II. Posterior Tibial Tendon Excision and Postoperative Pain in Adult Flatfoot Reconstruction: A Preliminary Report. The Duke Orthop J 2013;3(1):20-24.

Effects of a 4-Week Short-Foot Exercise Program on Gait Characteristics in Patients With Stage II Posterior Tibial Tendon Dysfunction

2021 ◽  
Vol 30 (1) ◽  
pp. 120-128
Author(s):  
Jinah Kim ◽  
Sung Cheol Lee ◽  
Youngmin Chun ◽  
Hyung-Pil Jun ◽  
Jeffrey G. Seegmiller ◽  
...  
Keyword(s):  
Ankle Joint ◽  
Tibialis Anterior ◽  
Muscle Activation ◽  
Stage Ii ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Foot Deformity ◽  
Posterior Tibial Tendon Dysfunction ◽  
Maximum Voluntary Isometric Contraction ◽  
Posterior Tibial

Context: Clinically, it has been suggested that increased activation of intrinsic foot muscles may alter the demand of extrinsic muscle activity surrounding the ankle joint in patients with stage II posterior tibial tendon dysfunction. However, there is limited empirical evidence supporting this notion. Objective: The purpose of this study was to investigate the effects of a 4-week short-foot exercise (SFE) on biomechanical factors in patients with stage II posterior tibial tendon dysfunction. Design: Single-group pretest–posttest. Setting: University laboratory. Participants: Fifteen subjects (8 males and 7 females) with stage II posterior tibial tendon dysfunction who had pain in posterior tibial tendon, pronated foot deformity (foot posture index ≥+6), and flexible foot deformity (navicular drop ≥10 mm) were voluntarily recruited. Intervention: All subjects completed a 4-week SFE program (15 repetitions × 5 sets/d and 3 d/wk) of 4 stages (standing with feedback, sitting, double-leg, and one-leg standing position). Main Outcome Measures: Ankle joint kinematics and kinetics and tibialis anterior and fibularis longus muscle activation (% maximum voluntary isometric contraction) during gait were measured before and after SFE program. Cohen d effect size (ES [95% confidence intervals]) was calculated. Results: During the first rocker, tibialis anterior activation decreased at peak plantarflexion (ES = 0.75 [0.01 to 1.49]) and inversion (ES = 0.77 [0.03 to 1.51]) angle. During the second rocker, peak dorsiflexion angle (ES = 0.77 [0.03 to 1.51]) and tibialis anterior activation at peak eversion (ES = 1.57 [0.76 to 2.39]) reduced. During the third rocker, the peak abduction angle (ES = 0.80 [0.06 to 1.54]) and tibialis anterior and fibularis longus activation at peak plantarflexion (ES = 1.34 [0.54 to 2.13]; ES = 1.99 [1.11 to 2.86]) and abduction (ES = 1.29 [0.50 to 2.08]; ES = 1.67 [0.84 to 2.50]) decreased. Conclusions: Our 4-week SFE program may have positive effects on changing muscle activation patterns for tibialis anterior and fibularis longus muscles, although it could not influence their structural deformity and ankle joint moment. It could produce a potential benefit of decreased tibialis posterior activation.

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

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0036
Author(s):  
Amr A. Mohammed ◽  
Hossam Abubeih ◽  
Ahmed Osman ◽  
Wael Eladly ◽  
Ahmed Khalifa ◽  
...  
Keyword(s):  
Disease Process ◽  
Stage Ii ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Posterior Tibial ◽  
Calcaneal Osteotomy ◽  
Additional Surgery ◽  
Flat Feet ◽  
Significant Difference ◽  
Adult Acquired Flatfoot Deformity

Category: Hindfoot; Midfoot/Forefoot Introduction/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.

Posterior Tibial Tendon and Spring Ligament Lesions in Rheumatoid Arthritis

2019 ◽  
Vol 35 (4) ◽  
pp. 65-69
Author(s):  
M. Bouysset ◽  
T. Tavernier ◽  
E. Decullier ◽  
C. Confavreux ◽  
J.G. Tebib ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Treatment Intensification ◽  
Flat Foot ◽  
Biologic Treatment ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Number Of Patients ◽  
Tendon Lesion

In rheumatoid arthritis, a significant number of patients have hindfoot pain while they are considered in low disease activity. Then the rheumatoid hindfoot may evolve in valgus flat foot with disability. The aim of our study was to observe the lesions of the main stabilizers of the hindfoot in rheumatoid arthritis to improve the followup and the treatment of the disease. Thirty-three feet (from 21 patients) with rheumatoid arthritis and pain of the hindfoot were consecutively observed. The patients have had no biologic treatment. Every foot had Magnetic Resonance Imaging (MRI) of the hindfoot with gadolinium injection. The tendon of the tibialis posterior muscle, the spring ligament and the inter-osseous talocalcaneal ligament were considered. All the feet presented tenosynovitis of the posterior tibial tendon. Structural lesions of the posterior tibial tendon (23/33 feet, 69.7%) were more frequent than lesions of the spring ligament (12/33 feet, 36.4%). There was no inferior spring ligament lesion without superior spring ligament lesion. No interosseous talocalcaneal ligament lesion was observed. In rheumatoid arthritis, the hindfoot, and particularly the posterior tibial tendon, should be evaluated during patient follow-up to detect a possible lesion. Posterior tibial tendon lesion arises at the same time as the spring ligament lesion, before interosseous talocalcaneal ligament lesion. Imaging, especially MRI, may complete clinical examination. If rheumatoid involvement of the posterior tibial tendon is observed, treatment intensification is required.

Intermediate Term Follow-up of Calcaneal Osteotomy and Flexor Digitorum Longus Transfer for Treatment of Posterior Tibial Tendon Dysfunction

2002 ◽  
Vol 23 (12) ◽  
pp. 1107-1111 ◽  
Author(s):  
Amir H. Fayazi ◽  
Hoan-Vu Nguyen ◽  
Paul J. Juliano
Keyword(s):  
Stage Ii ◽  
Posterior Tibial Tendon ◽  
Flexor Digitorum Longus ◽  
Posterior Tibial Tendon Dysfunction ◽  
Posterior Tibial ◽  
Calcaneal Osteotomy ◽  
Effective Form ◽  
Flexor Digitorum ◽  
Shoe Wear

Twenty-three patients with stage II posterior tibial tendon dysfunction who had failed non-surgical therapy were treated with flexor digitorum longus transfer and calcaneal osteotomy. At latest follow-up averaging 35±7 months (range, 24 to 51 months), 22 patients (96%) were subjectively “better” or “much better.” No patient had difficulty with shoe wear; however, four patients (17%) required routine orthotic use consisting of a molded shoe insert. AOFAS scores were available on 21 patients and improved from a preoperative mean of 50±14 (range, 27 to 85) to a postoperative mean of 89±10 (range, 70 to 100). Our experience, at an intermediate date follow-up is that calcaneal osteotomy and flexor digitorum longus transfer is a safe and effective form of treatment for stage II posterior tibial tendon dysfunction.

scholarly journals Weightbearing CT and MRI findings of Stage II Flatfoot Deformity

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0020 ◽  
Author(s):  
Cesar de Cesar Netto ◽  
Lauren Roberts ◽  
Guilherme Saito ◽  
Andrew Roney ◽  
Daniel Sturnick ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Stage Ii ◽  
Posterior Tibial Tendon ◽  
Mr Images ◽  
Mri Findings ◽  
Bone Deformity ◽  
Interosseous Ligament ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Weightbearing Ct

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) is a new imaging technique that allows excellent evaluation of the relative three-dimensional positioning of the tarsal bones in dynamic deformities such as AAFD. MRI, on the other hand, provides an accurate evaluation of soft tissue integrity in the unloaded foot. The objective of this study was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that a significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of involvement of ligaments and posterior tibial tendon (PTT). Methods: This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant. Results: We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04). Conclusion: This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Split Posterior Tibial Tendon Transfer Through the Interosseus Membrane in Spastic Equinovarus Deformity

1995 ◽  
Vol 16 (12) ◽  
pp. 754-759 ◽  
Author(s):  
Thomas Mulier ◽  
Pierre Moens ◽  
Guy Molenaers ◽  
Dominique Spaepen ◽  
Greta Dereymaeker ◽  
...  
Keyword(s):  
Tendon Transfer ◽  
Tibialis Posterior ◽  
Posterior Tibial Tendon ◽  
Modified Technique ◽  
Posterior Tibial ◽  
Technical Errors ◽  
Tendon Lengthening ◽  
Achilles Tendon Lengthening ◽  
Hindfoot Deformity

The split posterior tibial tendon transfer procedure was first reported by Green for correction of equinovarus hindfoot deformity in patients with cerebral palsy. A modification of the split posterior tibial tendon transfer combined with an Achilles tendon lengthening is described in 17 children (21 procedures) with a minimum follow-up of 3 years. This modified technique is indicated in young children with a continuously spastic posterior tibial tendon to correct a dynamic equinovarus. It restores active dorsiflexion when the anterior tibial and extensor muscles are weak. The anterior half of the split tibialis posterior is transferred through the interosseus membrane to the dorsum of the foot. Excellent or good results and two poor results were noted after a mean follow-up of 29 months. In the patients with an excellent or good result, marked improvement of their equinovarus foot deformity in stance and swing phase of gait was seen. In two patients, the procedure failed because of technical errors.

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