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.

scholarly journals Weightbearing CT and MRI findings of Stage II Flatfoot Deformity: Can We Predict Patients at High- Risk for Foot Collapse?

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0016
Author(s):  
Cesar de Cesar Netto ◽  
Guilherme Honda Saito ◽  
Andrew Roney ◽  
Lauren Roberts ◽  
Ashraf Fansa ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Subtalar Joint ◽  
Stage Ii ◽  
Mr Images ◽  
Mri Findings ◽  
Bone Deformity ◽  
Interosseous Ligament ◽  
Spring Ligament ◽  
Soft Tissue Involvement ◽  
Weightbearing Ct

Category: Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) allows excellent dynamic evaluation of the relative three-dimensional positioning of the tarsal bones. MRI provides accurate evaluation of soft tissue integrity in the unloaded foot. Study’s objective 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 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 soft tissue involvement. 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.

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 Insufficiency: Which Ligaments are Involved?

2005 ◽  
Vol 26 (6) ◽  
pp. 427-435 ◽  
Author(s):  
Jonathan T. Deland ◽  
Richard J. de Asla ◽  
Il-Hoon Sung ◽  
Lauren A. Ernberg ◽  
Hollis G. Potter
Keyword(s):  
Progressive Failure ◽  
Plantar Fascia ◽  
Control Group ◽  
Deltoid Ligament ◽  
Posterior Tibial Tendon ◽  
Cross Sectional ◽  
Interosseous Ligament ◽  
Posterior Tibial ◽  
Spring Ligament ◽  
Magnetic Resonance Imaging Mri

Background: The pathology manifested in posterior tibial tendon insufficiency (PTTI) is not limited to the posterior tibial tendon. The association of ligament failure with deformity has been discussed in numerous publications, but extensive documentation of the structures involved has not been performed. The purpose of this observational study was to identify the pattern of ligament involvement using standarized, high-resolution magnetic resonance imaging (MRI) in a series of 31 consecutive patients diagnosed with PTTI compared to an age matched control group without PTTI. Method: The structures evaluated by MRI were the posterior tibial tendon, superomedial and inferomedial components of the spring ligament complex, talocalcaneal interosseous ligament, long and short plantar ligaments, plantar fascia, deltoid ligament, plantar naviculocuneiform ligament, and tarsometatarsal ligaments. Structural derangement was graded on a five-part scale (0 to IV) with level 0 being normal and level IV indicating a tear of more than 50% of the cross-sectional area of the ligament. Standard flatfoot measurements taken from preoperative plain standing radiographs were correlated with the MRI grading system. Results: Statistically significant differences in frequency of pathology in the PTTI group and controls were found for the superomedial calcaneonavicular ligament ( p < 0.0001), inferomedial calcaneonavicular ligament ( p < 0.0001), interosseous ligament ( p = 0.0009), anterior component of the superficial deltoid ( p < 0.0001), plantar metatarsal ligaments ( p = 0.0002) and plantar naviculocuneiform ligament ( p = 0.0006). The ligaments with the most severe involvement were the spring ligament complex (superomedial and inferomedial calcaneonavicular ligaments) and the talocalcaneal interosseous ligament. Conclusion: Ligament involvement is extensive in PTTI, and the spring ligament complex is the most frequently affected. Because ligament pathology in PTTI is nearly as common as posterior tibial tendinopathy, treatment should seek to protect or prevent progressive failure of these ligaments.

3D foot kinematic difference in Posterior Tibial Tendon Dysfunction stage II/III and control group

2016 ◽  
Vol 22 (2) ◽  
pp. 11
Author(s):  
S. Wuite ◽  
K. Deschamps ◽  
C. Roels ◽  
M. van de Velde ◽  
F. Staes ◽  
...  
Keyword(s):  
Stage Ii ◽  
Control Group ◽  
Posterior Tibial Tendon ◽  
Posterior Tibial Tendon Dysfunction ◽  
Posterior Tibial ◽  
And Control

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.

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