Tendoscopic treatment of acute posterior tibial tendon dysfunction: case report

We present a case of a rheumatoid patient presenting with acute signs of posterior tibial tendon dysfunction (PTTD). Magnetic resonance imaging (MRI) results were inconclusive regarding the grade of posterior tibial tendon (PTT) tear. We performed posterior tibial tendoscopy, releasing all tendon adherences, and accomplished complete synovectomy. By the end of the procedure, we observed PTT integrity, normal excursion, and mild tendinosis. At 24-month follow-up, the Visual Analog Scale for pain (VAS-Pain) decreased from 9 (preoperatively) to 1. The Foot and Ankle Outcome Score (FAOS) increased from 16% (preoperatively) to 94%. Clinically, the patient had a symmetric bilateral heel rise test and no pain over the course of the PTT. A standard radiographic assessment demonstrated a normal foot arch and hindfoot alignment. This report illustrates how posterior tibial tendoscopy can simultaneously provide accurate diagnosis and surgically address acute PTTD on a rheumatoid patient, relieving symptoms and improving midterm clinical scores. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Clinical Outcomes of Single Excision Versus Kidner Procedure for Type II Accessory Navicular Associated with Flatfoot in Adults: Does accessory navicular induce flexible flatfoot?

Background Patients with type II accessory navicular (AN) originally complain of the medial pain of foot. With increasing frequency, some of them has been recognized flexible flatfoot (FFF) at the first weightbearing radiographic examination. Posterior tibial tendon (PTT) dysfunction is widely accepted as a significant contributor to FFF. However, the PTT was not affected in these patients. The relationship between AN and FFF remains controversial. The contribution of AN to FFF was designed in this study. Methods Adult patients who complained of medial pain and bone eminence between January 2014 and January 2020 were included. 61 patients were confirmed to have the AN with flatfoot and randomly divided into two operative groups. The AN was excised in Group A, and the PTT was reconstructed to the navicular region with an anchor in Group B. Preoperative and postoperative evaluations were performed, including clinical evaluations, the American Orthopedic Foot and Ankle Society (AOFAS) mid-foot scale, a visual analog scale (VAS) and radiographic assessments of Meary’s angle, Pitch angle, talonavicular coverage, Kite’s angle and naviculocuboid overlap. PTT decline angle (PDA) and AN-Navicular joint inclination angle (ANJCA) in the lateral view were designed to evaluate the effect of AN on FFF. Results Fifty-six patients (56 feet) were included in this study because 5 patients were excluded. The mean follow-up period was 22.29 months with single excision (Group A) and 20.86 months with Kidner procedure (Group B). The AOFAS mid-foot score improved from 70.39±7.78 pre-operationally to 89.46±7.06 at the last follow-up in Group A and from 67.14±8.14 pre-operationally to 89.64±6.88 at the last follow-up in Group B. The VAS score decreased from 2.82±0.39 and 2.86±0.36 to 0.89±0.31 and 0.79±0.42, respectively. The radiographic results representing flatfoot significantly increased in the two groups. In the lateral view, PDA significantly increased after the operation, and the effect of PTT on the arch upward was induced by pull angulations and shorter distances. Conclusion The FFF with AN may be induced by AN and its synchondrosis. The weakened plantar ligament of synchondrosis was impaired under chronic tension and shear forces may be implicated as the etiologic biomechanical mechanism. AN excision or it with PTT reconstruction could release the pain and benefit the PTT pulling sufficiency.

Intra- and Interobserver Reliability of the New Classification System of Progressive Collapsing Foot Deformity

Background: Historical concept of flatfoot as posterior tibial tendon dysfunction (PTTD) has been questioned. Recently, the consensus group published a new classification system and recommended renaming PTTD to Progressive Collapsing Foot Deformity (PCFD). The new PCFD classification could be effective in providing comprehensive information on the deformity. To date, there has been no study reporting intra- and interobserver reliability and the frequency of each class in PCFD classification. Methods: This was a single-center, retrospective study conducted from prospectively collected registry data. A consecutive cohort of PCFD patients evaluated from February 2015 to October 2020 was included, consisting of 92 feet in 84 patients. Classification of each patient was made using characteristic clinical and radiographic findings by 3 independent observers. Frequencies of each class and subclass were assessed. Intraobserver and inteobserver reliabilities were analyzed with Cohen kappa and Fleiss kappa, respectively. Results: Mean sample age was 54.4, 38% was male and 62% were female. 1ABC (25.4%) was the most common subclass, followed by 1AC (8.7%) and 1ABCD (6.9%). Only a small percentage of patients had isolated deformity. Class A was the most frequent component (89.5%), followed by C in 86.2% of the cases. Moderate interobserver reliability (Fleiss kappa = 0.561, P < .001, 95% CI 0.528-0.594) was found for overall classification. Very good intraobserver reliability was found (Cohen kappa = 0.851, P < .001, 95% CI 0.777-0.926). Conclusion: Almost half (49.3%) of patients had a presentation dominantly involving the hindfoot (A) with various combinations of midfoot and/or forefoot deformity (B), (C) with or without subtalar joint involvement (D). The new system may cover all possible combinations of the PCFD, providing a comprehensive description and guiding treatment in a systematic and individualized manner, but this initial study suggests an opportunity to improve overall interobserver reliability. Level of Evidence: Level III, retrospective diagnostic study.

Simultaneous traumatic dislocation of the posterior tibial tendon and long peroneal tendon: a case report

Background Viewing the existing literature, one can find several documents about dislocation of the peroneal tendons. Clinical findings, diagnostics, and therapy are well described. Instead, the list of documents describing dislocations of the posterior tibial tendon is short. We found no case in which a dislocation of both long peroneal tendon and posterior tibial tendon is described. Case presentation We present a case of a 29-year-old male patient who sustained an ankle injury after a fall at a boulder gym. He admitted himself with severe pain, tenderness, and swelling of his left ankle. Dislocation of the posterior tibial tendon and simultaneous dislocation of the long peroneal tendon was diagnosed using x-ray, computed tomography, and magnetic resonance imaging. Transosseous suture repair with periosteal augmentation of the flexor retinaculum was performed at the medial malleolus. At the lateral malleolus, transosseous suture was used to repair the superior retinaculum. The ankle was immobilized following surgery. The patient underwent physical therapy afterwards. The treatment resulted in good recovery, and the patient returned to the same level of performance at rock climbing. Conclusion Our novel finding is that simultaneously sustained dislocations of the posterior tibial tendon and the long peroneal tendon may occur and can be successfully treated as if each injury is treated individually. Level of evidence Level V, case report.

A Modified Extra-articular Lateral Column Lengthening Procedure for Adult Acquired Flatfoot Deformity

Background: Lateral column lengthening (LCL), originally described by Evans, is an established procedure to correct stage II adult acquired flatfoot deformity (AAFD). However, the relative position between the facets is violated, and other problems may include nonunion, malunion, and calcaneocuboid (CC) joint subluxation. Herein, we report a modified extra-articular technique of LCL with hockey-stick osteotomy, which preserves the subtalar joint as a whole, increases bony apposition to enhance healing ability, and preserves the insertion of the calcaneofibular ligament to stabilize the posterior fragment to promote adduction of the forefoot. Methods: We retrospectively recruited 24 patients (26 feet) with stage II AAFD who underwent extra-articular LCL. The mean age was 55.7 ± 15.7 years, and the mean follow-up period was 33.4 ± 12.1 months. Associated procedures of spring ligament repair/reconstruction and posterior tibial tendon plication or flexor digitorum longus transfer were routinely performed and may also include a Cotton osteotomy, heel cord lengthening, or hallux valgus correction. Clinical and radiographic outcomes at the final follow-up were compared with the preoperative assessments. Results: All patients achieved calcaneus union within 3 months of operation. The VAS pain score improved from 5.3 ± 0.75 preoperatively to 1.2 ± 0.79 at the final follow-up ( P < .001), and the AOFAS Ankle-Hindfoot Scale from 63.5 ± 8.5 to 85.8 ± 4.8 points ( P < .001). The radiographic measurements significantly improved in terms of the preoperative vs final angles of 8.9 ± 5.3 vs 15.2 ± 3.6 degrees for calcaneal pitch ( P < .001), 20.5 ± 9.2 vs 4.9 ± 4.8 degrees for Meary angle ( P < .001), 46.5 ± 5.2 vs 41.9 ± 3.2 degrees for lateral talocalcaneal angle ( P < .001), 23.9 ± 8.5 vs 3.9 ± 3.1 degrees for talonavicular coverage angle ( P < .001), and 18.2 ± 9.2 vs 7.3 ± 5.0 degrees for talus-first metatarsal angle ( P = .002). The CC joint subluxation percentage was 7.0% ± 5.4% preoperatively compared with 8.5% ± 2.4% at the final follow-up ( P = .101). No case showed progression of CC joint arthritis or CC joint subluxation (>15% CC joint subluxation percentage). One case showed transient sural nerve territory paresthesia, and 1 had pin tract infection. Three cases had lateral foot pain, which could be relieved by custom insoles. Conclusion: Modified extra-articular LCL as part of AAFD correction is a feasible alternative technique without subtalar joint invasion and may be associated with less CC joint subluxation compared with the Evans osteotomy. Level of Evidence: Level IV, retrospective case series.

Presence of adipose tissue along the posteromedial tibial border

Purpose The flexor digitorum longus and posterior tibial tendon as well as the perforating veins are located along the distal posteromedial tibial border. Adipose tissue may surround these structures and possibly play a role in reducing mechanical stress. This study aimed to examine the adipose tissue along the posteromedial tibial border via magnetic resonance imaging (MRI), ultrasound, and gross anatomical examination. Methods The lower legs of 11 healthy individuals were examined every 3 cm from the medial malleolus using MRI and ultrasound. The fat fraction was calculated using fat fraction images. In addition, the gross anatomy of the flexor digitorum longus origin and adipose tissue along the posteromedial tibial border was examined in seven fresh cadavers. The fat fraction was compared at different heights along the posteromedial tibial border and in Kager’s fat pads; we also compared the height of the flexor digitorum longus origin and adipose tissue. Results In vivo, the adipose tissue was identified along the entire posteromedial tibial border using MRI and ultrasound. There was no significant difference in fat fraction between Kager’s fat pads and the adipose tissue along the posteromedial tibial border, except at the 6 cm mark. All seven cadavers presented adipose tissue along the posteromedial tibial border, significantly more distal than the flexor digitorum longus origin. Conclusion The adipose tissue was identified along the posteromedial tibial border via MRI, ultrasound, and gross anatomical examination; thus, this tissue may play a role in reducing friction and compressive stress in tendons.

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

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.