Tendon transfers and realignment osteotomies for treatment of stage II posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction (PTTD) has been approached with a multitude of surgical techniques. This article outlines the current understanding of the flexor digitorum longus transfer and flexor hallucis longus transfer in the context of various osteotomy techniques for the correction of stage II PTTD. Pertinent clinical literature and scientific evidence will also be compared and analyzed.     

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

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

Posterior calcaneal displacement osteotomy for the adult acquired flatfoot

The posterior calcaneal displacement osteotomy with flexor digitorum longus tendon transfer is an accepted approach to the stage II posterior tibial tendon dysfunction flatfoot. This reconstructive osteotomy provides a viable alternative to isolated hindfoot arthrodesis procedures. Proper patient selection and sound surgical technique ensure favorable postoperative results. Complications, though limited, may include sural neuritis, peroneal tendonitis, undercorrection, and peritalar arthrosis.     

Flexor Digitorum Longus Tendoscopy

The flexor digitorum longus tendon is susceptible to injury along its entire course, and lacerations, ruptures, longitudinal tears, and stenosing tenosynovitis have all been reported. Moreover, this tendon is commonly used for reconstruction of dysfunctional posterior tibial and Achilles tendons. Traditionally, surgery involving the flexor digitorum longus tendon was performed via open incision. We describe a technique of flexor digitorum longus tendoscopy that may encourage the future development of a minimally invasive approach to flexor digitorum longus tendon procedures.     

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

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

Soft tissue procedures for the stabilization of medial arch pathology in the management of flexible flatfoot deformity

Soft tissue procedures for the stabilization of symptomatic, advanced hyperpronation deformity are performed most frequently in conjunction with osteotomy, arthrodesis, or arthroereisis of the subtalar joint. A variety of such procedures are available for the selective reinforcement or repair of the posterior tibial tendon, spring ligament, deltoid ligament, or medial intertarsal joint capsules. Recently, the focus has been on the direct repair or reinforcement of the posterior tibial tendon using the long flexor tendons. This article reviews additional procedures that have been of value in the management of posterior tibial tendon dysfunction and the procedures now most commonly employed.     

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.     

Treatment of stage I posterior tibial tendon dysfunction with medial soft tissue procedures

Seven patients with Stage I posterior tibial tendon dysfunction were treated with synovectomy, with or without tendon debridement. At the 11-month followup, six patients were completely pain free. The one patient who eventually required flexor digitorum longus transfer and lateral column lengthening because of progression to Stage II disease had significant intrasubstance tendinous degeneration. Early diagnosis and aggressive treatment are imperative to prevent progression of Stage I posterior tibial tendon dysfunction. Operative treatment is indicated if a reasonable trial of casting or bracing does not relieve symptoms.     

Tendoscopy of the ankle

In this article, the peroneus longus and brevis, posterior tibial, Achilles, and flexor hallucis longus tendon endoscopy are discussed individually. Tendoscopic indications and surgical technique are highlighted.     

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 slide calcaneal osteotomy. Technique, patient selection, and results

This article reviews the indications and the operative technique for the medial calcaneal slide osteotomy for the treatment of posterior tibial insufficiency. Patient selection, expected results, and complications of this technique are discussed. When used in combination with flexor digitorum longus transfer, the medial calcaneal slide osteotomy is an effective method of treatment for the adult acquired flatfoot associated with insufficiency of the posterior tibial tendon.     

Operative treatment of the difficult stage 2 adult acquired flatfoot deformity

In the flexible pes planovalgus deformity of stage 2 posterior tibial tendon dysfunction, osteotomies appear to have a significant role in operative management by restoring more normal biomechanics, allowing tendon transfers to function successfully. The options when considering osteotomies for stage 2 disease include lateral column lengthening, medial displacement calcaneal osteotomy, and combined double osteotomy technique. The tight Achilles tendon should be lengthened as well. Lateral column lengthening has been used extensively for treatment of flexible flatfeet. It has been shown clinically and radiographically to address all 3 components of the pes planovalgus deformity present in stage 2 posterior tibial tendon dysfunction. Lateral column lengthening is used in combination with a medial soft tissue rebalancing procedure. The mechanism of action is still speculative but clearly is not owing to tensioning of the plantar fascia as previously thought. Despite the excellent correction of foot posture obtained by use of lateral column lengthening for adult acquired flatfoot, many clinicians have reservations about its use because of reported secondary increases in the calcaneocuboid joint pressures. This increase in pressure has been shown to occur experimentally, increasing the potential risk of calcaneocuboid joint arthrosis. This experimental evidence is supported by Phillips' study of the original Evans procedure, which resulted in a 65% incidence of calcaneocuboid joint arthrosis at 13-year follow-up. Mosier-LaClair et al reported a 14% incidence of calcaneocuboid joint arthritis at 5-year follow-up after double osteotomy for stage 2 posterior tibial tendon dysfunction. This incidence has not been proved true in the remainder of the literature surrounding this procedure and its use for flexible flatfoot. To address the concern regarding potential calcaneocuboid arthrosis secondary to lateral column lengthening, calcaneocuboid joint distraction arthrodesis has been explored as an alternative technique. The results show good initial correction, but the follow-up is extremely limited, and one study reported loss of correction over time. Longer follow-up is needed to determine whether or not this technique would provide the lasting correction seen with the Evans procedure. Calcaneocuboid joint lengthening arthrodesis does result in some limitation of adjacent hindfoot motion. Although this limitation is significantly less compared with talonavicular and subtalar joint fusion, this procedure may result in increased local pressures and arthrosis of the midfoot or hindfoot. For the above-mentioned reasons, longer follow-up studies are needed to determine whether calcaneocuboid joint distraction arthrodesis would prove to be a reliable and safe alternative for lateral column lengthening in the treatment of adult acquired flatfoot. Medial displacement calcaneal osteotomy has been used for correction of the pes planovalgus foot in posterior tibial tendon dysfunction. It has been used extensively for the surgical treatment of flexible flatfoot throughout the literature. Medial displacement osteotomy, in combination with flexor digitorum longus tendon transfer, can address all 3 components of adult acquired flatfoot. It does not recreate the medial longitudinal arch in all patients, however. Although the mechanism of action of medial displacement calcaneal osteotomy is unknown, it has been proved that it is not through the tightening of the plantar fascia in a windlass effect as previously thought. In contrast to lateral column lengthening, however, medial displacement calcaneal osteotomy does address the deforming valgus force of the Achilles tendon. Functionally transferring the insertion of the Achilles tendon medially removes a constant valgus-deforming force. The osteotomy can then act as a double tendon transfer with the flexor digitorum longus tendon to aid in foot inversion. For stage 2 posterior tibial tendon insufficiency, the authors favor the combination double osteotomy technique with a flexor digitorum longus tendon-to-medial cuneiform tendon transfer, débridement or removal of the posterior tibial tendon, and percutaneous heel cord lengthening. Early results were positive at 1.5 years after surgery with respect to maintenance of correction and functional improvement with no evidence of calcaneocuboid arthrosis. More recently, the intermediate 5-year follow-up has been assessed for this combination of procedures, and similar results were found. There was a high rate of patient satisfaction and functional improvement, and surgical correction of the flatfoot deformity was maintained and compared favorably with the contralateral normal foot. Although the intermediate follow-up found a 14% incidence of calcaneocuboid arthrosis, 50% of these patients had preoperative evidence of calcaneocuboid joint arthritis. (ABSTRACT TRUNCATED)     

Tibialis posterior tendon dysfunction: a primary or secondary problem?

Seventeen patients with a mean follow-up of 64.4 months following a tibialis posterior tendon transfer to regain active foot dorsiflexion were clinically examined specifically for signs of tibialis posterior tendon dysfunction. The results show that 8 patients (47%) had Grade 4 or better power of eversion but none had a clinical flatfoot on the Harris-Beath footprints. Only 6% had forefoot abduction; 17% exhibited hindfoot valgus and 82% were able to perform the single-heel rise. Tibialis posterior tendon dysfunction therefore does not appear to be an inevitable sequel of tibialis posterior tendon transfer even in the presence of a functioning peroneal muscle. Other studies have noted that a pre-existent flatfoot was often present in patients with tibialis posterior tendon dysfunction. None of the patients in this study had pre-existent flatfoot. We suggest that a predisposition, in the form of a pre-existent tendency to flatfoot may also be a factor in the pathogenesis of tibialis posterior tendon dysfunction. This may explain the long-term failure of flexor digitorum longus and flexor hallucis longus tendon transfers in the treatment for tibialis posterior tendon dysfunction when the biomechanics of the foot has not been altered.     

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report.

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.     

Acute tarsal tunnel syndrome following partial avulsion of the flexor hallucis longus muscle: a case report.

An acute posterior tibial nerve compression from a partially ruptured flexor hallucis longus (FHL) muscle is reported. This etiology for acute tarsal tunnel syndrome has not been previously described. A 17-year-old male sustained multiple injuries in a motor vehicle accident, including a tibial shaft fracture and a posterior medial right ankle laceration of the same limb. The injured limb had no sensation on the plantar aspect of the foot and heel, decreased active great toe flexion, and associated leg pain. Exploration of the posterior tibial nerve for presumed laceration revealed the nerve to be intact, but compressed in a tense tarsal tunnel from a retracted partially ruptured flexor hallucis longus tendon. Decompression of the tunnel and resection of the devascularized muscle resulted in complete neurologic recovery.     

Acute tibialis posterior tendon rupture associated with a distal tibial fracture

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.     

Flexor hallucis longus dysfunction: an overview

Whereas acute and chronic injuries of the tibialis posterior, peroneal and Achilles tendon are frequently encountered, disorders of the flexor hallucis longus tendon are often overlooked, which may contribute to chronic pain and disability. Patients with stenosing tenosynovitis of the flexor hallucis longus tendon frequently present with overlapping signs and symptoms of flexor hallucis longus tendinitis, plantar fasciitis and tarsal tunnel syndrome, which the authors collectively refer to as "flexor hallucis longus dysfunction." A keen awareness of the presenting signs and symptoms and use of ancillary MR imaging and FHL tenography will assist the practitioner in recognizing this commonly misdiagnosed condition.     

Tendon transfer for dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy – A case report

Introduction and importanceIrreparable sciatic nerve palsy is a cause of foot drop and resulting in absent or weak most of the muscles in leg. There may be dysfunctions of all tendons in the leg excepting Achilles tendon and plantaris tendon. The treatment of this atypical neurologic injury has not been defined.Case presentationI reported a case of foot drop following irreparable sciatic nerve palsy in which there was a dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon. The medial gastrocnemius tendon and plantaris tendon were transferred into the anterior tibialis tendon, the extensor digitorum longus tendon and extensor hallucis longus tendon. The lateral gastrocnemius tendon was transferred into the peroneus brevis. Four months post-operative, he reported no pain and became capable of walking without the assistance of an orthosis or a crutch and without steppage gait.Clinical discussionAnterior transfer of the tibialis posterior tendon was the preferred procedure. If no posterior tibial tendon function was presented, then in order of preference, the extensor hallucis longus, extensor digitorum longus, peroneal, flexor hallucis longus tendon, medial gastrocnemius, lateral gastrocnemius and plantaris tendon would be used.ConclusionThe atypical dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy was presented. Tendon transfer using medial gastrocnemius tendon, lateral gastrocnemius tendon and plantaris tendon seemed to be a good choice for treatment of this injury. It allowed reconstruction of a stable, painless, plantigrade foot.Level of evidenceCase report.     

The Treatment of Posterior Tibial Tendon Insufficiency Using the Double Heel Osteotomy and Soft Tissue Reconstruction: The “All-American Procedure”

BackgroundMultiple treatment options have been proposed for the treatment of flexible (stage II) flatfoot with posterior tibial tendon insufficiency (PTTI). This article describes the rationale and technique of our joint-sparing approach to this problem with a combination of osteotomies and soft tissue reconstruction.MethodsLengthening of the lateral column (LCL) through the anterior calcaneal process diminishes the abduction of the forefoot related to the hindfoot, plantarflexes the first ray by tightening the peroneus longus tendon, and causes the arch to rise. Hindfoot valgus is addressed with a medializing calcaneal osteotomy (MCO). Additional soft tissue procedures include transfer of the flexor digitorum longus tendon (FDL), substituting for the diseased posterior tibial tendon and a percutaneous heel cord lengthening (HCL).Results and ConclusionsThe combination of a double heel osteotomy (LCL and MCO) and a soft tissue reconstruction (FDL transfer and HCL) has proven to be an excellent operation for supple PTTI in our practice for 25 years in approximately 1000 patients. Paying careful attention to the described details of the LCL portion of the procedure improves the results of the reconstruction. Removal of the LCL screw and any remaining osteophytes at the calcaneocuboid joint seems to solve the problem of lateral column pain and some overcorrection after the initial procedure.     

成人获得性平足的软组织重建

目的总结成人获得性平足(adult-acquired flatfoot deformity,AAFD)软组织重建的基础和临床研究进展。方法广泛查阅近年关于AAFD软组织修复和肌腱转移的相关文献,并进行综述。结果针对AAFD的软组织重建手术可分为静力性和动力性重建两种,其中静力性重建以弹簧韧带的修复重建为主;动力性重建术式较多,趾长屈肌腱转移术常用,但其生物力学效果欠佳,对于胫后肌功能正常的患者Cobb手术效果更佳。结论对于AAFD需根据畸形类型和分期选择软组织重建术式。