The acquired flatfoot: mid-term results of the medial displacement calcaneal-osteotomy with flexor digitorum longus transfer

AIM: The present retrospective study investigates the mid-term results after medial displacement calcaneal osteotomy combined with flexor digitorum longus transfer for the treatment of acquired flatfoot deformity due to posterior tibial tendon insufficiency at stage II (Johnson and Strom Classification). METHOD: 30 feet in 29 patients (6 male, 23 female) with an average age of 58 years (from 43 to 68 years) had surgery between 1995 and 2001. All feet were examined at an average follow-up of 58.5 months (range 35-97 months) and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score. RESULTS: The average AOFAS-Score was 88.8+/-10.7 points (range 48 to 100) at final follow-up. The AOFAS-pain-subscale score was 34+/-6.2 points. At the latest follow-up were 14 feet (47%) painfree, 14 feet (47%) noted mild pain and 2 feet (6%) had daily pain. One foot (3%) had pain due to subluxation of the musculus flexor digitorum longus tendon, in another one pain was caused by a contract Chopart joint (3%). Further complications were painful prominent hardware (17%) and neuralgia of the sural nerve (7%). CONCLUSION: The authors conclude that the combination of the medial calcaneal displacement osteotomy with flexor digitorum longus transfer may provide optimal results in patients with adult acquired flatfoot deformity and posterior tibialis 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.     

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.     

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.     

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.     

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)     

Recovery of the posterior tibial muscle after late reconstruction following tendon rupture

The purpose of this study was to determine the recovery potential of the posterior tibial muscle after late reconstruction following tendon rupture in stage II of posterior tibial tendon dysfunction. Fourteen patients (18 women, 6 men; mean age 59.8 years) were investigated 47 months (range, 24-76 months) after surgical reconstruction of a completely ruptured posterior tibial tendon (end-to-end anastomosis, side-to-side augmentation with the flexor digitorum longus tendon) in combination with a distal calcaneal osteotomy with a tricortical iliac crest bone graft for lengthening of the lateral column. At follow-up, clinical and radiological investigations were performed, including strength measurement and qualitative and quantitative MRI investigation. The overall clinical results were graded excellent in 12 patients, good in one, fair in one, and poor in none. The average ankle-hindfoot score (American Orthopaedic Foot and Ankle Society) improved from preoperatively 49.1 (range, 32-60) to 93.1 (range, 76-100) at follow-up. The functional result correlated with patient's satisfaction and sports activities (p <.05). All patients showed a significant strength of the posterior tibial muscle on the affected side, but it was smaller than on non-affected side (p <.05). The mean posterior tibial muscle strength was 75.1 N on affected and 104.9 N on nonaffected side, corresponding to a ratio of 0.73 between the two legs. The mean area of the posterior tibial muscle was 1.89 cm(2) on affected side, and 3.48 cm(2) on nonaffected side, corresponding to a ratio of 0.55 between the two legs. While fatty degeneration for the posterior tibial muscle was found in all patients, it was found to decrease with increasing strength of the posterior tibial muscle (p <.05) and muscular size (p <.05). On postoperative MRI, the posterior tibial tendon could be found to be intact in all patients. The recovery potential of the posterior tibial muscle was shown to be significant even after delayed repair of its ruptured tendon. A ruptured and/or diseased posterior tibial tendon should not be transected as it excludes any recovery possibilities of the posterior tibial muscle.     

Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon.

We analyzed our results of surgery for acquired flatfoot deformity after dysfunction of the posterior tibial tendon. This included lengthening the proximal lateral column by calcaneal osteotomy and reconstructing the medial soft tissue. Nineteen patients (9 women and 10 men; average age, 52.9 years [range, 24-72 years]) were treated for stage II and stage II-III insufficiency of the posterior tibial tendon. The medial soft tissue surgery included 18 reconstructions of the tendon, 11 transfers of the flexor digitorum longus tendon, 13 repairs of the deltoid ligament, and 3 repairs of the spring ligament. At follow-up (mean, 23.4 months), all patients had satisfactory restoration of their medial longitudinal arch, reduction of abduction in the forefoot, and restored height in the arch. All patients were able to bear weight fully on the foot that underwent surgery, and all but one were satisfied with the result achieved. The clinical result was rated as excellent in 6, good in 11, and fair in 2 cases. In all but one case, no loss of achieved correction in the foot was found. In one case, the calcaneocuboid joint had to undergo arthrodesis after 5 months because of painful degenerative joint disease. In the pes planovalgus and abductus deformities occurring in stage II disease, calcaneal osteotomy and reconstruction of the medial tendon and ligament seem to play a significant role in operative management. This was the case only when degenerative joint disease and significant subluxation of the subtalar or talonavicular joint or both had not already occurred. They seem to function by restoring more normal biomechanics, which allows reconstructed or transferred tendon to function successfully.     

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.     

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

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

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.     

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.     

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.     

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.     

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.     

Flexor digitorum longus transfer with medial displacement calcaneal osteotomy. Biomechanical rationale

The rationale behind combining a medical displacement calcaneal osteotomy with a flexor digitorum longus (FDL) transfer is to realign the valgus heel under the mechanical axis of the leg and to reduce the deforming valgus moment of the gastrocnemius soleus muscle group on the hindfoot. This reduces the antagonistic force on the relatively weak FDL transfer. This combination has a potential for producing a more mechanically balanced foot and acts as a double tendon transfer in which the Achilles tendon is transferred medially in addition to the FDL transfer, which substitutes for the degenerative posterior tibial tendon.     

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.     

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.     

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.