Subtalar arthrodesis for treatment of posterior tibial tendon insufficiency

Subtalar arthrodesis is an effective treatment of the planovalgus deformity of posterior tibial tendon insufficiency that provides stable and reliable results with minimal complications. Disadvantages include the risk of symptomatic adjacent joint arthrosis at long-term follow-up and less clinical and radiographic correction of the deformity as compared with other reconstructive options, which may make the joint-preserving procedures more attractive for the primary treatment of patients with a flexible pes planovalgus deformity without subtalar pain.     

Results of treatment of stage II posterior tibial tendon rupture with flexor digitorum longus tendon transfer and calcaneal osteotomy

In a retrospective study, we reviewed our results of treatment of stage II posterior tibial tendon rupture in 129 patients for whom surgery was performed between 1990 and 1997. During this period of time, 148 patients were treated with surgery following failure of nonsurgical methods of treatment. The 129 patients (117 females, 12 males) with an average age of 53 years (range, 34–75 years) had been symptomatic for an average of 2.8 years (range, 0.5–7 years). The indication for surgery was the presence of foot pain, which was refractory to shoe modifications, orthoses, and brace support. All patients had a painful flexible flatfoot without a fixed forefoot supination deformity. The surgery performed included a medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular. There were additional surgeries performed in 49 patients including repair of a tear of the spring ligament, talonavicular capsule or deltoid ligament (45), lengthening of the Achilles tendon (26), correction of hallux valgus deformity (5), and arthrodesis of the first tarsometatarsal joint (4). All patients were examined, radiographs obtained, and isokinetic evaluation of both feet and lower limbs performed with the KinCom apparatus at a mean of 4.6 years following surgery (range, 3–8 years). The AOFAS hindfoot scale was used to evaluate each patient, although, due to the time elapsed from the initiation of treatment, preoperative AOFAS scores were not retrospectively determined. The mean AOFAS score at the time of the follow-up examination was 79 points (range, 54–93). There were 7 significant complications in 6 patients including: significant progressive hindfoot valgus deformity in 1 patient treated with a triple arthrodesis; overcorrection of the hindfoot in 2 patients necessitating revision with a lateral closing wedge calcaneus osteotomy; 3 patients with symptomatic sural neuritis, and 1 patient with weakness of the gastrocnemius resulting from overlengthening of the Achilles tendon. Isokinetic inversion and plantarflexion power and strength were compared with the contralateral limb for 121 patients, and were noted to be symmetric in 95, mildly weak in 18, and moderately weak in 8. Motion of the subtalar joint was normal in 44%, slightly decreased in 51%, and moderately decreased in 5% of patients. Anteroposterior and lateral radiographs were evaluated for the talonavicular coverage angle, talus-first metatarsal angle, talocalcaneal angle, and the height of the medial cuneiform to the floor. For 4 of these 5 parameters evaluated, the correction obtained was statistically significant (p < 0.05). Of the patients examined, 123 were entirely satisfied, 4 partially satisfied, and 2 were dissatisfied with the outcome of the procedure. Most patients experienced pain relief (97%), an improvement of function (94%), noted an improvement in the arch of the foot (87%), and were able to wear shoes comfortably without resorting to shoe modifications or orthotic arch support (84%). In conclusion, the surgical correction of stage II posterior tibial tendon rupture with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications, and a high patient satisfaction rate.     

Treatment of stage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy

BACKGROUND: To assess the efficacy of surgical correction of stage II tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular, the authors retrospectively reviewed results of treatment of stage II posterior tibial tendon deficiency in 129 patients for whom surgery was performed between 1990 and 1997. METHODS: The indication for surgery included tendon weakness, flexible deformity, and foot pain refractory to nonsurgical treatment. All patients had a painful flexible flatfoot without fixed forefoot supination deformity (stage II). A medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular were done. The patients were examined, radiographs were obtained, and isokinetic evaluation of both feet was performed at a mean of 5.2 years postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale and Short Form Health Surgery (SF-36) were used to evaluate patients postoperatively. RESULTS: The mean AOFAS score at follow-up was 79 points (range, 54-93). There were seven significant complications in six patients. Isokinetic inversion and plantarflexion power and strength were symmetric with the contralateral limb in 95 patients, mildly weak in 18 patients, and moderately weak in eight patients. Subtalar joint motion was normal in 56 (44%), slightly decreased in 66 (51%), and moderately decreased in seven patients (5%). Correction was significant (p < .05) in all four radiographic parameters evaluated. Patients were entirely satisfied (118 patients), partially satisfied (seven patients), or dissatisfied (four patients). Further, 125 (97%) experienced pain relief, 121 (94%) showed improvement of function, 112 (87%) experienced improvement in the arch of the foot, and 108 (84%) were able to wear shoes comfortably without shoe modifications or orthotic arch support. CONCLUSIONS: The surgical correction of stage II posterior tibial tendon deficiency with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications and a high patient satisfaction rate.     

Intermediate term follow-up of calcaneal osteotomy and flexor digitorum longus transfer for treatment of posterior tibial tendon dysfunction

Twenty-three patients with stage II posterior tibial tendon dysfunction who had failed non-surgical therapy were treated with flexor digitorum longus transfer and calcaneal osteotomy. At latest follow-up averaging 35 +/- 7 months (range, 24 to 51 months), 22 patients (96%) were subjectively "better" or "much better." No patient had difficulty with shoe wear; however, four patients (17%) required routine orthotic use consisting of a molded shoe insert. AOFAS scores were available on 21 patients and improved from a preoperative mean of 50 +/- 14 (range, 27 to 85) to a postoperative mean of 89 +/- 10 (range, 70 to 100). Our experience, at an intermediate date follow-up is that calcaneal osteotomy and flexor digitorum longus transfer is a safe and effective form of treatment for stage II posterior tibial tendon dysfunction.     

Medial sliding calcaneal osteotomy with flexor hallucis longus transfer for the treatment of posterior tibial tendon insufficiency.

Medial sliding calcaneal osteotomy is a simple bone procedure to augment tendon transfer in treatment of stage 2 posterior tibial tendon dysfunction. This osteotomy moves the valgus heel under the weight-bearing axis of the leg, shifts the Achilles' insertion medially, and decreases strain on the spring ligament and deltoid ligaments. The osteotomy heals within 6 weeks. Consistently reproducible good-to-excellent results have been achieved using medial sliding calcaneal osteotomy in conjunction with FHL transfer.     

Limited plantar incision for flexor digitorum longus tendon harvest in surgical treatment of tibialis posterior tendon insufficiency

BackgroundSurgical correction of stage II tibialis posterior tendon dysfunction (TPTD) commonly utilises the Flexor Digitorum Longus (FDL) tendon to augment the tibialis posterior tendon. The aim of this study is to present our experience and clinical outcomes harvesting the FDL via a limited plantar incision technique.Methods25 flat foot operations for stage II TPTD were performed harvesting the FDL via a limited plantar incision centred half-way between the base of the heel to the base of the 2nd toe and two-thirds from the lateral border of the foot.ResultsThe FDL was isolated with no inter-tendonous connections requiring surgical division. There were no recorded cases of plantar nerve injury nor any technique-related complications observed.ConclusionsThe plantar harvest technique for FDL is safe, provides a long tendon graft for transfer and limits the need for an extensive medial midfoot dissection.     

Posterior tibial tendon dysfunction. Treatment by flexor digitorum longus transfer

Posterior tibial tendon dysfunction presents the clinician with such a broad spectrum of clinical problems that treatment must be based on the anatomic alignment of the foot as determined by the physical examination. There is no single method to treat PTT dysfunction, but rather a variety of conservative and operative procedures that are based on the pathologic anatomy.     

The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction

BACKGROUND: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). METHODS: Twelve patients were divided into two groups, depending on whether the PT tendon was excised (Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. RESULTS: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. CONCLUSION: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.     

Medial flexor digitorum longus tendon augmentation and lateral foot column lengthening or reorienting triple arthrodesis as surgical therapy of posterior tibial tendon dysfunction

QUESTION: The purpose of this study was to evaluate the alignment and functional outcome after surgical augmentation of the tibialis posterior by tendon transfer and lateral column lengthening by osteotomy of the os calcis, calcaneo-cuboidal arthrodesis or reorientating triple arthrodesis. METHODS: From 1991 to 1999 41 patients with the clinical and radiological diagnosis of dysfunction of the tibialis posterior tendon underwent surgical exploration and repair. These 41 patients (22 women, 19 men) had an average age of 44.3 years (range, 19-69 years) and had been symptomatic for an average of 2.3 years (range, 6 months to 6 years). All patients had the symptoms of a painful flatfoot deformity without dynamic support along the medioplantar aspect. Flexor digitorum longus (FDL) tendon transfer as reconstruction of the tibialis posterior tendon was performed in the cases without major deformity (n = 77). Patients underwent FDL transfer and lengthening osteotomy (n = 15) of the os calcis or calcaneocuboidal (c-c) arthrodesis (n = 12) if passive correction of the foot deformity was still possible and reorientating triple arthrodesis (n = 7) when a fixed flatfoot deformity had developed. AOFAS score and radiological examination were used preoperatively and in the follow-up. RESULTS: The AOFAS score improved for stage 1 patients after a mean follow-up of 43 months with FDL transfer from a preoperative mean of 54 to 84 points, for stage II patients with FDL transfer and lengthening osteotomy (mean follow-up 36 m) from 47 to 92 points, with c-c arthrodesis (follow-up 66 m) from 48 to 86 points, and for stage III patients with triple arthrodesis from 42 to 72 points. In two patients, the deformity failed to improve (stage I) necessitating a revision surgery with a calceneo-cuboidal lengthening arthrodesis for relapsing deformity. CONCLUSION: In order to correct deformity and provide substantial relief of foot pain and dysfunction, we recommend the transfer of the FDL tendon in flexible flat foot deformity together with lengthening osteotomy. This treatment will provide optimal restoration of a dynamic support along the medioplantar aspect of the foot and is functionally superior to a c-c arthrodesis. Reorientating triple arthrodesis showed fair functional results and is recommended--for fixed flatfoot deformity.     

Outcomes of flexor digitorum longus (FDL) tendon transfer in the treatment of Achilles tendon disorders

BackgroundIn patients with chronic Achilles tendon disorders, Achilles tendon debridement can be supplemented with a tendon transfer, with the flexor hallucis longus tendon (FHL) transfer representing the most common used technique. Our study describes clinical and functional results of patients treated with flexor digitorum longus (FDL) tendon transfer in the treatment of patients with chronic Achilles tendon disorders.MethodsRetrospective study of prospectively collected data of thirteen patients (15 feet) that underwent FDL tendon transfer as part of the treatment of chronic Achilles tendon disorders. Preoperative and postoperative assessment included visual analogue score (VAS) for pain, SF-36 survey and lower extremity functional scale (LEFS). The average follow-up was 26.4 (range, 14–56) months. Patients were also assessed for ability to perform single leg heel rise test, muscle power for plantar flexion of the lesser toes, surgical scar condition and associated complications.ResultsAt final follow-up, we found significant postoperative improvement in VAS score (6.6 ± 2.99 vs 1.06 ± 1.43; p < .0001), SF-36 physical component summary (PCS) (28.20 ± 10.71 vs 45.04 ± 11.19; p < .0001) and LEFS (36.13 ± 20.49 vs 58.73 ± 18.19; p < .0001). Twelve patients (92%) could perform a single leg heel rise test in the operated extremity, although there was significant difference when comparing operated and uninvolved sides (4.86 ± 3.36 cm vs 7.18 ± 3.40 cm; p = .0002). One patient reported weakness for plantar flexion of the lesser toes, without balance or gait disturbances. Two patients (2 feet, 13.3%) had superficial infections and one patient (one foot, 6.6%) needed operative debridement for a deep infection.ConclusionsFDL tendon transfer represent an operative alternative in the treatment of chronic Achilles tendon disorders. Our study showed good clinical outcomes with low complications and donor site morbidity.Level of evidenceObservational study, case series – level IV.     

Treatment of stage II posterior tibial tendon dysfunction with flexor hallucis longus transfer and medial displacement calcaneal osteotomy

Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibialis muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination, follow-up time 18 months (ave.). The AOFAS hindfoot score improved from 62.4/100 to 83.6/100. The subjective portion of the AOFAS hindfoot score improved from 31.0/60.0 to 48.9/60. Weightbearing preoperative and postoperative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform, or talonavicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, 6 patients satisfied with minor reservations, and 1 dissatisfied. No patient complained of donor deficit from the harvested FHL tendon. Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial displacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate.     

In situ tibialis posterior to flexor digitorum longus tendon transfer for tibialis posterior tendon dysfunction: a simplified surgical approach with outcome of 11 patients.

Outcomes for 11 patients who underwent an in situ tibialis posterior tendon to flexor digitorum longus tendon side-to-side anastamosis as the sole procedure for stage 2 tibialis posterior tendon dysfunction were reviewed. The average follow-up was 34.4 months. Using the American Orthopedic Foot and Ankle Society hindfoot rating scale, a mean improvement of 39.3 points was achieved, with preoperative scores of 38.8 improving to 78.1 postoperatively. Good to excellent results were achieved in nine patients. The in situ side-to-side anastamosis is technically easier to perform, has less tissue trauma, and compares favorably with other soft-tissue procedures and reconstructions for stage 2 tibialis posterior tendon dysfunction. Performing this transfer alone, while leaving the flexor digitorum longus tendon intact, theoretically provides a stronger transfer as the length-tension relationship of the flexor digitorum longus tendon is maintained near its physiologic level. The procedure can consistently restore inversion ability to the rearfoot and stop the progression of tibialis posterior tendon dysfunction.     

Influence of tendon transfer site on moment arms of the flexor digitorum longus muscle

BACKGROUND: Adult acquired flatfoot is a common condition that leads to significant morbidity. Along with bony procedures to operatively treat this condition, transfer of the flexor digitorum longus (FDL) tendon to the medial cuneiform or navicular is routinely performed. The goal of this tendon transfer is to increase the capacity of the FDL to invert the hindfoot and control the transverse tarsal joints. However, it is not known whether this biomechanical goal is met or whether one transfer site produces a larger mechanical advantage compared to another site. The purpose of this study was to calculate FDL muscle moment arms at the hindfoot with two clinically relevant transfer locations to quantify the change in mechanical advantage of the FDL after tendon transfer. METHODS: In seven cadaver specimens, muscle moment arms of the FDL with respect to hindfoot motion were measured using the tendon excursion method before and after the FDL was transferred to the plantar aspect of the navicular and medial cuneiform. The position and orientation of the foot and excursion of the FDL tendon were measured with an optoelectronic measurement system. RESULTS: The FDL moment arm did not increase after tendon transfer to either the medial cuneiform or navicular when compared to its native site. There were significant decreases in FDL moment arm when transferred from its native site to the medial cuneiform (56% decrease, p=0.018) and navicular (46% decrease, p=0.026). CONCLUSIONS: In contrast to the clinical proposition that FDL transfer to the navicular or medial cuneiform increases this muscle's mechanical advantage to invert the hindfoot, this cadaver study suggests that, to the contrary, FDL muscle moment arms decrease after tendon transfer.     

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: a middle-term clinical follow-up.

HYPOTHESES/PURPOSE: The medial displacement calcaneal osteotomy has recently become a popular addition to flexor digitorum longus transfer for stage II posterior tibial tendon dysfunction. We reviewed the results of 26 patients who had undergone the procedure at an average of 32 months prior to follow-up (range 12 to 70 months) with particular attention to objective functional parameters. CONCLUSIONS/SIGNIFICANCE: FDL transfer and medial displacement calcaneal osteotomy provides good functional and symptomatic results in the middle-term. The operation preserves the majority of subtalar motion and is objectively durable as assessed by the continued ability to perform a single-leg toe rise. Although moderate radiographic improvement in the arch is frequent, often patients fail to notice this clinically. A prolonged period of steady improvement in symptoms after surgery is common. SUMMARY OF METHODS/RESULTS: Between 1993 and 1998, 26 patients underwent flexor digitorum longus transfer and medial displacement calcaneal osteotomy performed by the senior author. Sixteen returned for the study and were seen for physical exams. Three were included on the basis of chart review including one who was deceased and two who could not be contacted. Five further patients included on the basis of chart review were also contacted for telephone interviews. For the survival analysis, however, their last physical examination was used as the follow-up date. Two patients who had early technical failures were not interviewed but were counted as early failures of the procedure in the survival analysis. Functionally, all patients except three could perform a single-leg toe rise at follow-up, a maneuver none could perform preoperatively. Of these three, two cases were technical failures with loss of fixation of the FDL transfer early in the postoperative course, ultimately requiring revision procedures including one subtalar fusion. Another patient was a late failure after developing increasing pain and weakness during a pregnancy 69 months after the procedure. Clinically assessed subtalar motion remained 81 +/- 15% of the contralateral side in those patients with unilateral disease. Although improvement in the radiographic alignment of the foot was commonly noted, only 50% of patients felt the conformation of their foot had noticeably changed, and only one (4%) felt the improvement to be significant. Pain relief was rated excellent by 75% and good by 16%; the average AOFAS Hindfoot pain subscale score was 35.2 (out of 40 possible). Function was felt to be markedly improved by all patients except the three who were unable to perform a single-leg toe rise. The average score for the four functional symptom categories of the AOFAS score was 26.8 (out of 28 possible). Most patients noted that although they were able to perform daily activities after their postoperative immobilization was liberalized, there was a prolonged period of steady improvement in symptoms and function after surgery. The median length of time to self-rated maximal medical improvement was 10 months.     

Simultaneous rupture of the tibialis posterior and flexor digitorum longus tendons in a closed tibial fracture

An interposition of ruptured tendons of the tibialis posterior and flexor digitorum longus occurred between the lower third tibial fracture fragments in a closed tibial fracture in a 26-year-old man. The tendon ruptures were not diagnosed preoperatively but were recognized at the time of open reduction. The tendons were repaired and the fracture internally fixed. Six months postoperatively, the patient had a 10 degree dorsal extension deficit in the ankle joint, the motion was painless, and the strength of the posterior tibial compartment muscles was grade 5.     

Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-II dysfunction of tibialis posterior. Three- to five-year results

The treatment of acquired flat foot secondary to dysfunction of the posterior tibial tendon (PTT) of stage II, as classified by Johnson and Strom, remains controversial. Joint sparing and soft-tissue reconstructive procedures give good early results, but few studies describe those in the medium-term. We studied prospectively the outcome of surgery in 51 patients with classical stage-II dysfunction of the PTT treated by a medial displacement calcaneal osteotomy and transfer of the tendon of flexor digitorum longus. We reviewed 44 patients with a mean follow-up of 51 months (38 to 62). The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot rating scale improved from 48.8 before operation to 88.5 at follow-up. The operation failed in two patients who later had a calcaneocuboid fusion. The outcome in 43 patients was rated as good to excellent for pain and function, and in 36 good to excellent for alignment. There were no poor results.     

Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer

Fourteen patients were treated by flexor digitorum superficialis transfer for irreparable flexor pollicis longus lesions. Results measured by return of interphalangeal joint motion were good in 12 patients, with one patient achieving a fair result and one failure. This is a reliable procedure in thumbs with a grade I or II (Boyes) tendon bed and should be considered as an alternative to free tendon grafting for reconstruction in patients in whom return of interphalangeal motion is desirable.