Correlation between three-dimensional medial longitudinal arch joint complex mobility and medial arch angle in stage II posterior tibial tendon dysfunction.

BACKGROUND: The purpose of this study was to evaluate correlation between three-dimensional medial longitudinal arch joint complex mobility and medial arch angle in stage II posterior tibial tendon dysfunction flatfoot under loading. METHODS: CT scans of 15 healthy feet and 15 feet with stage II posterior tibial tendon dysfunction flatfoot were taken both in non- and simulated weight-bearing condition. The CT images of the hindfoot and medial longitudinal arch bones were reconstructed into three-dimensional models with Mimics and Geomagic reverse engineering software. The three-dimensional complex mobility of each joint in the medial longitudinal arch and their correlation with the medial arch angle change were calculated. RESULTS: From non- to simulated weight-bearing condition, the medial arch angle change and the medial longitudinal arch joints mobility were significant larger in stage II posterior tibial tendon dysfunction flatfoot (p<0.05). The eversion of the talocalcaneal joint, the proximal translation of the calcaneus relative to the talus, the dorsiflexion of the talonavicular joint, the dorsiflexion and abduction of the medial cuneonavicular joint, and the lateral translation of the medial cuneiform relative to the navicular, and the dorsiflexion of the first tarsometatarsal joint were all significantly correlated to the medial arch angle change in stage II posterior tibial tendon dysfunction flatfoot (all r>0.5, p<0.05). CONCLUSIONS: There is increased mobility in the medial longitudinal arch joints in stage II posterior tibial tendon dysfunction flatfoot and the medial arch angle change under loading causes displacement not only at hindfoot joints but also involve midfoot and forefoot joint.

Severe Stage 2: Fuse or Reconstruct.

Stage II posterior tibial tendon dysfunction encompasses a wide range of patients with varying degrees of deformity and function. The spectrum of patients can be difficult to treat with a single surgical approach, as evidenced by the wide range of techniques present in the literature. Severity of the deformity, patient functional level, age, and comorbidities must be considered to determine the best course of treatment. This article examines when fusion versus reconstruction is the appropriate treatment of patients with severe stage II posterior tibial tendon dysfunction and its subclassifications.

Relationship Between Grading With Magnetic Resonance Imaging and Radiographic Parameters in Posterior Tibial Tendon Dysfunction.

The objective of the present study was to elucidate the relationship between the state of the posterior tibial tendon (PTT) on magnetic resonance images and foot deformity. The cases included 34 feet in 27 patients with PTT deformity and the controls included 18 feet in 12 patients who had undergone magnetic resonance imaging for other foot diseases. The PTT was closely examined on the magnetic resonance images and classified using the Conti classification. The control feet with no injury to the PTT were classified as grade 0. The talonavicular coverage angle, lateral talo-first metatarsal angle, medial cuneiform to fifth metatarsal height, calcaneal pitch angle, and varus-valgus angle were measured as radiographic parameters for flatfoot deformation, and the relation between the Conti classification and each parameter was examined statistically. A significant difference was observed in the talonavicular coverage angle between grade 0 and the other grades; the lateral talo-first metatarsal angle between grade 0 and the other grades and between grades 1 and 3; the medial cuneiform to fifth metatarsal height among grades 0, 2, and 3 and grades 1, 2, and 3; the calcaneal pitch angle between grades 1 and 3; and the varus-valgus angle among grades 0, 2, and 3 and between grades 1 and 3. Eversion of the forefoot was observed, along with an advanced collapse in the medial longitudinal arch, from an early stage of PTT injury.

Radiographic Outcomes Following Lateral Column Lengthening With a Porous Titanium Wedge.

BACKGROUND: Lateral column lengthening (LCL) is commonly utilized in treating stage II posterior tibialis tendon dysfunction. This study aimed to analyze the outcomes of LCL with porous titanium wedges compared to historic controls of iliac crest autograft and allograft. We hypothesized that the use of a porous titanium wedge would have radiographic improvement and union rates similar to those with the use of autograft and allograft in LCL. METHODS: Between May 2009 and May 2014, 28 feet in 26 patients were treated with LCL using a porous titanium wedge. Of the 26 patients, 9 were males (34.6%). The average age for males was 43 years (range, 17.9-58.7), 48.7 years (range, 21-72.3) for females. Mean follow-up was 14.6 months. Radiographs were examined for correction of the flatfoot deformity and forefoot abduction. All complications were noted. RESULTS: Radiographically, the patients had a significant deformity correction in the anteroposterior talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch. All but 1 patient (96%) had bony incorporation of the porous titanium wedge. The average preoperative visual analog scale pain score was 5; all patients but 3 (12%) had improvements in their pain score, with a mean change of 3.4. CONCLUSION: LCL with porous titanium had low nonunion rates, improved radiographic correction, and pain relief. LEVEL OF EVIDENCE: Level IV, case series.

Posterior tibial tendon dysfunction in the adult: current concepts.

The management of posterior tibial tendon dysfunction in adults has evolved substantially, and controversy persists regarding a specific recommended algorithm for treatment. The current focus is on early diagnosis and treatment of this disorder with joint-sparing surgeries, such as corrective osteotomies and tendon transfers, when nonsurgical modalities have been exhausted. It is helpful to be familiar with the pertinent pathophysiology and diagnostic pearls associated with posterior tibial tendon dysfunction, its treatment options, pertinent literature, and technique tips for the procedures currently being used.

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.

Addressing stage II posterior tibial tendon dysfunction: biomechanically repairing the osseous structures without the need of performing the flexor digitorum longus transfer.

The clinical presentation of adult flatfoot can range from a flexible deformity with normal joint integrity to a rigid, arthritic flat foot. Debate still exists regarding the surgical management of stage II deformities, especially in the presence of medial column instability. This article reviews and discusses various surgical options for the correction of stage II flatfoot reconstructive procedures. The authors discuss their opinion that is not always necessary to transfer the flexor digitorum longus tendon to provide relief and stability in this patient population. The anatomy, diagnosis, and current treatments of flexible flatfoot deformity are discussed.

Surgical decision making for stage IV adult acquired flatfoot disorder.

Adult acquired flatfoot deformity is a debilitating musculoskeletal condition affecting the lower extremity. Posterior tibial tendon dysfunction (PTTD) is the primary etiology for the development of a flatfoot deformity in an adult. PTTD is classified into 4 stages (with stage IV subdivided into stage IV-A and IV-B). This classification is described in detail in this article.

Total and distributed plantar loading in subjects with stage II tibialis posterior tendon dysfunction during terminal stance.

BACKGROUND: In subjects with stage II tibialis posterior tendon dysfunction (TPTD), the function of the tibialis posterior muscle is altered and may be associated with a change in total and distributed loading. METHODS: Thirty subjects with a diagnosis of stage II TPTD and 15 matched control subjects volunteered to participate in a study to examine the total and distributed plantar loading under the foot during the terminal stance phase of gait. Plantar loading, measured as the subject walked barefoot, was assessed using instrumented flexible insoles. A secondary analysis was done to explore the contribution of flatfoot kinematics to plantar loading patterns. RESULTS: Overall, there was reduced total plantar loading in subjects with stage II TPTD compared with controls. Accounting for differences in total loading, the presence of clinically measured weakness in subjects with TPTD was associated with reduced lateral forefoot loading. Medial longitudinal arch height was significantly correlated with loading patterns but explained only 21% of the variance in observed loading patterns. CONCLUSION: Subjects with TPTD who are strong exhibited loading patterns similar to controls. Changes in total and distributed loading during terminal stance suggest there are altered ankle mechanics at push-off during the functional task of gait. CLINICAL RELEVANCE: Strength, in the presence of TPTD, may be important to stabilize the midfoot during gait and might be important in rehabilitation protocols.

PTT functional recovery in early stage II PTTD after tendon balancing and calcaneal lengthening osteotomy.

BACKGROUND: The decision to offer surgery for Stage II posterior tibial tendon deficiency (PTTD) is a difficult one since orthotic treatment has been documented to be a viable alternative to surgery at this stage. Taking this into consideration we limited our treatment to bony realignment by a lengthening calcaneus Evans osteotomy and tendon balancing. The goal of the study was to clinically evaluate PTT functional recovery with this procedure. METHOD: The patient population included 17 feet in 13 patients. Inclusion was limited to early Stage II PTTD flatfeet with grossly intact but deficient PTT. Deficiency was assessed by the lack of hindfoot inversion during single heel rise test. The surgical procedure included an Evans calcaneal opening wedge osteotomy with triceps surae and peroneus brevis tendon lengthening. PTT function at follow up was evaluated by an independent examiner. Evaluation was performed at an average of 4 (range, 2 to 6.3) years. RESULTS: One case presented postoperative subtalar pain that required subtalar fusion. Every foot could perform a single heel rise with 13 feet having active inversion of the hindfoot during elevation. CONCLUSIONS: The results of this study provide evidence of PTT functional recovery without augmentation in early Stage II. It challenges our understanding of early Stage II PTTD as well as the surgical guidelines recommending PTT augmentation at this specific stage.

Functional results of posterior tibial tendon reconstruction, calcaneal osteotomy, and gastrocnemius recession.

BACKGROUND: This study aimed to assess and provide prospective outcome data following reconstruction of Stage II posterior tibial tendon insufficiency, as well as evaluate the effect of reconstruction with gastrocnemius recession on plantarflexion strength. METHODS: A prospective evaluation of 24 patients undergoing reconstruction for Stage II posterior tibial tendon insufficiency was granted IRB approval. The reconstructive procedures consisted of a flexor digitorum longus transfer, medial displacement calcaneal osteotomy, lateral column lengthening, and gastrocnemius recession. Patients were asked to complete multiple outcome measures preoperatively, 6 months, 1 year, and 2 years postoperatively. A dynamometer was utilized to evaluate peak torque plantarflexion preoperatively, 6 months, and 1 year postoperatively. RESULTS: In the study, 14 patients completed preoperative surveys, and 23 patients had 2-year followup. Patients were highly satisfied with the results of their surgery. All outcome measures showed statistically significant improvement. Improvement was seen at 6 months, but results continued to improve at the 1-year mark. By the second year, improvement largely reached a plateau. Biodex testing showed no loss of plantarflexion strength after reconstruction and gastrocnemius recession. CONCLUSION: Reconstruction of the flexible adult acquired flatfoot with FDL transfer, double calcaneal osteotomy, and gastrocnemius recession yielded excellent functional results for the treatment of Stage II posterior tibial tendon insufficiency. Plantarflexion weakness was not found to be a concern. A good functional outcome can be anticipated after the early postoperative period. However, it should be expected to take at least 1 year for maximal benefit.

Effect of ankle-foot orthotic devices on foot kinematics in Stage II posterior tibial tendon dysfunction.

BACKGROUND: Data are limited on the various orthotic devices available for patients with Stage II posterior tibial tendon dysfunction (PTTD). Foot kinematics observed while walking with an orthotic device are hypothesized to be associated with clinical outcomes and could be used to refine future device designs. METHODS: Fifteen subjects (age, 63.6 ± 6.8 years) with Stage II PTTD walked in the lab under four conditions: (1) shoe only (control condition), (2) shoe with a custom solid AFO (Arizona Co, Mesa, AZ), (3) shoe with a custom articulated AFO (Arizona Co, Mesa, AZ), and (4) shoe with an off-the-shelf AFO (AirLift, DJ Orthopedics). Kinematic data were collected to determine the degree of hindfoot inversion, forefoot plantarflexion (reflective of raising the MLA), and forefoot adduction associated with each condition. RESULTS: The custom articulated device was associated with greater hindfoot inversion compared to the shoe only condition at loading response (p = 0.002), mid-stance (p < 0.001), and terminal stance (p = 0.02). The custom articulated device, custom solid device, and off-the-shelf device were associated with greater forefoot plantarflexion compared to the shoe only condition across all four phases of stance. There were no differences between any of the devices and the shoe condition associated with forefoot adduction. CONCLUSION: The custom devices were associated with greater hindfoot inversion and forefoot plantarflexion compared to walking with only a shoe, while the off-the-shelf device was associated with forefoot plantarflexion but no change in hindfoot motion. None of the devices corrected forefoot abduction compared to the shoe only condition. CLINICAL RELEVANCE: The current biomechanical data may aid in understanding the clinical outcomes seen using these devices as well as provide data to support new designs.

The RAM classification: a novel, systematic approach to the adult-acquired flatfoot.

In summary, prior classifications have provided broad guidelines for treating the AAFF without accounting for case-specific variables in determining a treatment plan. The current system breaks down the deformity into three independent levels of involvement: the rearfoot, the ankle, and the midfoot. Via a simple, easy to remember, and reproducible schema based off the original Johnson and Strom classification, each level can be independently evaluated and a patient-specific surgical treatment plan can be formulated based on our most current understanding of the AAFF.

Radiographic evaluation of endoscopic gastrocnemius recession, subtalar joint arthroereisis, and flexor tendon transfer for surgical correction of stage II posterior tibial tendon dysfunction: a pilot study.

UNLABELLED: The best procedure for surgical correction of stage II posterior tibial tendon dysfunction has long been a source of debate among foot and ankle surgeons. A combination of endoscopic gastrocnemius recession, subtalar joint arthroereisis, and flexor digitorum longus tendon transfer has been used in an attempt to avoid some of the complications seen with calcaneal osteotomies, and to allow an earlier return to function and weight bearing. A retrospective analysis of preoperative and postoperative radiographic changes in 10 patients for whom surgical correction of the deformity was performed between 2003 and 2006 is presented as a pilot study. Seven radiographic variables considered standard for the radiographic assessment of posterior tibial tendon dysfunction were measured. The outcome measure of interest was the return of radiographic variables to normal ranges following surgical correction of the deformity. In addition, preoperative and postoperative clinical outcomes were assessed to evaluate the long-term clinical benefits of this trio of procedures. Radiographic values were noted to return to normal ranges in all cases following this trio of surgical procedures; these changes were statistically significant (P < or = .05). These preliminary results suggest that this surgical combination provides satisfactory correction of deformity in patients presenting with stage II posterior tibial tendon dysfunction. LEVEL OF CLINICAL EVIDENCE: 4.

Plantar pressure analysis in cadaver feet after bony procedures commonly used in the treatment of stage II posterior tibial tendon insufficiency.

BACKGROUND: Bony procedures play an essential role in the operative treatment of stage II posterior tibial tendon insufficiency and often substantially alter the loading characteristics of the foot. METHODS: Eight matched pairs of cadaver lower extremities were axially loaded onto a TekScan HR Mat. (TekScan, Inc., South Boston, MA) After intact testing, each specimen had a lateral column lengthening (either a calcaneocuboid distraction arthrodesis [CCDA] or Evans procedure), a medializing calcaneal osteotomy (MCO), and a plantarflexion (Cotton) osteotomy of the medial cuneiform. The measured plantar pressures were divided into three forefoot regions, two midfoot regions, and two hindfoot regions. For each region, average pressure, peak pressure, and contact area data were collected. RESULTS: Despite the fact that both lateral column lengthening procedures resulted in increased lateral forefoot pressures, no significant differences were noted between the CCDA and the Evans procedure. The addition of a MCO did not significantly alter the plantar pressures measured after the lateral column lengthening alone. Although the Cotton osteotomy resulted in increased average pressures within the medial forefoot, a compensatory significant decrease in lateral forefoot pressures was not observed. CONCLUSIONS: The present study demonstrated increased lateral forefoot pressures after a combined lateral column lengthening and MCO and does not support the idea that a Cotton osteotomy significantly reduces loading of the lateral forefoot. CLINICAL RELEVANCE: The incidence of lateral forefoot pain and fifth metatarsal stress fractures subsequent to either lateral column lengthening procedure may not significantly decline after a Cotton osteotomy.

Posterior tibial tendon rupture: a refined classification system.

Since Johnson's and Strom's classification system in 1989 an increasingly complex array of deformities of the foot has been recognized in association with PTTR. This wide spectrum of deformity is not completely addressed by the current classification system, nor does it leave sufficient room for variation within a given treatment stage. Taking into account ankle and hindfoot valgus, forefoot supination, forefoot abduction, and medial column instability we present and discuss a refined classification for PTTR. Potential treatments for each stage are provided.

Stage IV posterior tibial tendon rupture.

Adult acquired flatfoot deformity progresses through well defined stages as set out by Johnson and Strom. Myerson modified this classification system with the addition of a fourth, more advanced stage of the disease. This stage describes the involvement of the tibiotalar joint in addition to the hindfoot malalignment seen in stages II and III. This most advanced stage is comprised of a hindfoot valgus deformity, resulting from degeneration of the posterior tibial tendon, with associated valgus tilting of the talus within the mortise. The deformity at the tibiotalar joint may or may not be rigid. Although rigid deformities are still best treated with fusions of the ankle and hindfoot, supple tibiotalar deformity may be treated with joint sparing procedures involving reconstructive procedures of the foot and deltoid ligaments.

Preliminary gait analysis results after posterior tibial tendon reconstruction: a prospective study.

The purpose of this study was to investigate the effect on gait in patients who underwent reconstruction for stage II posterior tibial tendon (PTT) dysfunction. Twelve patients with stage II PTT dysfunction underwent surgical reconstruction consisting of debridement of the posterior tibial tendon, flexor digitorum longus tendon transfer to the navicular tuberosity, medial displacement calcaneal osteotomy, and spring ligament reconstruction. Midfoot arthrodesis was performed in six patients and gastrocnemius recession in three. Gait analysis was performed 2 weeks prior to surgery and 1 year postoperatively. Preoperative and postoperative data were compared to determine differences in temporal-spatial parameters, lower limb kinematics, and ankle push-off power. Step length for the operated side increased from 52.6 +/- 9.6 cm before the surgery to 57.5 +/- 7.1 cm after the surgery (p =.048). Cadence improved from 100.2 +/- 10.7 steps/min to 109.1 +/- 8.5 steps/min (p =.05), thus increasing velocity from 87.6 +/- 22.6 cm/s to 103.4 +/- 15.9 cm/s (p =.042). Single support percentage was unchanged. Maximum sagittal ankle joint power at push-off increased from 0.79 +/- 0.35 W before surgery to 1.2 +/- 0.5 W after surgery (p =.042). There were statistically significant improvements in all radiographic parameters studied. This is the first prospective study to evaluate the in vivo effects on gait in patients undergoing this common surgical procedure. Analysis demonstrated statistically significant improvement in kinetic and kinematic parameters of gait function.

The indications and biomechanical rationale for various hindfoot procedures in the treatment of posterior tibialis tendon dysfunction.

Several procedures are available for the treatment of posterior tibialis tendon dysfunction. The procedure that is chosen for a specific patient should address the patient's unique problem and make biomechanical sense. A fusion should be avoided, if possible; however, if a fusion is the appropriate solution, one should not hesitate to do it.