Endoscopic assisted flexor digitorum longus transfer in flexible flatfoot

BACKGROUND

Posterior tibial tendon insufficiency is the commonest cause of adult flexible flatfoot. Transfer of the flexor digitorum longus (FDL) has been described a therapeutic arsenal in flexible flat feet and posterior tibial tendon disorders. It is often combined with bony procedure (open or percutaneous calcaneal osteotomy).

METHODS

We describe a technique and the steps endoscopic approach of FDL transfer.

RESULTS

The procedure is able to be performed safely and reproducible under perfect viewing CONCLUSION: In the future with a clinical study investigating, we purpose the results of such surgery in a cohort of patients with flexible flatfoot. Level IV Therapeutic study: case serie. No funding was received for this research project.

Tibial Retro-Malleolar Groove Morphology in Patients With Posterior Tibialis Tendon Dysfunction

The posterior tibial tendon is a gliding tendon which courses around the medial malleolus and fails in posterior tibialis tendon dysfunction (PTTD) leading to a flat foot deformity. Distal tibial bone spurs have been identified as a secondary sign of PTTD although they have not been quantified in detail. The aim of this study was to assess the association of tendon dysfunction with the bony morphology of the tibial retro-malleolar groove. We performed a retrospective review of the clinical presentation, plain radiographs, and 103 magnetic resonance imaging (MRI) scans in 82 consecutive patients with PTTD compared with a non-PTTD group. We carried out a quantitative and qualitative assessment of the presence of plain radiographic bone spurs, stage of PTTD and MRI imaging of the morphology of the tibial bony malleolar groove. Plain radiographic bone spurs, as a secondary sign of PTTD, were present in 21.3% of ankle radiographs. MRI bone spurs were identified in 26/41 (63.4%) for all high-grade partial and complete tears and 7/41 (17.1%) for isolated complete tears compared with only 3.9% of the non-PTTD group. There was a significant association between the presence of bone spurs on MRI imaging and high-grade partial and complete tibialis posterior tears (p < .001; odds ratio of 4.98). Eleven of 103 (10.7%) of spurs were large and in 4/103 (3.9%) were substantial enough to create a tunnel-like hypertrophic groove not previously reported. There is variation in the bony structure of the malleolar groove in PTTD not observed in the non-PTTD group. Further investigation over time may elucidate whether the groove morphology may lead to mechanical attrition of the tibialis posterior tendon and contribute to failure of healing and progressive tendon degeneration.

Characteristics and Future Direction of Tibialis Posterior Tendinopathy Research: A Scoping Review

Background and Objectives: Tibialis posterior tendon pathologies have been traditionally categorized into different stages of posterior tibial tendon dysfunction (PTTD), or adult acquired flatfoot deformity (AAFD), and more recently to progressive collapsing foot deformity (PCFD). The purpose of this scoping review is to synthesize and characterize literature on early stages of PTTD (previously known as Stage I and II), which we will describe as tibialis posterior tendinopathy (TPT). We aim to identify what is known about TPT, identify gaps in knowledge on the topics of TPT, and propose future research direction. Materials and Methods: We included 44 studies and categorized them into epidemiology, diagnosis, evaluation, biomechanics outcome measure, imaging, and nonsurgical treatment. Results: A majority of studies (86.4%, 38 of 44 studies) recruited patients with mean or median ages greater than 40. For studies that reported body mass index (BMI) of the patients, 81.5% had mean or median BMI meeting criteria for being overweight. All but two papers described study populations as predominantly or entirely female gender. Biomechanical studies characterized findings associated with TPT to include increased forefoot abduction and rearfoot eversion during gait cycle, weak hip and ankle performance, and poor balance. Research on non-surgical treatment focused on orthotics with evidence mostly limited to observational studies. The optimal exercise regimen for the management of TPT remains unclear due to the limited number of high-quality studies. Conclusions: More epidemiological studies from diverse patient populations are necessary to better understand prevalence, incidence, and risk factors for TPT. The lack of high-quality studies investigating nonsurgical treatment options is concerning because, regardless of coexisting foot deformity, the initial treatment for TPT is typically conservative. Additional studies comparing various exercise programs may help identify optimal exercise therapy, and investigation into further nonsurgical treatments is needed to optimize the management for TPT.

Posterior Tibial Tendon Integrity Can Be Screened With Plain Anteroposterior Foot Radiography

Posterior tibial tendon integrity is an important consideration when treating adult-acquired flatfoot caused by posterior tibial tendon dysfunction. The condition of this tendon traditionally has been evaluated with ultrasonography or magnetic resonance imaging, but recent advances in radiography have increased the resolution of radiographic soft tissue images. The authors examined whether the posterior tibial tendon could be screened with anteroposterior foot radiographs, based on interobserver agreement and accuracy. The authors retrospectively evaluated consecutive patients who underwent weight-bearing foot radiography and ultrasonography based on suspicion of posterior tibial tendinopathy. The integrity of the posterior tibial tendon was evaluated by 2 orthopedic surgeons with foot radiographs and scored as normal or abnormal. The authors evaluated interobserver agreement and compared the findings of ultrasonography and radiography to evaluate diagnostic accuracy. The study included 21 patients with a mean age of 51.5±15.7 years. Ultrasonography showed that 4 patients had normal tendon integrity, 6 patients had tenosynovitis and no tendinopathy, 8 patients had tendinopathy and tendon continuity, and 3 patients had loss of tendon continuity. The surgeons provided consistent radiographic findings for 81.0% of patients (17 of 21). On the basis of the ultrasonographic findings, the surgeons' accuracy was 76.2% (16 of 21) and 61.9% (13 of 21). The results indicate that weight-bearing anteroposterior foot radiography can be used to evaluate posterior tibial tendon integrity, which may allow orthopedic surgeons to predict the prognosis of patients with posterior tibial tendon dysfunction, determine the extent of surgical treatment, and evaluate tendon integrity postoperatively. [Orthopedics. 2020;43(6):e503-e507.].

IS THERE ANY ROOM FOR TENDOSCOPY IN THE SURGICAL TREATMENT OF POSTERIOR TIBIAL TENDON INSUFFICIENCY?

Posterior tibial tendon insufficiency (PTTI) is nowadays considered to be the main cause of adult-acquired flatfoot deformity (AAFD). The purpose of this study is to report the outcomes of tendoscopic treatment of tibialis poste- rior tendon (TP) in eleven patients with stage 1 or 2 PTTI and failed prior conservative treatment. Tendoscopy was carried out as a solitary procedure in 8 patients, while in 3 patients additional procedures such as ,,mini-open" tubularization of TP or anterior ankle arthroscopy were necessary. In a single patient transfer of flexor digitorum longus tendon was performed as a second stage surgery due to complete rupture of TP. Related with tendoscopic procedure, no complications were re- ported. TP tendoscopy is a useful and beneficial minimally invasive procedure to treat TP pathology at earlier stages of PTTI. It is a technically demanding procedure that requires extensive experience in arthroscopic management of small ioints and excellent knowledge of repional anatomy.

Surgery for adult acquired flatfoot due to posterior tibial tendon dysfunction reduces pain, improves function and health related quality of life

BACKGROUND

Patients with adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD) may require surgery but few reports have evaluated the outcome.

METHODS

We evaluated 21 patients with a median age of 60 (range 37-72) years who underwent different surgical reconstructions due to stage II AAFD before and 6 and 24 months after surgery by the validated Self-Reported Foot and Ankle Score (SEFAS), Short Form 36 (SF-36) and Euroquol 5 Dimensions (EQ-5D).

RESULTS

The improvement from before to 24 months after surgery was in SEFAS mean 12 (95% confidence interval 8-15), SF-36 physical function 21 (10-22), SF-36 bodily pain 28 (17-38), EQ-5D 0.2 (0.1-0.3) and EQ-VAS 11 (2-21).

CONCLUSION

Surgery for AFFD due to PTTD results in reduced pain and improved function and health related quality of life. The outcome scores have been demonstrated as useful. It has also been shown, since there is a further improvement between 6 and 24 months after surgery, that a minimum follow-up of 2 years is needed.

LEVEL OF CLINICAL EVIDENCE

III - prospective observational cohort study.

Posterior tibial tendon transfer improves function for foot drop after knee dislocation

BACKGROUND

Knee dislocation may be associated with an injury to the common peroneal nerve with a subsequent foot drop. Previous studies have demonstrated good functional results after posterior tibial tendon transfer in patients with foot drop. No studies, to our knowledge, have focused exclusively on knee dislocation as the cause of common peroneal nerve injury leading to foot drop.

QUESTIONS/PURPOSES

We determined the percentage of patients developing common peroneal nerve paresis after knee dislocation, the symptom improvement rate in these patients, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot score), ankle dorsiflexion strength, and ROM in patients with no symptom improvement treated with posterior tibial tendon transfer.

METHODS

Two hundred forty-seven patients with knee dislocation, defined as an injury to both the ACL and PCL with an additional injury to the lateral and/or medial ligaments (Schenck Classification II to IV), were registered in a single institution's database between 1996 and 2011. The database was queried for the frequency of documented injuries to the common peroneal nerve and, among those, the frequency of spontaneous resolution after this injury. Patients demonstrating no active dorsiflexion 12 months after injury generally were offered posterior tibial tendon transfer. Postoperatively, patients were evaluated for AOFAS score, ankle dorsiflexion strength, and ROM.

RESULTS

Forty-three patients (17%) had a common peroneal nerve paresis at admission. At 1-year followup, 15 of 43 patients (35%) had experienced symptom improvement. One patient experienced spontaneous improvement later than 1 year after injury. One patient was lost to followup. A below-knee amputation was performed in one patient due to the initial trauma. Seven patients were satisfied with their function using a brace or had medical contraindications to surgical treatment, while four patients refused the proposed operation with a tendon transfer, leaving 14 patients treated with posterior tibial tendon transfer. In the 12 patients available for evaluation, mean AOFAS score was 91 of 100. Mean (± SD) dorsiflexion strength was 118 (± 55) Nm on the operated side and 284 (± 94) Nm on the unaffected side (p < 0.001). Mean ROM was 67° (± 15°) on the operated side and 93° (± 14°) on the unaffected side (p < 0.001).

CONCLUSIONS

Based on these findings, we recommend posterior tibial tendon transfer for treatment of foot drop that persists at least 1 year after knee dislocation.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

[Progress in soft tissue reconstruction of adult-acquired flatfoot deformity]

OBJECTIVE

To review the progress in clinical and biomechanical study on soft tissue reconstruction of adult-acquired flatfoot deformity (AAFD).

METHODS

The recent original articles of soft tissue repair and tendon transfer for AAFD were extensively reviewed.

RESULTS

The soft tissue procedures for AAFD can be divided into two components: static restoration of medial column stability and dynamic reconstruction of the posterior tibial tendon. The most important static structure to be repaired for AAFD is the spring ligament. On the other hand, various methods can be used for dynamic reconstruction. The flexor digitorum longus transfer is widely used, but results of biomechanical studies do not support the advantage of this method. For patients having normal function of the posterior tibial muscle, the Cobb procedure may be more suitable.

CONCLUSION

The soft tissue reconstruction procedures of AAFD should be chosen individually based on the stage and type of the deformity.

The use of arthrodesis to correct rigid flatfoot deformity

Rigid adult flatfoot deformity ranges in severity and is caused by a variety of conditions. Treatment is based on the etiology, the severity of symptoms, the stage of the deformity, and patient goals. Posterior tibial tendon pathology, osteoarthritis, posttraumatic arthritis/deformity, inflammatory arthropathy, and neuropathic arthropathy are all known causes of adult flatfoot deformity. Regardless of the cause, treatment goals are the same-restore a plantigrade foot, decrease symptoms, and increase function. When nonsurgical modalities have failed, many surgical reconstructive options are available to restore anatomy and function.

The management of complications following the treatment of flatfoot deformity

Adult acquired flatfoot deformity encompasses a wide spectrum of clinical conditions. Current management approaches have emerged from a growing understanding of its manifestations, which have been learned from decades of clinical trial and error. Although surgical trends continue to evolve, many basic principles and practices have endured. Adult flatfoot deformity can arise from multiple causes, the most common of which remains posterior tibial tendon rupture with subsequent elongation of secondary supportive structures. Regardless of the cause, the fundamental goals of surgical management include correcting peritalar subluxation, restoring hindfoot-midfoot-forefoot relationships and muscle balance, attaining a plantigrade foot, and preserving motion when possible. Surgical correction may be associated with a variety of potential problems, including errors in decision making, undertreatment, overcorrection, and technical mistakes. These complications can lead to adjacent joint arthritis, recurrent deformity, rigidity, nonunion, and persistent pain.

[Acquired adult flatfoot deformity: a pragmatic approach]

Acquired adult flatfoot deformity is a commonly encountered entity in orthopaedic practice. It results mainly from posterior tibial tendon (PTT) dysfunction, is more common in women and frequently associated with obesity. The four severity stages are based on dysfunction of the PTT, on the reducibility of the deformity, and on the condition of the hindfoot joints. Conservative treatment is functionally efficient in the early stages and may also contribute to analgesia in advanced stages. The goal of surgery is to restore a functional mobility in the early stages and to achieve rigid stabilization of the hindfoot in the late stages. The treatment's choice and the control of the predisposing factors for acquired flatfoot depends upon a close collaboration between the family physician and the orthopaedic surgeon.

Calcaneal osteotomies for the treatment of adult-acquired flatfoot

Calcaneal osteotomies are useful procedures for the treatment of stage 2 adult-acquired flatfoot. Often combined with adjunctive soft-tissue procedures, the posterior calcaneal displacement osteotomy and Evans procedure provide effective realignment of pes planovalgus deformity. Preoperative evaluation, indications, contraindications, surgical considerations and techniques are discussed.

Management of hindfoot disease in rheumatoid arthritis

There is a wide variety of hindfoot disease seen in patients with rheumatoid arthritis. Initial treatment is conservative including optimizing medical management to control the disease process. Should symptoms persist, surgical treatment may be performed, although there is an increased complication rate related to both the disease and the side effects of the medications used to treat it.

[Treatment of serious subtalar joint osteoarthritis and stage II posterior tibial tendon dysfunction by subtalar arthrodesis]

OBJECTIVE

To assess the curative effect of the subtalar arthrodesis on the serious subtalar joint with the posterior tibial tendon dysfunction.

METHODS

From October 2000 to February 2006, 31 patients (18 males, 13 females; age 23-62 years, averaged 36.4 years) with serious subtalar joint osteoarthrisis and stage II posterior tibial tendon dysfunction were treated by the subtalar arthrodesis. The tibial tendon dysfunction involved 15 right and 16 left lower extremities, which were caused by retrograde osteoarthritis in 14 patients, sequel of an injury in 8 patients, infection in 7 patients, and anatomic structural abnormity in 2 patients. The treatment course averaged 9. 5 months (range, 6-30 months). Before the subtalar arthrodesis, the injured tendons were repaired, and then the bone grafting was performed in the tarsus sinus. All of the patients were assessed before and after operation according to the Hindfoot scores system (American Orthopedics Foot and Ankle Society, AOFAS).

RESULTS

Among the patients, 28 were followed up on an average of 23.6 months (range, 8-61 months). The AOFAS scores ranged from 45.30+/-1.08 before operation to 79.60+/-2.14 after operation. The pain indexes ranged from 15.40+/-2.23 before operation to 38.50+/-2.61 after operation. The functional indexes of the foot and ankle joint ranged from averaged 21.60+/-3.01 before operation to averaged 37.40+/-2.83 after operation. The statistical analysis of the t-test on all the above data showed that there was a significant difference between before operation and after operation (P<0.01). The angles between the longitudinal line of the talar and the calcaneal bone were 43.70+/-1.06 degrees before operation and 29.40+/-0.98 degrees after operation, and the deviation angles between the calcaneal line and the talus were 48.20+/- 0.85 degrees before operation and 39.40+/-1.02 degrees after operation. There was a significant difference between before operation and after operation (P<0.01).

CONCLUSION

The subtalar arthrodesis combined with the bone grafting in the tarsus sinus and the repair of the injured tendons can effectively correct the deformity of the deformity of the metapodium, relieve the pain, retain the adjacent joint motion ability, and this method can be recommended for the adult patient who suffers from serious subtalar osteoarthritis and stage II osterior tibial tendon dysfunction.

The flexible flatfoot in the adult

The adult acquired flatfoot deformity is characterized by flattening of the medial longitudinal arch with insufficiency of the supporting posteromedial soft tissue structures of the ankle and hindfoot. While the etiology of this deformity can be arthritic or traumatic in nature, it is most commonly associated with posterior tibial tendon dysfunction (PTTD). By one estimate, PTTD affects approximately five million people in the United States. The clinical presentation of adult flatfoot can range from a flexible deformity with normal joint integrity to a rigid, arthritic foot.

The effect of flatfoot deformity and tendon loading on the work of friction measured in the posterior tibial tendon

BACKGROUND

There is limited information regarding the mechanical factors contributing to the progression of posterior tibial tendon dysfunction. Therefore, an investigation of the mechanical forces on the posterior tibial tendon may improve our understanding of this pathology.

METHODS

The gliding resistance and excursion of the posterior tibial tendon in the retromalleolar region was measured in seven cadaveric lower limbs in the coronal, transverse, and sagittal planes. These data were used to calculate the work of friction and to characterize the effect of different tendon loading levels (0.5, 1.0, and 2.0 kg) in the intact and flatfoot conditions.

FINDINGS

Flatfoot deformity significantly increased the excursion of the posterior tibial tendon (P<0.05), increased forefoot and hindfoot range of motion in the coronal and transverse planes (P<0.05) and the work of friction in the coronal and transverse planes (P<0.05), but not in the sagittal plane. There was a significant increase in the work of friction between 0.5 and 2 kg (P<0.05) in all three planes of motion.

INTERPRETATION

The motions in the coronal and transverse planes have a greater effect on the work of friction of the posterior tibial tendon than sagittal plane motion in the flatfoot condition. This study suggests that aggressive treatment of early stage PTT dysfunction with bracing designed to limit coronal and transverse motions, while permitting sagittal motion should be investigated further. Such bracing may decrease the potential of progressive deformity while allowing for more normal ambulation.

The Cobb procedure for treatment of acquired flatfoot deformity associated with stage II insufficiency of the posterior tibial tendon

BACKGROUND

A supple flatfoot deformity caused by posterior tibial tendon (PTT) dysfunction may include a supination deformity of the forefoot that usually is not sufficiently corrected by the commonly suggested treatment options. The use of a partial anterior tibial tendon (ATT) graft that is rerouted through the first cuneiform to the proximal stump of the PTT may restore plantarflexion power of the first ray (Cobb procedure).

METHODS

Twenty-two consecutive patients with stage II PTT dysfunction and a supple supination deformity of the forefoot were included. A clinical examination, a subjective score, and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale were evaluated.

RESULTS

The mean AOFAS score increased from preoperatively 53.2 (range 40 to 68) to 88.5 (range 78 to 94) at a followup of 24 (range 12 to 46) months. The overall clinical results were excellent in nine patients (41.0%), good in 12 (54.5%), fair in one (4.5%), and poor in none. None of the patients had decreased power of the anterior tibial tendon compared to the contralateral foot. Nineteen patients (86%) were able to wear shoes without shoe modifications.

CONCLUSIONS

The Cobb procedure provided satisfactory correction of associated forefoot supination deformity in stage II PTT dysfunction. All patients had improved function because of the increased stability of the first ray. There was no evidence of loss of ATT power. The Cobb procedure may be considered an appropriate alternative to arthrodeses in selected patients with supple supination deformity in flatfeet.

Combined anterior tibial tendon rupture and posterior tibial tendon dysfunction in advanced flatfoot

The combination of spontaneous anterior tibial tendon rupture and posterior tibial tendon dysfunction has rarely been reported in the literature. This is a case report of a 78-year-old patient presenting with a history of longstanding, progressive flatfoot deformity, clinically grade III posterior tibial tendon dysfunction, and dropfoot gait. Radiographic films revealed severe flatfoot, and the clinical examination was consistent with a complete rupture of the anterior tibial tendon and severe posterior tibial tendon degeneration as well as rupture of the spring and deltoid ligaments. Treatment by triple arthrodesis and repair of the anterior tibial tendon affected pain relief and clinical as well as radiographic correction at the 4-month postoperative assessment.

[Tibialis posterior tendon dysfunction. An often neglected cause of painful adult flatfoot]

The posterior tibialis tendon is the most important dynamic stabilizer of the medial longitudinal arch of the foot. Posterior tibial tendon dysfunction (PTTD) may result from an acute trauma or a progressive degeneration of the tendon and should be suspected in painful flatfoot. The diagnosis is largely clinical, based on pain, tenderness and swelling along the tendon underneath the medial malleolus, the too-many-toes sign and persistant hindfoot valgus during heel rise. Untreated PTTD often results in total collapse of the longitudinal arch and severe osteoarthritis of the ankle or hindfoot. In traumatic cases acute repair of the tendon should be considered.

Current concepts for treatment of the painful flatfoot in the elderly

Flatfoot deformities are predominantly asymptomatic variants of normal, which do not adversely affect function. However, the acquired flatfoot deformity secondary to attrition of the posterior tibial tendon is a progressively painful condition, ultimately affecting the hindfoot, midfoot, and forefoot. It is most common during the sixth and seventh decades of life. Chronic micro-trauma to the tendon causes eventual rupture and the resulting deformity. Prior to tendon rupture, early symptoms are those of a unilateral localized inflammatory condition with tenderness and swelling behind the medial malleolus of the ankle. Early diagnosis is a key factor in limiting patient disability.

Recovery of the posterior tibial muscle after late reconstruction following tendon rupture

The purpose of this study was to determine the recovery potential of the posterior tibial muscle after late reconstruction following tendon rupture in stage II of posterior tibial tendon dysfunction. Fourteen patients (18 women, 6 men; mean age 59.8 years) were investigated 47 months (range, 24-76 months) after surgical reconstruction of a completely ruptured posterior tibial tendon (end-to-end anastomosis, side-to-side augmentation with the flexor digitorum longus tendon) in combination with a distal calcaneal osteotomy with a tricortical iliac crest bone graft for lengthening of the lateral column. At follow-up, clinical and radiological investigations were performed, including strength measurement and qualitative and quantitative MRI investigation. The overall clinical results were graded excellent in 12 patients, good in one, fair in one, and poor in none. The average ankle-hindfoot score (American Orthopaedic Foot and Ankle Society) improved from preoperatively 49.1 (range, 32-60) to 93.1 (range, 76-100) at follow-up. The functional result correlated with patient's satisfaction and sports activities (p <.05). All patients showed a significant strength of the posterior tibial muscle on the affected side, but it was smaller than on non-affected side (p <.05). The mean posterior tibial muscle strength was 75.1 N on affected and 104.9 N on nonaffected side, corresponding to a ratio of 0.73 between the two legs. The mean area of the posterior tibial muscle was 1.89 cm(2) on affected side, and 3.48 cm(2) on nonaffected side, corresponding to a ratio of 0.55 between the two legs. While fatty degeneration for the posterior tibial muscle was found in all patients, it was found to decrease with increasing strength of the posterior tibial muscle (p <.05) and muscular size (p <.05). On postoperative MRI, the posterior tibial tendon could be found to be intact in all patients. The recovery potential of the posterior tibial muscle was shown to be significant even after delayed repair of its ruptured tendon. A ruptured and/or diseased posterior tibial tendon should not be transected as it excludes any recovery possibilities of the posterior tibial muscle.

A classification of severity with an analysis of causative problems related to the type of treatment

The current classification systems provide broad guidelines for treating the acquired adult flat foot. They essentially place the acquired flat foot into categories of no deformity, flexible deformity, or rigid deformity, as well as the condition of the PTT; however, there are many more variables that need to be taken into account to provide optimal care. As our knowledge and experience grows in treating the adult flat foot, more options will be available. The physician treating this condition must stay up-to-date and must not rely solely on the existing classification systems to direct care.

Nonoperative treatment of adult acquired flat foot with the Arizona brace

Nonoperative treatment of posterior tibial tendon dysfunction can be successful with the Arizona AFO brace, particularly when treatment is initiated in the early stages of the disease. This mandates that the orthopedist has a high index of suspicion when evaluating patients to make an accurate diagnosis. Although there is a role for surgical management of acquired flat feet, a well-fitted, custom-molded leather and polypropylene orthosis can be effective at relieving symptoms and either obviating or delaying any surgical intervention. In today's climate of patient satisfaction directed health care, a less invasive treatment modality that relieves pain may prove to be more valuable than similar pain relief that is obtained after surgery. Questions regarding the long-term results of bracing remain unanswered. Future studies are needed to determine if disease progression and arthrosis occur despite symptomatic relief with a brace. Furthermore, age- and disease stage-matched control groups who are randomized to undergo surgery or bracing are necessary to compare these different treatment modalities. At this time, the Arizona AFO brace can be a useful weapon in the orthopedist's armamentarium for treating acquired flat foot deformity.

Soft tissue procedures

Soft tissue procedures for PTT dysfunction and adult acquired flat foot improve function and preserve joint motion. These procedures can only be applied to patients who have correctable deformities. The durability of these procedures, without the addition of bone realignment procedures, has been questioned and needs to be investigated further. Reconstruction of the spring ligament complex corrects the flat foot in cadavers but has not been studied clinically. There is still much to be learned in this condition so we are able to provide optimal care for our patients.

Lateral-sided bony procedures

Treatment of any hindfoot deformity should include correction of the deformity and preservation of complex hindfoot motion. This important motion is protective of adjacent, and more removed, joints in that it serves a shock-absorbing function and protects them from stresses. Lateral column lengthening combined with a medial soft-tissue procedure is the treatment of choice for stage II flat foot. Patients who have significant subluxation of the subtalar joint will also need a medial displacement calcaneal osteotomy to correct the hindfoot valgus. Only patients who have a rigid foot secondary to degenerative changes will require an arthrodesis to correct the deformity and provide pain relief. Unfortunately, although fusion works well to correct deformity, it accelerates future degenerative changes.

Medial-sided bony procedures: why, what, and how?

The adult acquired flat foot deformity is a common clinical entity; rupture or incompetence of the posterior tibial tendon is a frequent cause. The natural history is characterized by progressively worsening deformity and early recognition is important. Nonoperative treatment can alleviate symptoms and control progression in nearly all stages of the disease. Should this fail to control symptoms or prevent progression of deformity, operative intervention should be considered. In stage I disease, exploration and debridement, with or without FDL tendon transfer, is a viable option. In stage II disease, the PTT becomes elongated and the medial soft tissues become attenuated. Exploration and debridement of the PTT is performed, but frequently a FDL tendon transfer or side-to-side anastomosis is required. It has been shown that soft tissue procedures alone may fail to correct deformity and this can lead to deterioration of results over time. Combined procedures, including soft tissue reconstructions to restore PTT function and bony procedures to correct deformity, have become popular. When the PTT is intact and degeneration or elongation is minimal, as in stage I or early stage II disease, reconstruction of the medial column with advancement of an osteoperiosteal flap based on the PTT insertion, combined with selective arthrodeses of the medial column, may be considered. These procedures have been well described for the treatment of symptomatic flexible flat foot in children and adolescents but experience in adults is lacking. Although it may be theoretically possible to passively correct hindfoot valgus with these procedures, it seems prudent to limit the indications to patients who have early disease accompanied by an isolated midfoot sag. In more advanced stage II disease, correction of deformity with a tendon transfer combined with a medial displacement calcaneal osteotomy or a lateral column lengthening is currently recommended. This allows for correction of deformity while sparing the hindfoot joints, which may be particularly important in young or active patients. Short-term studies showed excellent results, but long-term results are lacking. In stage III disease, in which the deformity is fixed, arthrodesis is the procedure of choice. Isolated talonavicular arthrodesis has been shown to correct nearly all aspects of the deformity with long-lasting results. This procedure results in nearly complete lack of hindfoot motion and may predispose the patient to adjacent joint arthrosis. In a patient who has stage III disease with arthrosis confined to the talonavicular joint, isolated talonavicular arthrodesis may be considered. This clinical situation is rare, and, in most patients, a triple arthrodesis is probably preferred. If residual deformity is present after these procedures, it must be addressed. Residual medial column instability may be addressed by adding a selective arthrodesis of the naviculo-cuneiform or first metatarsocuneiform joint, whereas residual forefoot varus or supination may be addressed with selected midfoot fusions with or without a cuneiform osteotomy.

Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report

BACKGROUND

The purpose of this study was to evaluate preliminary results with Kalix subtalar arthroereisis in sinus tarsi for stage II posterior tibial tendon dysfunction.

METHODS

Twenty-one patients with stage II posterior tibial dysfunction, according to Johnson and Storm, underwent surgical treatment between July 1999 and December 2000. All patients were evaluated clinically using the America Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle score. We performed a tendon repair depending on the type and location of the injury and implanted a Kalix endorthesis in the sinus tarsi.

RESULTS

Nineteen patients attended for clinical review with an average follow-up of 27.31 months (range, 19-36). AOFAS scale improved from a preoperative average of 47.2 to an average of 81.6 at revision. The most important improvement was observed in pain (16.3 preoperative to 31.6 postoperative). Two cases required removal of the endorthesis for pain, probably because the endorthesis was too big, without any loss of correction. Patient satisfaction was "satisfied" or "very satisfied" in 17/19. All except three patients would have elected to undergo the same procedure.

CONCLUSIONS

Subtalar arthroereisis by means of implantation of a Kalix endorthesis in the sinus tarsi, with prior correction of the deformity and tendon repair, offers an alternative to bone operations such as calcaneal osteotomies, lengthening the external column, or arthodesis in patients with stage II posterior tibial dysfunction.

Anatomical reconstruction of the spring ligament using peroneus longus tendon graft

Posterior tibial tendon insufficiency is often associated with failure of the spring ligament and flatfoot deformity. Arch correction procedures involving bony realignment, such as lateral column lengthening or joint fusions, can predispose to arthritis. Soft tissue reconstruction may provide a more anatomical correction without these complications. The purpose of this investigation was to compare the ability of three different spring ligament reconstruction procedures to correct flatfoot deformity. A deformity model of 5 degrees - 15 degrees talonavicular abduction was created in 10 cadaver foot-ankle specimens. Three reconstructions utilizing the peroneus longus tendon were evaluated for their ability to correct talonavicular abduction and subtalar eversion under 357 N vertical GRF load. A superomedial/plantar passage of the tendon through the calcaneus and navicular was shown to be more effective than either of the other two approaches, correcting the talonavicular joint from 9.1 degrees +/- 8.1 degrees abducted to 1.0 degree +/- 6.8 degrees adducted, and the subtalar joint from 3.1 degrees +/- 3.3 degrees everted to 0.4 degrees +/- 4.2 degrees inverted. Thus, an anatomical reconstruction of a model of a failed spring ligament was demonstrated to be effective in the correction of a flatfoot deformity produced in cadaver foot-ankle specimens.

Stage II flatfoot: what fails and why

Stage II PTT dysfunction is a complex problem that has multiple treatment options. Whether it is treated nonoperatively or operatively, multiple factors affect the success of treatment. The orthopedic literature reports many factors that can lead to failure. Although it is virtually impossible to account for every possible scenario, adhering to sound principles and understanding what can go wrong and why, can help to avoid many of the pitfalls.

Changes in collagen matrix composition in human posterior tibial tendon dysfunction

OBJECTIVE

To investigate whether tendon degeneration in posterior tibial tendon dysfunction syndrome is associated with changes in extracellular matrix collagen composition.

METHODS

Specimens from grossly abnormal tendon regions from 9 patients with posterior tibial tendon dysfunction syndrome were prepared for routine histology. Collagens I, III and V were typed by immunoblotting and quantified by densitometry after SDS-PAGE. Proline and hydroxyproline residues were determined by liquid chromatography. Four other samples from grossly normal homologous tendon regions and one surgical specimen from a healthy patient undergoing arthrodesis of the ankle after an accident were included as control.

RESULTS

In the grossly abnormal surgical posterior tibial tendon specimens we observed three types of histopathologic conditions present to varying degrees: increased mucin content, fibroblast hypercellularity and neovascularization. Analysis of degenerate tendons demonstrated a 79.3% increase in total proline and a 32.4% increase in 4-hydroxyproline. In addition, damaged tissue contained a higher proportion of collagen type III (mean increase: 53.6%) associated with a concomitant increase in type V collagen (mean increase: 26.4%). These alterations were accompanied by a reduction in type I collagen (mean decrease: 41.4%).

CONCLUSIONS

In posterior tibial tendon dysfunction syndrome, the degenerative process results from marked changes in both structural organization and molecular composition of matrix collagens. The higher proportion of type V and type IlI collagens in degenerated tendons is likely to contribute to a decrease in the mechanical resistance of the tissue.