Tendon Transfer Combined with Calcaneal Osteotomy for Treatment of Posterior Tibial Tendon Insufficiency: A Radiological Investigation

1995 ◽  
Vol 16 (11) ◽  
pp. 712-718 ◽  
Author(s):  
Mark S. Myerson ◽  
John Corrigan ◽  
Francesca Thompson ◽  
Lew C. Schon
Keyword(s):  
Tendon Transfer ◽  
Posterior Tibial Tendon ◽  
Flexor Digitorum Longus ◽  
First Metatarsal ◽  
Posterior Tibial ◽  
Metatarsal Angle ◽  
Medial Cuneiform ◽  
Before And After ◽  
The Mean ◽  
Flexor Digitorum

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38–72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21° (range, 3–45°) and 34° (range, 0–55°), respectively. The mean postoperative values for these angles were 8.5° (range, 0–35°) and 21° (range, −30–45°), respectively. The mean talar-first metatarsal angle decreased from 21° to 8.5°, a mean improvement of 12.5°, and the mean talonavicular coverage angle decreased from 34° to 21°, a mean improvement of 13°. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were −22° (range, −10 to −40°) and 9 mm (range, 1–19 mm), respectively. The mean postoperative values were −9° (range, +5 to −25°) and 16 mm (range, 10–28 mm), respectively. The mean talar-first metatarsal angle decreased from −22 to −9° (a mean improvement of 13°), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

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

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0003
Author(s):  
Connor Pihl ◽  
Bruce Sangeorzan ◽  
William Ledoux ◽  
Kylie Edinger ◽  
Ravi Balasubramanian ◽  
...  
Keyword(s):  
Tendon Transfer ◽  
Stance Phase ◽  
Standard Treatment ◽  
Posterior Tibial Tendon ◽  
Flexor Digitorum Longus ◽  
Posterior Tibial ◽  
Surgical Methods ◽  
In Series ◽  
Robotic Gait ◽  
Flexor Digitorum

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

scholarly journals The Deltoid Ligament

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Neal Ormsby ◽  
Simon Platt ◽  
Gillian Jackson ◽  
Paul Evans
Keyword(s):  
Weight Bearing ◽  
Control Group ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Talonavicular Joint ◽  
Corrective Surgery ◽  
First Metatarsal ◽  
Posterior Tibial ◽  
Metatarsal Angle ◽  
The Mean

Category: Basic Sciences/Biologics, Hindfoot, Midfoot/Forefoot Introduction/Purpose: The medial ligaments are integral in stabalising the medial column. Failure of these structures causes adult acquired flatfoot deformity (AAFD). The superomedial-cancaneonavicular component of the spring ligament(SLC) includes the medial capsule of the talonavicular joint and merges with the anterior superficial component of the deltoid complex, stabilising the talonavicular joint. However, when disrupted, it does not cause planovalgus deformity until the foot is cyclically loaded. We hypothesise that the next structure in the sequential failure cascade is the tibionavicular component of the Deltoid complex(TN) . With the failure of the SLC and the secondary effect of the posterior tibial tendon this ligament is the gatekeeper to stability of the midfoot, preventing plantar subluxation of the talus, and maintaining the radiographic lateral talo-first metatarsal angle. Methods: A prospective case control study using a novel MRI technique to image the TN. We scanned 20 consecutive normal feet and 20 with clinical and radiological AFFD. The AFFD group was subdivided into normal or abnormal TN. We assessed for pathology in the SLC, deltoid ligament (with conventional sequences) and posterior tibial tendon (PT). Imaging of the TN was performed using a novel sequence, which was an oblique view in both T1 and T2 sequence in the plane of the TN ligament to identify the normal ligament in the control group, and compare it to the patients with clinical AAFD. All patients had weight bearing AP and lateral radiographs in order to measure the calcaneal pitch, lateral talo-first metatarsal angle, and talo-calcaneal angle. We followed up patients, the end point being surgery or definitive conservative management and discharge. Results: 2 distinct groups of patients were identified. Normal TN(11/20) A mixture of medial ligament pathology was associated with this. All were managed conservatively and discharged from follow-up. The mean Meary’s angle was 6.8°. Abnormal TN(9/20) The ligament was thickened proximally, with distal attenuation and intrasubstance oedema. On sagittal sequence it had the appearance of an omega(O), with dorsal bulging and high signal on T2. The mean Meary’s angle was 13.2°(p 0.013). All patients had PT dysfunction and 8 had SLC attenuation. 5 of these patients have undergone corrective surgery. None had been discharged. The prevalence of the omega in AFFD was 30%. We confirm that the prevalence of deltoid involvement in AFFD is high, particularly in patients with more severe disease. Conclusion: Imaging of the TN is valuable in AFFD, and adds no cost or risk. There is no doubt that sequential failure of the medial ligaments occurs in AFFD. We have shown that the deltoid is involved more often than previously reported. In those with normal TN, our preliminary findings suggest that management can focus on protecting the medial structures. When the TN is attenuated(‘O’ on MRI), this represents a foot transitioning to a more severe deformity, both clinically and structurally. From our experience, these patients are more likely to have a progressive, less flexible planovalgus deformity, often requiring corrective surgery.

The Response of the Flexor Digitorum Longus and Posterior Tibial Muscles to Tendon Transfer and Calcaneal Osteotomy for Stage II Posterior Tibial Tendon Dysfunction

2005 ◽  
Vol 26 (9) ◽  
pp. 671-674 ◽  
Author(s):  
Peter F. Rosenfeld ◽  
Jonathan Dick ◽  
Terence S. Saxby
Keyword(s):  
Tendon Transfer ◽  
Contralateral Side ◽  
Muscle Volume ◽  
Stage Ii ◽  
Posterior Tibial Tendon ◽  
Flexor Digitorum Longus ◽  
Posterior Tibial Tendon Dysfunction ◽  
Posterior Tibial ◽  
Calcaneal Osteotomy ◽  
Flexor Digitorum

Background: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). Methods: Twelve patients were divided into two groups, depending on whether the PTtendon was excised(Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. Results: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. Conclusion: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.

Foot and ankle functions and deformities focus on posterior tibial tendon dysfunction using magnetic resonance imaging in patients with rheumatoid arthritis

2021 ◽  
Author(s):  
Takeshi Mochizuki ◽  
Yuki Nasu ◽  
Koichiro Yano ◽  
Katsunori Ikari ◽  
Ryo Hiroshima ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Pitch Angle ◽  
Posterior Tibial Tendon ◽  
Foot And Ankle ◽  
Resonance Imaging ◽  
Posterior Tibial Tendon Dysfunction ◽  
First Metatarsal ◽  
Posterior Tibial ◽  
Metatarsal Angle

ABSTRACT Objectives Posterior tibial tendon dysfunction (PTTD) affects the support of the medial longitudinal arch and stability of the hindfoot. The purpose of this study was to assess the relationships of PTTD with foot and ankle functions and foot deformities in patients with rheumatoid arthritis (RA). Methods A total of 129 patients (258 feet) who underwent magnetic plain and contrast-enhanced magnetic resonance imaging were enrolled in this study. Positive magnetic resonance imaging findings were defined as tenosynovitis and incomplete and complete rupture of the posterior tibial tendon. Foot and ankle functions were assessed using the Japanese Society for Surgery of the Foot standard rating system for the RA foot and ankle scale (JSSF-RA) and self-administered foot evaluation questionnaire. Plain radiographs were examined for the hallux valgus angle, first metatarsal and second metatarsal angle, lateral talo-first metatarsal angle, and calcaneal pitch angle. Results PTTD was associated with motion in the JSSF-RA (p = .024), activities of daily living in JSSF-RA (p = .017), and pain and pain-related factors in the self-administered foot evaluation questionnaire (p = .001). The calcaneal pitch angle was significantly lower in the feet with PTTD than in those without PTTD (median: 16.2° vs. 18.0°; p = .007). Conclusions The present study shows that PTTD was associated with foot and ankle functions and flatfoot deformity. Thus, a better understanding of PTTD in patients with RA is important for the management of foot and ankle disorders in clinical practice.

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