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.

A comparison between the Bluman et al. and the progressive collapsing foot deformity classifications for flatfeet assessment.

INTRODUCTION: Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS: We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS: Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS: Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.

[Minimally invasive components of the treatment of tibialis posterior insufficiency in adults : Tendoscopy of the Achilles tendon, minimally invasive calcaneus displacement osteotomy and the sinus tarsi spacer]. / Minimal-invasive Komponenten der Therapie der Tibialis-posterior-Insuffizienz des Erwachsenen : Tendoskopie der Achillessehne, minimal-invasive Kalkaneusverschiebeosteotomie und Sinus-tarsi-Spacer.

Minimally invasive medializing calcaneal osteotomy, the implantation of a tarsi spacer and the tendoscopy of the posterior tibial tendon have been established as treatment options for tibialis posterior insufficiency grade II. The minimally invasive medializing calcaneal osteotomy allows a correction of the hindfoot valgus like an open procedure with a significantly lower risk of wound healing problems. It has gained increasing popularity within recent years. There is also good evidence for arthroereisis, with the use of the sinus tarsi spacer being primarily an addition to calcaneus sliding osteotomy. The possibilities for tendoscopy of the posterior tibial tendon are limited to debridement and synovectomy. Various papers report minimally invasive alternatives to the strayer procedure for a shortened gastrocnemius muscle. The proximal lengthening of the medial head of the gastrocnemius muscle is particularly popular as a soft tissue-sparing, less traumatic procedure. So far, no reports of a minimally invasive cotton osteotomy have been found in the literature.

Posterior Tibial Tendinopathy and Osteopenia as Primary Symptoms of Celiac Disease: A Case Report.

This case report describes posterior tibial tendon (PTT) tendinopathy, valgus deformity with tenosynovitis, and osteopenia at the medial malleolus as the primary symptoms of a young patient with celiac disease (CD) without gastrointestinal symptoms. CD is an autoimmune condition that is a chronic inflammatory disorder of the small intestine triggered by ingestion of gluten in individuals with a particular genetic background. Without typical gastrointestinal symptoms, CD patients are often misdiagnosed or undiagnosed. The patient was diagnosed with CD by duodenal biopsy. He underwent a surgical procedure, including medial displacement calcaneal osteotomy, tenosynovectomy of the PTT and flexor digitorum longus (FDL), FDL transfer to the navicular for a pes planovalgus deformity, and drilling of the medial malleolus for a stress reaction. The mechanism of the PTT tear and associated heel valgus deformity was assumed to be related to the fact that his heel alignment on the affected side changed gradually from normal to valgus and pes planus owing to CD and mechanical stress, because his normal-side heel alignment was neutral before surgery and at final follow-up. His operated ankle was pain-free, with full range of motion, 1.5 years after surgery. The patient was able to restart running and exercise gradually. Foot and ankle specialists should consider the possibility of CD in patients presenting with a PTT tear without injury or trauma and osteopenia with no obvious reason.

Posterior Tibial Tendon Allograft Reconstruction for Stage II Adult Acquired Flatfoot: A Case Series.

Surgical treatment for a stage II adult acquired flatfoot has consisted of reconstruction of the diseased posterior tibial tendon with flexor digitorum longus tendon transfer, combined with osteotomies to address the underlying deformity. This case series presents an alternative to tendon transfer using allograft tendon for posterior tibial tendon reconstruction. Four patients who underwent stage II flatfoot reconstruction with posterior tibial tendon allograft transplantation were included. All patients had preoperative radiographs demonstrating flatfoot deformity and magnetic resonance imaging showing advanced tendinopathy of the posterior tibial tendon. Allograft tendon transplant was considered in patients demonstrating adequate posterior tibial tendon excursion during intraoperative assessment. Additional procedures were performed as necessary depending on patient pathology. Postoperatively, all patients remained non-weightbearing in a short leg cast for 6 weeks. Radiographs performed during the postoperative course demonstrated well-maintained and improved alignment. No complications were encountered. Each patient demonstrated grade 5 muscle strength and were able to perform a single-limb heel rise at the time of final follow-up. The average follow-up duration was 19.0 months. Flexor digitorum longus transfer has been studied extensively for stage II adult acquired flatfoot. However, the flexor digitorum longus has been shown to be much weaker relative to the posterior tibial tendon, and concern remains regarding its ability to recreate the force of the posterior tibial tendon. Our results demonstrate that posterior tibial tendon allograft reconstruction combined with flatfoot reconstruction is a reasonable option. This alternative has the advantage of preserving the stronger muscle without disturbing regional anatomy.

Comparison of screw fixation versus non-fixation in dorsal opening wedge medial cuneiform osteotomy of adult acquired flatfoot.

BACKGROUND: The aim of this study was to compare the radiographic and functional results between fixation and non-fixation in the Cotton osteotomy for the treatment of adult acquired flatfoot. METHODS: A retrospective, case-controlled study of consecutive stage IIB posterior tibial tendon dysfunction (PTTD) patients treated with the same bony reconstructive surgery including cotton osteotomy between 2013 and 2017. Meary's angle, the medial arch sag angle (MASA), and medial cuneiform cobb angle (MCCA) were evaluated pre-operation, at first weight bearing after surgery, and 12 months post operation. RESULTS: Forty feet were included in the study. The cotton osteotomy utilized screw fixation (n = 20) or non-fixation technique (n = 20). No significant differences between groups were found in pre-operative and follow-up radiographic parameters, union rate, and functional results. CONCLUSION: The non-fixation with press fit technique is a reliable procedure for Cotton osteotomy and as effective as screw fixation. LEVEL OF EVIDENCE: Level III, case control study.

Posterior tibial tendon dysfunction: Imperfect specificity of magnetic resonance imaging.

MRI is frequently used in the evaluationand treatment of tibialis posterior tendon (PTT) dysfunction. MRI is reported to have sensitivity up to 95%, with 100% specificity, in the detection of rupture of the PTT. We present three cases where MRI demonstrated complete or partial rupture of the PTT, where subsequent surgery showed an intact PTT with tenosynovitis. In all cases, there was a source of inflammation external to the tendon. It is hypothesized that this exogenous origin of inflammation caused changes in the MRI signal in the PTT that resemble that seen in ruptures. These cases show that in the presence of inflammation near the tibialis posterior tendon, the MRI may falsely indicate a high-grade rupture of the tendon. Recommendations for treatment of suspected PTT rupture in the presence of significant other sources of inflammation are proposed.

Surgical Considerations: Repair of Long Segment Defect Posterior Tibial Tendon Using Fresh Frozen Tibial Tendon Allograft.

Tibialis posterior (TP) tendon ruptures are common after ankle injuries, degenerative processes, or biomechanical instability. The TP tendon decelerates the subtalar joint pronation and internal rotation of the leg during the contact phase. It also plantarflexes and inverts the foot on the leg during the static phase of gait. When this function is lost, the medial longitudinal arch collapses, increasing the length of time of rearfoot pronation, eventually rupturing the TP tendon. Conservative treatment includes immobilization, strapping, antiinflammatories, custom-fabricated orthotics, and physical therapy. If the TP tendon rupture is severe, conservative treatment will provide little relief and surgery is indicated. This case study presents 53-year-old female who presented with left TP tendon rupture with a defect of 6 cm after sustaining an ankle injury that was surgically repaired using a TP tendon fresh frozen allograft and flexor digitorum longus tenodesis. After a 16-month follow-up, the patient was healed without complications and returned to preinjury activity. We believe that surgically repairing a TP tendon rupture with a TP tendon allograft and flexor digitorum longus tenodesis can be 1 of the treatment options for patients with extensive disruption of the TP tendon.

Repair of the Deltoid Ligament Using Posterior Tibial Tendon Autograft:A Novel Technique.

Posterior tibial tendon dysfunction (PTTD) is a progressive disorder secondary to advanced degeneration of the posterior tibial tendon, leading to the abduction of the forefoot, valgus rotation of the hindfoot, and collapse of the medial longitudinal arch. Eventually, the disease becomes so advanced that it begins to affect the deltoid ligament over time. This attenuation and eventual tear of the deltoid ligament leads to valgus deformity of the ankle. Surgical correction of PTTD is performed to protect the ankle joint at all costs. Generally, this is performed using osteotomies of the calcaneus and repair or augmentation of the deltoid ligament. Unfortunately, there has been no universal procedure adapted by foot and ankle surgeons for repair or augmentation of the deltoid ligament. Articles have discussed the use of suture and suture anchors, suture tape, nonanatomic allograft repair, nonanatomic autograft repair with plantaris, peroneal and extensor halluces longus tendons to repair and augment the deltoid ligament. There is very little literature, however, in regard to using the posterior tibial tendon to augment the deltoid ligament in accordance with hindfoot fusion for end-stage PTTD deformity. In general, the posterior tibial tendon in triple and medial double arthrodesis is generally removed because it is thought to be a pain generator. This article presents a case study and novel technique using the posterior tibial tendon to augment and repair the laxity of the deltoid ligament in an advanced flatfoot deformity.

Occurrence of Lateral Ankle Ligament Disease With Stage 2 to 3 Adult-Acquired Flatfoot Deformity Confirmed via Magnetic Resonance Imaging: A Retrospective Study.

Lateral hindfoot pain associated with stage 2 to 3 adult-acquired flatfoot is often attributed to subfibular impingement. Preoperative magnetic resonance imaging (MRI) is generally performed to assess the extent of degeneration within the posterior tibial tendon, attenuation of medial soft tissue constraints, and degeneration of hindfoot and/or ankle articulations. The purpose of this study is to determine the incidence of lateral collateral ligament disease/injury associated with stages 2 and 3 adult-acquired flatfoot. The subjects were identified using a searchable computerized hospital database between 2015 and 2017. Stage 2 or 3 adult-acquired flatfoot deformity was confirmed in patients via chart review and MRI analysis. Lateral ankle ligament injury was confirmed using patient MRI results per the hospital radiologist and documented within the patients' chart. Inclusion criteria required that patients be diagnosed with Johnson and Strom stage 2 or 3 flatfoot deformity with documented lateral ankle pain and that preoperative MRI scans be available with the radiologist's report. Patient exclusion criteria included patients <18 years of age, patients with flatfoot deformity caused by previous trauma, tarsal coalition, neuropathic arthritis, patients with previous surgery, or patients with incomplete medical records. In total, 118 patients were identified with these parameters. Of the 118 patients, 74 patients (62.7%) had documented lateral ankle ligament injury on MRI. Of the 77 patients with stage 2 adult-acquired flatfoot, 55 (71.4%) had confirmed lateral ankle ligament injury on MRI. Of the 41 patients with stage 3 adult-acquired flatfoot, 19 (46.3%) had confirmed lateral ankle ligament injury on MRI. This study demonstrates a relatively high incidence of lateral ligament disease associated with adult-acquired flatfoot deformity. These findings might have long-term implications regarding ankle arthritis after surgical management of adult-acquired flatfoot.

Remodeling of the Calcaneocuboid Joint in the Acquired Flatfoot.

There has been debate recently as to whether the lateral column is actually short in the acquired flatfoot. Doubters argue that it is not possible for the lateral column to change in length and actually shorten, especially in the acquired type. In this series of 21 consecutive patients operated on for an acquired flatfoot, the calcaneocuboid joint (CC) had remodeled in all, resulting in the calcaneal side being short, facing laterally and dorsally. These findings give evidence to the rationale for performing a lateral column lengthening (LCL) proximal to the CC joint to treat the acquired flatfoot. When performing a LCL, one should attempt to restore length to the calcaneal side of the joint and to redirect it medially and plantarward. (Journal of Surgical Orthopaedic Advances 27(3):237-245, 2018).

The arthroereisis procedure in adult flexible flatfoot grade IIA due to insufficiency of posterior tibial tendon.

BACKGROUND: To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. METHODS: We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. RESULTS: Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2-81.9 and 61.5-83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary's angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. CONCLUSIONS: Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

Results of subtalar arthroereisis for posterior tibial tendon dysfunction stage IIA1. Based on 35 patients.

BACKGROUND: The aim of the study was to evaluate the clinical and radiological results obtained in the treatment of adult flexible flatfoot secondary to posterior tibial dysfunction with subtalar arthroereisis using a Kalix ® endorthesis. METHODS: 35 patients (37 feet) were studied, having been operated between January 2010 and January 2015 for reducible flatfoot secondary to posterior tibial tendon dysfunction stage IIA1 of Bluman. RESULTS: The average follow up was 47.52 months with a minimum of 14 months and a maximum of 75 months. The average age was 54.85, with an age range from 40 to 80 years old. In 74% of cases excellent or good results were obtained, according to our evaluation. The most common complication of this procedure was persistent pain in the sinus tarsi. 35% of cases in this group required implant removal for this reason. CONCLUSIONS: We believe that arthroereisis is valid for the treatment of flat foot secondary to posterior tibial tendon dysfunction at this stage, giving a high percentage of good and excellent results.

Surgical treatment of stage II posterior tibialis tendon dysfunction: ten-year clinical and radiographic results.

INTRODUCTION: Grade II chronic tibialis posterior tendon dysfunction (PTTD) poses a reconstructive challenge to the orthopaedic surgeon. Aim of this retrospective study is to report the clinical and radiographical results of a case series of 63 patients (102 ft) affected by grade II PTTD who underwent tailored surgical treatment at 10-year mean follow-up. MATERIALS AND METHODS: Sixty-three patients (102 ft) were available for clinical and radiological evaluation and were retrospectively reviewed at a mean follow-up of 125.1 ± 14.9 months. Tibialis posterior (PTT) treatment was based on the pathological anatomy of the degenerated tendon. PTT repair was performed in 53 cases. Flexor digitorum longus transfer was performed in the remaining 49. Associated procedures were represented by medial displacement calcaneal osteotomy (MDCO) and lateral column lengthening (LCL) depending on the main clinical feature of the foot (hindfoot valgus and forefoot abduction, respectively). Patients' evaluation included AOFAS score and radiographic examination with measure of lateral talus-first metatarsal angle (LTFMA) and talo-navicular coverage angle (TNCA). RESULTS WE OBSERVED FOUR FAILURES: AOFAS hindfoot score was 89 ± 10 points at final follow-up. Eighty-six per cent of the patients declared to be satisfied or satisfied with minor reservations. An overall statistical significant decrease was observed in both LTFMA and TNCA values. A better TNCA correction was observed in case of associated LCL with respect to MDCO. DISCUSSION: Tailored PTT treatment associated with MDCO or LCL seems provide long-term pain relief and satisfactory function in the treatment of stage II posterior tibial tendon dysfunction.

Surgical Planning for Flexor Digitorum Longus Tendon Transfers: An Anatomic Study.

Posterior tibial tendon dysfunction is often coupled with various degrees of hindfoot valgus and equinus. Preoperative planning is essential to appropriate procedure choice and surgical efficiency. The purpose of the present study was to assess the anatomy at the harvest site for flexor digitorum longus tendon transfer, specifically at the master knot of Henry. Thirty fresh-frozen below-the-knee cadavers were used for dissection. A standard anatomic approach was performed for posterior tibial tendon debridement and flexor digitorum longus tendon transfer. The flexor digitorum longus tendon was harvested and measured at the master knot of Henry. The present anatomic study evaluated the tendon width of the flexor digitorum longus tendon at a common harvest site. Of the 30 specimens, 20 (67%) measured 5 mm and 10 (33%) measured 4 mm. A 5.0-mm interference screw would be acceptable in each specimen and therefore would be the safest choice. A 4.0-mm interference screw would be acceptable in only 33% of the specimens. Males have a slightly more robust flexor digitorum longus tendon than females at the harvest site. This information will assist surgeons in preoperative planning during stage II flatfoot correction for posterior tibial tendon dysfunction.

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.

Interosseous membrane window size for tibialis posterior tendon transfer-Geometrical and MRI analysis.

BACKGROUND: Tibialis posterior (TP) tendon transfer through the interosseous membrane is commonly performed in Charcot-Marie-Tooth disease. In order to avoid entrapment of this tendon, no clear recommendation relative to the interosseous membrane (IOM) incision size has been made. OBJECTIVE: Analyze the TP size at the transfer level and therefore determine the most adequate IOM window size to avoid muscle entrapment. METHODS: Eleven lower extremity magnetic resonances were analyzed. TP muscle measurements were made in axial views, obtaining the medial-lateral and antero-posterior diameter at various distances from the medial malleolus tip. The distance from the posterior to anterior compartment was also measured. These measurements were applied to a mathematical model to predict the IOM window size necessary to allow an ample TP passage in an oblique direction. RESULTS: The average tendon diameter (confidence-interval) at 15cm proximal to the medial malleolus tip was 19.47mm (17.47-21.48). The deep posterior compartment to anterior compartment distance was 10.97mm (9.03-12.90). Using a mathematical model, the estimated IOM window size ranges from 4.2 to 4.9cm. CONCLUSION: The IOM window size is of utmost importance in trans-membrane TP transfers, given that if equal or smaller than the transposed tendon oblique diameter, a high entrapment risk exists. A membrane window of 5cm or 2.5 times the size of the tendon diameter should be performed in order to theoretically diminish this complication.

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.

Technical tips: reconstruction of deep and superficial deltoid ligaments by peroneus longus tendon in stage 4 posterior tibial tendon dysfunction.

The deltoid ligament is composed of the superficial and deep layers. Disruption of the deltoid ligament can occur in rotational ankle fracture, chronic ankle instability, or stage 4 posterior tibial tendon dysfunction. Correcting valgus tilt at the time of flatfoot reconstruction in case of stage 4 posterior tibial tendon dysfunction may prevent future collapse and the need for ankle arthrodesis or possibly ankle arthroplasty. We describe a technique of reconstruction of both the superficial and deep deltoid ligaments by peroneus longus tendon.