胫后肌腱功能障碍的手术治疗

目的探讨胫后肌腱功能障碍的手术治疗方法。方法2002年12月至2005年6月,手术治疗8例单侧胫后肌腱功能不良患者,男2例,女6例;年龄36～56岁,平均47岁。左足6例,右足2例;胫后肌腱功能不良Ⅱ期2例,Ⅲ期6例。根据Maryland足部评分标准,术前足踝功能为可2例、差6例。对每例患者设计个体化手术方案,联合应用足外侧柱延长术、关节融合术、胫后肌腱修复术、弹簧韧带紧缩术及趾长屈肌腱转移术等术式。骨性手术一般辅以一种以上相关的软组织手术,其中4例行胫后肌腱前移加强术,2例行弹簧韧带紧缩术,4例行趾长屈肌腱转移术。术后以短腿管型石膏将患足固定于内翻跖屈位,4～6周后改用短腿后托石膏将患足于中立位继续固定4周,拆除外固定后,根据骨愈合情况逐渐开始负重训练。结果全部病例均获得随访,随访时间12～40个月,平均28个月。根据Maryland足部评分标准,术后优4例、良3例、可1例,优良率为87.5%。所有患者术后足外形均恢复良好,能穿普通鞋。术后X线片测量的足弓高度及提示前足外展、后足外翻畸形矫正程度的特异性角度明显改善(P<0.01),其中弓高平均增加8mm,侧位距跟角平均减少14°,前后位距跟角平均减少12°,侧位第一跖距角平均减少17°,跟骨倾斜角平均增加11°,距舟覆盖角平均减少6°。结论骨性手术结合软组织手术组成的个体化联合术式治疗胫后肌腱功能不良可获得较理想的疗效。     

Arthrodesis for chronic lateral subtalar joint dislocation caused by posterior tibial tendon dysfunction: A case report

IntroductionAdult acquired flatfoot deformity (AAFD) caused by posterior tibial tendon dysfunction (PTTD) can lead to the development of peritalar subluxation (PTS) and much more rarely to lateral subtalar dislocation.Presentation of caseA 75-year-old woman was referred to our hospital with an approximately 15-year history of pain in her right foot without obvious trauma. The lateral shifting foot deformity had worsened in the previous 5 years. On presentation, she had tenderness over the talonavicular joint, and the skin overlying the talar head on the medial foot was taut. Imaging revealed lateral displacement of the calcaneus with simultaneous dislocation of the talonavicular and talocalcaneal joints. We diagnosed lateral subtalar dislocation including the talonavicular and talocalcaneal joints caused by PTTD, which we treated by reduction and fusion of the subtalar joint complex. The foot and ankle were immobilized with a cast for 6 weeks.DiscussionAt the 1-year follow-up visit, the patient reported no pain during daily activities, although flatfoot persisted.ConclusionWe report a rare case of chronic lateral subtalar dislocation caused by PTTD that was treated by fusion of the talonavicular and talocalcaneal joints.     

Lateral column osteotomy versus subtalar arthroereisis in the correction of Grade IIB adult acquired flatfoot deformity: A clinical and radiological follow-up at 24 months

BackgroundAdult acquired flat foot deformity (AAFD) is a spectrum of conditions which can be progressive if untreated. Surgical correction and restoration of anatomical relationship are often required in the treatment of symptomatic Grade II AAFD after a failed course of conservative treatment. There is a paucity of literature recommending best practice–especially in the adult population. The authors aim to compare radiological and clinical outcomes of two widely employed surgical techniques in the treatment of symptomatic AAFD.MethodsA retrospective study of 76 patients with Grade IIB AAFD and had undergone either lateral column lengthening (LCL) or subtalar arthroereisis (STA) surgical correction of their symptomatic AAFD. Each technique was augmented with both bony osteotomy and soft tissue transfer as determined by on table assessment. Clinical and radiological outcomes were reviewed 24 months after surgery.ResultsLCL and STA groups had comparable radiological outcomes at 24 months after surgery. However, LCL group demonstrated superior American Orthopaedic Foot and Ankle Society (AOFAS) midfoot (90.3 ± 12.6 vs 81.1 ± 20.6, p < 0.001) as well as Visual Analogue Scale (VAS) midfoot scores (0.5 ± 1.6 vs 1.3 ± 2.4, p < 0.001) at 24 months compared to the STA group. STA had a higher complication rate (20.6% vs 4.4%), with all cases complaining of sinus tarsi pain requiring subsequent removal of implant.ConclusionThere is a role for either techniques in the treatment of symptomatic AAFD. LCL whilst more invasive has demonstrated superior outcome scores and lower complication rates at 24 months compared to STA. Patients need to be counselled appropriately to appreciate the benefits of each technique.     

距下关节制动矫治儿童平足症的应用进展

目的总结距下关节制动术在儿童平足症中的应用进展,分析存在的问题及进一步研究方向。方法查阅近年国内外距下关节制动术在儿童平足症中应用的相关文献,进行总结分析。结果距下关节制动术技术成熟、操作简便、并发症少,对于有手术指征的儿童平足症疗效确切。结论距下关节制动术是治疗儿童平足症有效方法之一,但其详细生物力学机制及相关并发症的应对策略仍需进一步明确。     

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.     

Alternative treatment of posterior tibial tendon dysfunction

Posterior tibial tendon insufficiency is a well-recognized entity. Treatment of this condition, however, is controversial.The process has been categorized into three surgical stages. Stage I disease is usually treated with tenosynovectomy and release of the sheath and retinaculum after failure of conservative methods. Stage II disease is treated with various tendon transfers with or without calcaneal osteotomy, and Stage III disease is most often treated with arthrodesis. This article presents a review of the various historical, physical and radiographic findings associated with this condition. In addition, an alternative approach to the surgical treatment of stage I or II posterior tibial insufficiency is presented. The procedure involves tenosynovectomy, tendon repair, deepening of the tendon groove, and pulley reconstruction. The procedure is simple, requires minimal postoperative immobilization, and by 6 weeks, patients have regained full motion and are able to ambulate with full weight bearing.     

副舟骨切除胫后肌腱止点重建跟骨内移截骨术治疗与副舟骨相关的平足症

 目的 探讨副舟骨切除胫后肌腱止点重建跟骨内移截骨术治疗与副舟骨相关的平足症的临床疗效。方法 2009年3月至2011年10月,采用副舟骨切除胫后肌腱止点重建跟骨内移截骨术治疗与副舟骨相关的平足症13例(16足),男4例,女9例;年龄18～64 岁,平均41.3岁。单足10例,双足3例;均有明显的跟骨外翻。术后以美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分评估后足功能,于X线片上测量足弓高度、跟骨倾斜角(CI)、距跟角(TC)、距骨-第一跖骨角(TMT)。结果 13例均获得随访,随访时间12~31个月,平均16.8个月。术后6个月时11例(13足)无任何疼痛,2例(3足)有长距离行走后足部疼痛。术后随访时AOFAS评分从术前(52.4±6.4)分提高至(88.1±2.8)分;负重侧位X线片上足弓高度从(3.8±0.3) mm提高至(12.0±1.1) mm,CI从9.5°±1.1°提高至20.1°±1.5°,TC从47.3°±2.5°改善至32.3°±2.5°,TMT从17.6°±1.6°改善至6.8°±1.0°;负重正位X线片上TC从39.5°±2.3°改善至26.2°±2.0°,TMT从15.2°±1.7°改善至6.3°±1.0°;轴位X线片上跟骨外翻角从11.3°±1.4°改善至4.2°±2.0°。结论 对与副舟骨相关的平足症的治疗,当存在后足外翻畸形时,副舟骨切除胫后肌腱止点重建跟骨内移截骨术可以明显缓解疼痛,有效矫正畸形,近期疗效良好。     

Tendoscopy of the posterior tibial tendon

An anatomic cadaver study was performed and subsequently, in a prospective study, diagnostic and therapeutic tendoscopy (tendon sheath endoscopy) was performed in 16 consecutive patients with a history of persistent posteromedial ankle pain for at least 6 months. All patients had pain on palpation over the posterior tibial tendon, a positive tibial tendon resistance test, and local swelling. The indications were diagnostic procedure after surgery in 5 patients, diagnostic procedure after fracture in 5, diagnostic after trauma in 1, chronic tenosynovitis in 2, screw removal in 1, and posterior ankle arthrotomy in 2 patients. Inspection and surgery of the complete tendon and its tendon sheath can be performed by a standard two-portal technique. A new finding is the vincula that was consistently present in all our autopsy specimens as well as all our patients. At 1-year follow-up, 3 of the 4 patients in whom resection of a pathological thickened vincula, and 2 patients in whom tenosynovectomy and tendon sheath release were performed, were free of symptoms. Other procedures such as removal of adhesions and screw removal could well be performed. In 2 patients with a posteromedially located loose body, successful removal took place by means of a posterior tibial tendoscopic approach. There were no complications.     

Use of the Maxwell-Brancheau arthroereisis implant for the correction of posterior tibial tendon dysfunction.

Successful management of the flexible flatfoot deformity relies not only on correcting causal factors, but also on addressing the adaptive changes that have occurred and any coexisting deformities present. The three primary goals of any therapy--relief of pain, biomechanical control of excessive pronation, and prevention of the progression of the deformity--should be considered. With thorough assessment of causal factors and planal dominance of the deforming and compensative forces, one can expect to increase the predictability and success of the surgical management of PTTD in the flexible adult flatfoot deformity.     

Adult flatfoot/posterior tibial tendon dysfunction: Outcomes analysis of surgical treatment utilizing an algorithmic approach

A new classification scheme is presented along with an algorithmic surgical approach to the treatment of posterior tibial tendon dysfunction (PTTD). This classification scheme treats as separate entities the soft-tissue and osseous components of PTTD. The soft-tissue pathology is staged from tendinitis to tendinosis to that of complete rupture. The osseous element is graded as no planar deformity, reducible planar deformity, or rigid planar deformity. The stage of soft-tissue pathology is then combined with the grade of the osseous condition, leading to a comprehensive surgical treatment plan. Based on this classification, 13 patients were retrospectively evaluated. Only those patients falling into a specific classification (2A and 2B) were included in this analysis. The American Orthopedic Foot and Ankle Society clinical hindfoot-ankle scale was utilized. The mean preoperative clinical rating was 32.8. The mean postoperative clinical rating was 88.0. Pre- and postoperative radiographic criteria were also analyzed. Overall patient satisfaction utilizing this treatment algorithm was good to excellent.     

The Cobb procedure for stage II posterior tibial tendon dysfunction.

Flexor digitorum longus transfer or augmentation is currently the most popular adjunctive procedure for the repair of an attenuated or ruptured tibialis posterior tendon. Although the procedure is efficacious, an important functional muscle is sacrificed. Results show that similar results can be achieved with a tenodesis procedure by way of a split anterior tibial tendon repair. The authors have modified the Cobb procedure, and do not create a hole through the medial cuneiform or navicular. The thick, fibrous periosteal tissue at the medial aspect of the cuneiform is a sufficient tunnel for securing and positioning the tibialis anterior tendon. An additional site of healing and potential complications are avoided. The Cobb procedure is a useful and successful treatment option for PTTD, provides strong autograft augmentation to the posterior tibial tendon without sacrificing function of other tendons, and offers the surgeon and patient predictable outcomes with long-term satisfaction.     

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.

A comparison of outcomes of posterior arthroscopic subtalar arthrodesis with or without bone graft for treatment of subtalar arthritis

BackgroundIt remains unclear whether to perform a bone graft is necessary during posterior arthroscopic subtalar arthrodesis. The present research aimed to comparatively analyze the outcomes of arthroscopic subtalar arthrodesis through a 3-portal posterior approach with or without bone graft.MethodsA total of 93 patients with subtalar arthritis who underwent posterior arthroscopic subtalar arthrodesis were retrospectively examined. The patients were divided into two groups according to whether they received bone graft or not. The clinical outcomes were compared for analysis.ResultsAmong the 93 patients included, 53 received bone graft and 40 did not. The union rate and time to osseous fusion suggested no significant difference between the two groups. The improvement of clinical outcomes were comparable between the two groups at the final follow-up.ConclusionsIn the present study, bone graft could not effectively reduce the risk of nonunion and improve the outcome.     

胫后静脉一期动脉化治疗下肢动脉广泛闭塞

应用在下肢闭塞以上正常动脉与腓静脉入口远侧胫后静脉之间搭桥及破坏胫后静脉远侧瓣膜的方法．一期完成胫后静脉动脉化，用于治疗下肢动脉广泛性闭塞病变15例（17肢），术后观察1～10年，除2例（2肢）又分别行截肢及带蒂网膜移植外。其余15肢效果良好。本法具有手术可一期完成、适应证广、对静脉回流影响小和缺血症状解除快等优点。     

Flexor digitorum longus transfer and medial displacement calcaneal osteotomy for the treatment of stage II posterior tibial tendon dysfunction: kinematic and functional results of fifty one feet

Purpose

Stage II posterior tibial tendon dysfunction (PTTD) can be treated by flexor digitorum longus (FDL) tendon transfer and medial displacement calcaneal osteotomy (MDCO). Numerous authors have studied the clinical and radiographic results of this procedure. However, little is known about the kinematic changes. Therefore, the purpose of this study was to assess plantar-pressure distribution in these patients.

Methods

Seventy-three patients with PTTD stage II underwent FDL tendon transfer and MDCO. Plantar pressure distribution and American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed 48 months after surgery. Pedobarographic parameters included lateral and medial force index of the gait line, peak pressure (PP), maximum force (MF), contact area (CA), contact time (CT) and force-time integral (FTI).

Results

In the lesser-toe region, PP, MF, CT, FTI and CA were reduced and MF in the forefoot region was increased. These changes were statistically significant. We found statistically significant correlations between AOFAS score and loading parameters of the medial midfoot.

Conclusions

Study results reveal that FDL tendon transfer and MDCO leads to impaired function of the lesser toes during the stance phase. However, there seems to be a compensating increased load in the forefoot region.     

Medial displacement calcaneal osteotomy versus lateral column lengthening to treat stage II tibialis posterior tendon dysfunction,a prospective randomized controlled study

PurposeAdult-acquired flatfoot deformity (AAFD) requires optimum planning that often requires several procedures for deformity correction. The objective of this study was to detect the difference between MDCO versus LCL in the management of AAFD with stage II tibialis posterior tendon dysfunction regarding functional, radiographic outcomes, efficacy in correction maintenance, and the incidence of complications.Patient and methods42 Patients (21 males and 21 females) with a mean age of 49.6 years (range 43–55), 22 patients had MDCO while 20 had LCL. Strayer procedure, spring ligament plication, and FDL transfer were done in all patients. Pre- and Postoperative (at 3 and 12 months) clinical assessment was done using AOFAS and FFI questionnaire. Six radiographic parameters were analyzed, Talo-navicular coverage and Talo-calcaneal angle in the AP view, Talo- first metatarsus angle, Talo-calcaneal angle and calcaneal inclination angle in lateral view and tibio-calcaneal angle in the axial view, complications were reported.ResultsAt 12 months, significant improvement in AOFAS and FFI scores from preoperative values with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups were maintained at 12 months. However, the calcaneal pitch angle and the TNCA were better in the LCL at 12 months than MDCO, 17̊ ± 2.8 versus 13.95̊ ± 2.2 (p = 0.001) and 13.70̊ ± 2.2 versus 19.05̊ ± 3.2 (p < 0.001) respectively. 11 patients (26.2%) had metal removal, seven (16.6%) in the MDCO, and four (9.6%) in the LCL. Three (7.1%) in the LCL group had subtalar arthritis, only one required subtalar fusion.ConclusionLCL produced a greater change in the realignment of AAFD, maintained more of their initial correction, and were associated with a lower incidence of additional surgery than MDCO, however, a higher incidence of degenerative change in the hindfoot was observed with LCL.     

Triple arthrodesis and subtalar joint arthrodesis. For the treatment of end-stage posterior tibial tendon dysfunction.

The current literature clearly supports the use of subtalar and triple arthrodeses for the treatment of end-stage PTTD. There is debate, however, regarding whether or not an isolated fusion is preferable to the triple arthrodesis. Complete evaluation of the patient's deformity and symptoms is imperative before choosing to perform a rearfoot fusion. If the deformity can be isolated to the STJ, then perhaps a limited fusion is appropriate. With the close interrelationship of the subtalar and midtarsal joints, however, it is the authors' opinion that chronic dysfunction of the posterior tibial tendon infrequently causes isolated STJ pathology. Perhaps earlier intervention in the process of tendon degeneration, before multiple joint adaptations, would warrant an isolated fusion. We anticipate further research into the advantages of STJ and double arthrodeses over the triple arthrodesis. Clearer identification of the patients in whom these limited fusions are warranted is necessary, especially with respect to adult flatfoot secondary to PTTD. Currently, isolated and combined hindfoot fusions continue to be valuable salvage procedures in the treatment of end-stage arthritic deformities.     

胫骨去后倾化截骨在合并后倾角异常增大患者前交叉韧带翻修术中的临床应用北大核心CSCD

目的探讨胫骨去后倾化截骨加前交叉韧带(anterior cruciate ligament,ACL)翻修术治疗ACL初次重建术后失效合并胫骨平台后倾角(posterior tibial slope,PTS)异常增大患者的临床疗效。方法回顾分析2018年1月—2020年1月收治且符合选择标准的9例ACL初次重建术后失效合并PTS异常增大(≥17°)患者的临床资料。男8例,女1例;年龄21~42岁,中位年龄30岁。9例患者Lachman试验均为阳性;轴移试验阴性6例,Ⅰ度阳性2例,Ⅱ度阳性1例。PTS为(17.78±1.09)°、胫骨平台前移距离(anterior tibial translation,ATT)为(11.58±1.47)mm。国际膝关节文献委员会(IKDC)评分为(51.0±3.8)分,Lysholm评分为(49.7±4.6)分、Tegner评分为(3.7±0.7)分。初次重建至翻修时间为12~33个月,平均19.6个月。采用胫骨去后倾化截骨加ACL翻修术治疗。术后采用IKDC评分、Lysholm评分及Tegner评分评价膝关节功能改善情况,行Lachman试验、轴移试验评价膝关节稳定性,测量PTS及ATT观察膝关节形态学变化。结果术后切口均Ⅰ期愈合,未出现切口感染、脂肪液化、坏死以及下肢深静脉血栓形成、神经血管损伤等并发症。9例患者均获随访,随访时间12~36个月,平均25.8个月。末次随访时Lachman试验和轴移试验均为阴性。IKDC评分为(85.0±4.0)分、Lysholm评分为(87.7±2.8)分、Tegner评分为(6.8±0.7)分,PTS减小至(9.89±0.60)°,ATT缩短至(0.91±0.29)mm,与术前比较差异均有统计学意义(P<0.05)。结论胫骨去后倾化截骨加ACL翻修术治疗ACL初次重建术后失效合并PTS异常增大患者早期临床疗效明确,在改善膝关节稳定性同时可较好地维持正常膝关节形态。     

副舟骨切除结合胫后肌腱止点前置重建治疗副舟骨源性平足症

目的探讨副舟骨切除结合胫后肌腱止点前置重建治疗副舟骨源性平足症的方法及临床疗效。方法 2006年5月-2011年6月,收治33例(40足)经6个月以上保守治疗无效的副舟骨源性平足症患者。男14例(17足),女19例(23足);年龄16～56岁,平均30.1岁。均有双侧副舟骨,其中单侧发病26例,双侧7例。出现平足症状至入院时间为7个月～9年,中位时间24个月。中足功能采用美国矫形足踝协会(AOFAS)评分标准评定为(47.9±7.3)分。X线片检查示,均有足部Ⅱ型副舟骨,足弓高度不同程度丢失,均伴后足轻度畸形。术中切除副舟骨,行胫后肌腱止点前置带线锚钉重建术治疗。结果术后患者切口均Ⅰ期愈合,无相关并发症发生。术后30例(36足)患者获随访,随访时间6～54个月,平均23个月。患者术后6个月足部疼痛均消失,足部外观明显改善。末次随访时中足功能AOFAS评分为(90.4±2.0)分,与术前比较差异有统计学意义(t=29.73,P=0.00)。X线片检查,均无内固定锚钉松动、断裂等发生;足弓高度、跟骨倾斜角、跟距角及距骨-第1跖骨角与术前比较,差异均有统计学意义(P<0.01)。结论采用副舟骨切除结合胫后肌腱止点前置重建治疗副舟骨源性平足症可有效纠正平足畸形,足功能恢复好,并发症少。     

Conservative management of posterior tibial tendon dysfunction, subtalar joint complex, and pes planus deformity.

Conservative management of PTTD can present from fairly simple to quite complex based on the wide range of clinical presentation that is inherent to this pathology. Treatment for PTTD ranges from the use of orthopedic footwear to the use of PTB AFOs, which certainly substantiates the prevalence of this disorder and the high rate of conservative management. With the increase in the population number and the fitness and health awareness that pervades our society, PTTD will more than likely continue to be a large part of the conservative footcare practitioner's practice in the future. The footcare team should include the pedorthist and orthotist to care for all the stages of PTTD. Perhaps with the increase in popularity of comfort footwear and increased use of orthoses (over the counter and custom-made), physicians can deter and alter the established pathway of the progression of this disorder. Preventive measures may, in some way, affect the foot health of the aging population. Conservative management of PTTD certainly has a place in today's healthcare climate.