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.     

The medial approach to triple arthrodesis. Indications and technique for management of rigid valgus deformities in high-risk patients

Between 1995 and 2002 the authors treated 17 patients who had a rigid hindfoot valgus deformity, and for whom a triple arthrodesis was planned, using a single medial incision. The indication for surgery was pain that was refractory to shoe wear, orthotic, and brace modifications. The severity of the hindfoot deformity itself was not a sufficient indication for this procedure. All 17 patients were examined a mean of 3.5 years following surgery (1-8 years). Subtalar and talonavicular arthrodesis was achieved in all patients and calcaneocuboid arthrodesis was achieved in 15 of 17 patients (2 asymptomatic pseudoarthrosis). The medial approach to triple arthrodesis is a reliable procedure, and can be used with a predictable outcome in patients who are at risk for wound healing complications for correction of hindfoot valgus deformity.     

Complete tendon transfer and inverse Lambrinudi arthrodesis: preliminary results of a new technique for the treatment of paralytic pes calcaneus

BACKGROUND: Paralytic pes calcaneus is commonly associated with myelomeningocele and continues to be one of the most difficult deformities to treat. The purpose of the present study is to describe and report the preliminary results of a new procedure to dynamically correct paralytic pes calcaneus. MATERIALS AND METHODS: Since 2002, the senior surgeon operated on six patients with myelomeningocele and developed a new procedure to dynamically correct paralytic pes calcaneus. This new procedure combines a complete tendon transfer (tibialis anterior and posterior, peroneus brevis and longus, and extensor digitorum and hallucis longus) to the Achilles tendon and an additive triple arthrodesis. The extent of the calcaneus deformity was evaluated by measuring the talocalcaneal angle. The mean followup was 32 months. RESULTS: Excellent results were achieved in five of the six patients with a mean age of 17.5 years. Using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale, pain and function improved from an average of 41.6 preoperatively to 72.0 postoperatively. The deformity as assessed by the talocalcaneal angle, the calcaneal pitch, and the talometatarsal I angle improved after surgery significantly (p < 0.004). After 12 months, an additional surgery was required in two patients due to disabling drop-foot. CONCLUSION: This new surgical technique to correct paralytic pes calcaneus including complete tendon transfer and triple arthrodesis is promising. Although this is a technically demanding procedure, it provides an excellent functional result without the residual complications associated with ankle arthrodesis.     

Cadaveric flatfoot model: Ligament attenuation and Achilles tendon overpull

Flatfoot deformity is characterized by loss of the medial longitudinal arch, forefoot abduction, hindfoot eversion, and often Achilles tendon contracture. Our objectives were to validate a cadaveric flatfoot model that involves selective ligament attenuation and to determine if Achilles tendon overpull is associated with increased pes planus severity. We measured the three‐dimensional (3D) orientation of the bones of interest in the unloaded, loaded, and Achilles tendon overpull conditions. A flatfoot model was created by attenuating ligaments involved in the pes planus deformity followed by cyclic axial loading, and bone orientations were acquired in the three conditions. Significant differences seen between normal feet and flat feet were consistent with those seen with the pes planus deformity. The first metatarsal dorsiflexed and abducted relative to the talus. The navicular abducted relative to the talus. The calcaneus everted relative to the tibia. The talus plantar flexed and adducted. Achilles overpull resulted in first metatarsal‐to‐talus dorsiflexion and navicular‐to‐talus abduction. Thus, selective ligament attenuation followed by cyclic axial loading can create a cadaveric flatfoot model consistent with the in vivo deformity. Longitudinal arch depression, hindfoot eversion, talonavicular joint abduction, forefoot abduction, and talar plantar flexion were seen. Simulated Achilles tendon contracture increased the severity of the deformity, particularly in arch depression and forefoot abduction. © 2009 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:1547–1554, 2009     

Intermediate follow-up on the double osteotomy and tendon transfer procedure for stage II posterior tibial tendon insufficiency

26 patients with 28 pes planovalgus feet secondary to Johnson stage 2 posterior tibial tendon insufficiency were treated with flexor digitorum longus tendon transfer, lateral column lengthening, medial displacement calcaneal osteotomy, and heel cord lengthening. The mean patient age at surgery was 48.5 years. The AOFAS ankle-hindfoot scale was applied postoperatively to assess clinical outcome. Preoperative and postoperative standing radiographs of the foot and ankle were analyzed to determine radiographic correction of the pes planovalgus deformities. The mean follow-up to date is 5 years. The mean ankle-hindfoot score was 90 postoperatively. The medial cuneiform to fifth metatarsal distance improved from -0.2 mm preoperatively to 7.6 mm postoperatively. Similarly, the talonavicular distance improved from 19.4 mm preoperatively to 10.9 postoperatively. There were no nonunions. Four feet (14%) displayed radiographic signs of calcaneocuboid arthritis at follow-up. Only one was symptomatic requiring calcaneocuboid joint fusion. The double osteotomy technique provides symptomatic relief and lasting correction of the pes planovalgus deformity associated with stage 2 posterior tibial tendon insufficiency at intermediate follow-up. It has a high patient satisfaction based on the AOFAS ankle-hindfoot scale and radiographic measurements demonstrate maintenance of correction of the adult acquired flatfoot.     

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。     

Anatomical reconstruction of the spring ligament using peroneus longus tendon graft

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

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

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

Posterior tibial tendon insufficiency. Isolated fusion of the talonavicular joint

In selected patients, fusion of the talonavicular joint can be an effective treatment of adult flatfoot deformity. Restriction of motion and altered hindfoot mechanics, however, are a consequence of talonavicular fusion and can lead to accelerated arthrosis of adjacent joints. In patients with severe long-standing deformity, medial displacement calcaneal osteotomy may be a necessary adjunct to talonavicular fusion for adequate correction of heel valgus.     

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。     

Modifizierte Arthrodese nach Lambrinudi mit zus?tzlichem Transfer der Tibialis-posterior-Sehne zur Behandlung des adulten Fallfu?es

Objective

Treatment of adult instable drop foot by modified Lambrinudi arthrodesis (removal of a wedge between the talus and calcaneus), followed by a posterior tibial tendon transfer to the medial cuneiform in order to provide active dorsiflexion.

Indications

Severe drop foot (of various etiologies) in combination with hindfoot instability. Sufficient function of the posterior tibial muscle.

Contraindications

Neurologic dysfunction of the posterior tibial muscle, infection of foot/hindfoot, Charcot arthropathy, and insufficient patient compliance.

Relative contraindications

Previous surgery of posterior tibial tendon, critical soft tissues/skin conditions, insufficient neurovascular conditions.

Surgical technique

Lateral skin incision. Debridement of sinus tarsi and removal of the bifurcate ligament to expose the subtalar, calcaneocuboidal, and talonavicular joints. Resection of a bone wedge from the calcaneus and talus (25?C30°) to correct the drop foot deformity. Cartilage removal from the calcaneocuboid joint. Debridement of both the talar head and the navicular to allow adequate fitting. After reduction (neutral dorsiflexion and 10° foot abduction), preliminary fixation with Kirschner wires. Final fixation with canulated screws (talonavicular, calcaneocuboidal, and subtalar joints). Medial skin incision at the navicular tuberositas to deattach the posterior tibial tendon with a bony fragment. The tendon stump is harvested 10?cm proximal to the tibiotalar joint. Small skin incision at the anterolateral aspect of the distal lower leg. The posterior tibial tendon is transferred through the interosseous membrane and reattached to the medial cuneiform with a screw.

Postoperative management

Immobilization with a removable short leg cast for 2?C4?days. Ambulation with full weightbearing in a cast for 8?weeks. Radiographic assessment 8?weeks postoperatively. After bony healing, mobilization in normal shoes is allowed. Intensive physiotherapy to train the dorsiflexion.

Results

The average correction of drop foot deformity was 18.7°. Active dorsiflexion increased significantly from 30° preoperatively to 10° postoperatively.     

Isolated Medial Incisional Approach to Subtalar and Talonavicular Arthrodesis

Triple arthrodesis is commonly used to correct complex deformity with hindfoot valgus. The authors use an isolated medial incisional approach for subtalar and talonavicular joint arthrodesis to correct hindfoot deformity, including high degrees of hindfoot valgus. To assess outcomes achieved with this approach, we reviewed the records of 45 patients from the practices of 5 surgeons. Independent variables evaluated included patient age, primary pathology, use of biologic agents, operative time, time to union, and complications. The median patient age was 57 years (range, 14-78 years). Pathology leading to fusion included 27 (60%) posterior tibial tendon dysfunction, 6 (13.3%) tarsal coalition, 7 (5.5%) degenerative joint disease, 2 (4.4%) rheumatoid arthritis, and 1 (2.2%) each, with Charcot neuroarthropathy, multiple sclerosis, and poliomyelitis. Orthobiological materials were used in 27 (60.0%) of the patients. The median duration of surgery was 87 minutes (range, 65-164 minutes), and the median time to successful arthrodesis was 8 weeks (range, 6-20 weeks). A complication was observed in 6 (13.3%) of the patients, including 1 each of the following: painful calcaneal-cuboid joint, talar fracture, incision dehiscence, poor exposure that required abandonment of the procedure, elevated first ray, and painful fixation. None of the patients experienced a nonunion or an adverse event related to the medial neurovascular structures. Based on our experience with the procedure, the single medial–incision subtalar and talonavicular joint arthrodesis is a useful alternative to triple arthrodesis for the correction of hindfoot valgus deformity.     

Surgical treatment of acquired flatfoot deformity: what is the state of practice among academic foot and ankle surgeons in 2002?

PURPOSE: This study was performed to review the present approach to the surgical treatment of acquired flatfoot deformity among a cross section of academic foot and ankle surgeons in the United States. METHODS: A typical case of stage II posterior tibial tendon dysfunction was developed. The hypothetical patient was a healthy 62-year-old male with a symptomatic acquired flatfoot deformity with posterior tibial tendon dysfunction. Nonoperative management had failed. A series of academic foot ankle surgeons were surveyed to identify their proposed operative treatment. Each surgeon surveyed was affiliated with an orthopaedic residency program and was directly responsible for teaching orthopaedic residents. Each surgeon had foot and ankle patients as the major component of their practice. The overall response rate was 81% (104/128). RESULTS: Ninety-seven percent (101/104) of respondents reported that they would employ some type of bony procedure in their surgical treatment. Eighty-eight percent (89/104) described techniques that would preserve the subtalar and talonavicular joints. These included a medializing calcaneal osteotomy in 73% (76/104), a lateral column lengthening in 41% (43/104), and a medial column stabilization (first tarsometatarsal and/or navicular cuneiform arthrodesis) in 15% (16/104). Twelve percent (12/104) reported that they would perform an arthrodesis of one or more of the hindfoot joints. Ninety-eight percent (102/104) of respondents reported that they would employ some type of soft-tissue procedure. Ninety-four percent (98/104) would augment the posterior tibial tendon, 53% (55/104) would formally repair the spring ligament, and 70% (73/104) would address a presumed equinus contracture. CONCLUSIONS: There is a wide variation in the approach to surgical treatment of stage II acquired adult flatfoot deformity among academic foot and ankle surgeons. Most surgeons employed a combination of bony and soft-tissue procedures that preserved the subtalar and talonavicular joints.     

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.     

Flatfoot Deformity Due to Isolated Spring Ligament Injury

Patients with acquired flatfoot deformity due to isolated injury of the spring ligament, with healthy posterior tibialis tendon, are rarely identified. Between December 2004 and September 2011 (6 years and 9 months), we treated 10 patients with acquired flatfoot deformity due to spring ligament injury without tibialis posterior tendon tear. One patient (10%) was lost to follow-up. The mean age of the patients was 44.33 ± 12.91 years; 4 (44.4%) were female, and 5 (55.56%) were male. Clinical presentation included mild to moderate hindfoot valgus and pain extending from the inferior part of the medial malleolus to the navicular, inferior to tibialis posterior. Forefoot abduction was not always present. Weightbearing radiographs and magnetic resonance imaging (MRI) scans were obtained in all cases. Six patients (66.66%) of the patients had a history of minor trauma. Spring ligament repair was performed in all cases, and 4 patients (44.44%) underwent adjunct procedures. After surgery, a cast was applied, and weightbearing was avoided for 6 weeks. The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was 39.66 ± 18.55, and this improved to 84.88 ± 12.41 after surgery (p = .023). No statistically significant differences were found between males and females or between isolated repairs and adjunct procedures. The mean duration of follow-up was 45.33 ± 37.11 months (range 15 to 120), and no complications were identified. Isolated injuries of the spring ligament with normal posterior tibialis tendon are rarely described and may be more prevalent than generally appreciated.     

Transcalcaneal talonavicular dislocation

BACKGROUND: The combination of dorsal dislocation of the navicular from the talus and an associated comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury. Six cases have been described previously. The purposes of this study were to report the prevalence of this injury and the variations in injury pattern and to characterize methods of treatment and patient outcomes. METHODS: Eight patients with nine cases of transcalcaneal talonavicular dislocation were treated by the senior author between January 1, 1990, and February 28, 1998. The comminuted fracture of the calcaneus was apparently caused by plantar flexion of the talus through the anterior portion of the calcaneus. There were five open Grade-III injuries and three associated lacerations of the posterior tibial artery. After initial provisional stabilization of the hindfoot and management of the soft tissues, all injuries were treated with delayed open reduction and internal fixation of the calcaneus and fusion of the subtalar joint. At the last follow-up examination, the outcomes were rated with the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot rating score, and the Creighton-Nebraska score for all patients who had not had an amputation. RESULTS: The duration of follow-up ranged from 1.1 to eight years. Chronic osteomyelitis developed in four patients, and three of them ultimately had an amputation. The Creighton-Nebraska scores for the remaining six feet ranged from 33 to 92 points, with only one having a good or excellent result. Five of the six patients had a limp, difficulty with shoe wear, limitation with regard to walking, and moderate pain. CONCLUSIONS: Transcalcaneal talonavicular dislocation is a severe injury that often leads to osteomyelitis and amputation. Patients who do not lose the leg as a result of uncontrolled infection should be counseled to expect severe functional limitations and/or chronic pain.     

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.     

Triple arthrodesis

Triple arthrodesis is largely used to restore painful hindfoot deformity. However, the procedure has been connected to several postoperative complications. Therefore, an isolated fusion of the talonavicular and the subtalar joint through a single medial approach has gained popularity. This "diple" arthrodesis provides effective correction of deformities and reduces the risk of wound healing problems on the lateral side of the foot.     

Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults

BackgroundA common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column.MethodsWe retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated.ResultsAll radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon.ConclusionDMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity.     

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.