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Surgery for posterior tibial tendon dysfunction

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  #1  
Old 8th July 2008, 01:57 PM
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Default Surgery for posterior tibial tendon dysfunction

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Surgical reconstruction of posterior tibial tendon dysfunction: Prospective comparison of flexor digitorum longus substitution combined with lateral column lengthening or medial displacement calcaneal osteotomy.
Marks RM, Long JT, Ness ME, Khazzam M, Harris GF.
Gait Posture. 2008 Jul 4. [Epub ahead of print]
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Posterior tibial tendon dysfunction (PTTD) may require surgical intervention when nonoperative measures fail. Different methods of bony reconstruction may supplement tendon substitution. This study compares two types of bony procedures used to reinforce reconstruction of the posterior tibial tendon-the lateral column lengthening (LCL), and the medial displacement calcaneal osteotomy (MDCO). Twenty patients with PTTD were evaluated before and after scheduled reconstruction comprised of either flexor digitorum longus (FDL) substitution combined with MDCO (MDCO group, 14 patients) or FDL substitution with LCL fusion or osteotomy (LCL group, 6 patients). Foot/ankle kinematics and temporal-spatial parameters were analyzed using the Milwaukee Foot Model, and results were compared to a previously evaluated normal population of 25 patients. Post-operatively, both patient groups demonstrated significantly improved stride length, cadence and walking speed, as well as improved hindfoot and forefoot position in the sagittal plane. The LCL group also demonstrated greater heel inversion. All post-operative subjects revealed significant improvement in the talo-MT1 angle in the A/P and lateral planes, calcaneal pitch and medial cuneiform-MT5 height. Surgical reconstruction of PTTD with either the LCL or MDCO shows comparable improvements in gait parameters, with better heel inversion seen with the LCL, but improved 1st ray plantarflexion and varus with the MDCO. Both procedures demonstrated comparable improvements in radiographic measurements.
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Old 8th July 2008, 05:01 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Related;
other threads on posterior tibial tendon dysfunction
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  #3  
Old 9th July 2008, 07:06 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

another option:

When it's unilateral and the overall pes valgoplanus deformity is secondary to weak Post Tib tendon (with good ROM of the subtalar joint and ankle and a relatively normal contralateral foot) a repair of the Post Tibial tendon along with an absorbable subtalar joint arthroreisis works well.

My theory on this approach is this: If the deformity is secondary to a weak post tibial tendon then if one can correct this the problem will be solved. I normally do a Post tibial to FDL tenodesis after a removal of the navicular tuberosity and reattachment of the tendon, and along with the absorbable STJ implant the Post tibial muscle can be strengthened and become functional again.

Anyone else doing these?

Steve
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Old 30th August 2008, 08:47 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

Posterior tibial tendon insufficiency results at different stages.
Deland JT, Page A, Sung IH, O'Malley MJ, Inda D, Choung S.
HSS J. 2006 Sep;2(2):157-60.
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The results of surgical treatment of posterior tibial tendon insufficiency (PTTI) may be different at different stages of the disease. No single study has compared the results at different stages. This comparison can be helpful to the patient and physician if the patient asks "What if I wait and the disease progresses, how will my results be different?" A preliminary study comparing results for stage IIa, stage IIb (advanced stage II), and stage III was performed followed by a larger study comparing IIa and IIb with 26 and 22 patients, respectively. American Orthopaedic Foot and Ankle Society (AOFAS) outcome scores as well as radiographs and functional questions were used. Nearly all patients, regardless of stage, felt they were helped by surgical treatment. However, the lowest AOFAS score was in stage III, the most advanced stage investigated in this study. In comparing stage IIa and IIb patients, stage IIb patients had a statistically higher incidence of lateral discomfort. Although statistically significant differences were not found in all comparisons, this study suggests that the results of surgical treatment for PTTI declines with increasing stage or severity of disease.
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Old 11th March 2009, 01:29 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot.
Arangio GA, Salathe EP.
Clin Biomech (Bristol, Avon). 2009 Mar 7. [Epub ahead of print]
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BACKGROUND: Biomechanical models have been used to study stress in the metatarsals, subtalar motion, lateral column lengthening and subtalar arthroereisis. Posterior tibial tendon dysfunction has been associated with increased loads in the arch of the acquired flat foot. We examine whether a 10 millimeter (mm) medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular reduces these increased loads in the flat foot.

METHODS: The response of a normal foot, a foot with posterior tibial tendon dysfunction, and a flat foot to an applied load of 683Newton was analyzed using a multi-segment biomechanical model. The distribution of load on the metatarsals, the moment about each joint, the force on each of the plantar ligaments and the muscle forces were computed.

FINDINGS: Posterior tibial tendon dysfunction results in increased load on the medial arch, which may cause the foot to flatten. A 10mm medial displacement calcaneal osteotomy substantially decreases the load on the first metatarsal and the moment at the talo-navicular joint and increases the load on the fifth metatarsal and the calcaneal-cuboid joint. Adding the flexor digitorum longus transfer to the medial displacement calcaneal osteotomy has only a small effect on the flattened foot.

INTERPRETATION: Our biomechanical analysis illustrates that when the foot becomes flat, the force on the talo-navicular joint increases substantially from its value for the normal foot, and that medial displacement calcaneal osteotomy can reduce this increased force back toward the value occurring in the normal foot. This study provides a biomechanical rationale for medial displacement calcaneal osteotomy treatments for posterior tibial tendon dysfunction.
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Old 11th April 2009, 04:17 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Cobb procedure and Rose calcaneal osteotomy for the treatment of tibialis posterior tendon dysfunction.
Madhav RT, Kampa RJ, Singh D, Angel JC.
Acta Orthop Belg. 2009 Feb;75(1):64-9.
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Forty-three patients with stage 2 posterior tibialis tendon dysfunction underwent surgical reconstruction in the form of a Cobb procedure and Rose calcaneal osteotomy between 1997 and 2003, and were evaluated pre- and postoperatively. The average age was 57 years, and the mean followup time was 51 months (range 10-83). The average AOFAS score preoperatively was 58 and improved to 85 postoperatively (p < 0.0001). Sixty-six per cent of patients achieved a single heel raise. Eighty-four per cent expressed a subjective satisfaction rate, whilst 16% reported no improvement. Seventy-eight per cent of the patients were able to use normal shoes and 65% no longer required the use of any orthotics. The minor complication rate was 16% with no major complications. All osteotomies united uneventfully. Two patients have subsequently developed subtalar osteoarthritis, and six calcaneal screws had to be removed for prominence and tenderness. Our results compare very favourably with other less anatomical reconstructions, any donor site morbidity has been avoided and there have been very low complication rates.
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Old 13th July 2009, 05:08 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

Hindfoot motion following reconstruction for posterior tibial tendon dysfunction.
Brodsky JW, Charlick DA, Coleman SC, Pollo FE, Royer CT.
Foot Ankle Int. 2009 Jul;30(7):613-8.
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INTRODUCTION: Due to advances in technology, segmental gait analysis of the foot is now possible and can elucidate hindfoot deformity in persons with posterior tibial tendon dysfunction (PTTD). This study evaluated the motion of the hindfoot and ankle power following surgical reconstruction for PTTD utilizing a segmental foot model during gait.

MATERIALS AND METHODS: Twenty patients who underwent posterior tibial tendon reconstruction for Stage 2 PTTD using transfer of the flexor digitorum longus tendon to the navicular tuberosity, reconstruction of the calcaneo-navicular ligament complex, and a medial displacement calcaneal osteotomy were evaluated at a minimum followup of 1 year. Three-dimensional gait analysis was performed utilizing a 4-segment foot model. Temporal-spatial parameters included walking velocity, cadence, step length, and single support time. Sagittal, coronal, and transverse hindfoot motion with respect to the tibia/fibula and ankle power was calculated throughout the gait cycle.

RESULTS: Walking velocity, cadence, and step length were not significantly different between the study subjects and the normal control group. Study patients did show a significantly smaller single support time on both the affected and unaffected limbs compared to controls. There was no statistical difference in plantarflexion-dorsiflexion, varus-valgus, or ankle push-off power between the affected and unaffected sides of the study subjects, or between the affected side and the controls.

CONCLUSION: In this preliminary postoperative study, surgical reconstruction for PTTD effects quantifiable objective improvement in walking velocity, hindfoot motion and power.
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Old 9th October 2009, 08:55 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Hindfoot motion following reconstruction for posterior tibial tendon dysfunction.
Brodsky JW, Charlick DA, Coleman SC, Pollo FE, Royer CT.
Foot Ankle Int. 2009 Jul;30(7):613-8.
Quote:
INTRODUCTION: Due to advances in technology, segmental gait analysis of the foot is now possible and can elucidate hindfoot deformity in persons with posterior tibial tendon dysfunction (PTTD). This study evaluated the motion of the hindfoot and ankle power following surgical reconstruction for PTTD utilizing a segmental foot model during gait.

MATERIALS AND METHODS: Twenty patients who underwent posterior tibial tendon reconstruction for Stage 2 PTTD using transfer of the flexor digitorum longus tendon to the navicular tuberosity, reconstruction of the calcaneo-navicular ligament complex, and a medial displacement calcaneal osteotomy were evaluated at a minimum followup of 1 year. Three-dimensional gait analysis was performed utilizing a 4-segment foot model. Temporal-spatial parameters included walking velocity, cadence, step length, and single support time. Sagittal, coronal, and transverse hindfoot motion with respect to the tibia/fibula and ankle power was calculated throughout the gait cycle.

RESULTS: Walking velocity, cadence, and step length were not significantly different between the study subjects and the normal control group. Study patients did show a significantly smaller single support time on both the affected and unaffected limbs compared to controls. There was no statistical difference in plantarflexion-dorsiflexion, varus-valgus, or ankle push-off power between the affected and unaffected sides of the study subjects, or between the affected side and the controls.

CONCLUSION: In this preliminary postoperative study, surgical reconstruction for PTTD effects quantifiable objective improvement in walking velocity, hindfoot motion and power.
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Old 23rd October 2009, 11:04 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Correction and Prevention of Deformity in Type II Tibialis Posterior Dysfunction.
Parsons S, Naim S, Richards PJ, McBride D.
Clin Orthop Relat Res. 2009 Oct 22. [Epub ahead of print]

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Cobb described a method of reconstruction in Johnson and Strom Type II tibialis posterior dysfunction (TPD) using a split tibialis anterior musculotendinous graft. We assessed patient function and satisfaction after a modified Cobb reconstruction in a group of patients with a narrow spectrum of dysfunction, examined a modification of the Johnson and Strom classification to emphasize severity of deformity, and assessed the ability of the technique to prevent subsequent fixed deformity. We prospectively followed 32 patients managed by this technique and a translational os calcis osteotomy with early flexible deformity after failed conservative treatment. There were 28 women and four men with unilateral disease. The average followup was 5.1 years. Staging was confirmed clinically and with imaging. The modified surgery involved a bone tunnel in the navicular rather than the medial cuneiform with plaster for 8 weeks followed by orthotics and physiotherapy. All of the osteotomies healed and 29 of the 32 patients could perform a single heel rise test at 12 months. The mean postoperative American Orthopaedic Foot and Ankle Society hindfoot score was 89. One patient had a superficial wound infection and one a temporary dysesthesia of the medial plantar nerve; both resolved. The observations suggest the technique is a comparable method of treating early Johnson and Strom Type II TPD.
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Old 17th March 2010, 02:31 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Patient factors in the selection of operative versus nonoperative treatment for posterior tibial tendon dysfunction.
O'Connor K, Baumhauer J, Houck JR.
Foot Ankle Int. 2010 Mar;31(3):197-202.
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BACKGROUND: The influence of demographic, medical history, and treatment variables on the maintenance of nonoperative care or progression to operative intervention in Posterior Tibial Tendon Dysfuction (PTTD) was explored. This retrospective study compared demographic, medical history and treatment variables between operative and nonoperative care in subjects with PTTD.

MATERIALS AND METHODS: Charts with the ICD-9 codes (726.72, 726.90) and brace distribution records for 2005 and 2006 were used to identify subjects. From these, 166 of 606 charts included documentation of PTTD. Variables were grouped into three categories including demographics (Age, body mass index, gender and working status), medical (stage, symptom duration, pain at initial evaluation, and past treatments) and treatment (initial brace, length of care episode, and brace change). Statistical comparisons between subjects treated nonoperatively and operatively were made. Significant variables were entered into a logistic regression analysis. Accuracy (sensitivity/specificity) was assessed by examining the success of predicting which subjects were treated operatively or nonoperatively.

RESULTS: Of the 166 subjects, 125 (75.4%) received nonoperative care and 41 (24.6%) operative care. Nine variables distinguished the operative from the nonoperative group (p < 0.05): including BMI, work status, stage, symptom duration, prior orthotic use, prior injection, custom brace, brace changes, and length of care episode. The logistic regression model identified BMI, symptom duration, prior cortisone injections, and prior orthotic use as significant and resulted in a specificity of 95.4% and sensitivity of 38.2%.

CONCLUSION: This retrospective analysis provides a patient profile of factors in the success of nonoperative care in PTTD.
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Old 11th June 2010, 01:27 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Results of treatment of stage II posterior tibial tendon rupture with flexor digitorum longus tendon transfer and calcaneal osteotomy
T. Badekas
Médecine et Chirurgie du Pied
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In a retrospective study, we reviewed our results of treatment of stage II posterior tibial tendon rupture in 129 patients for whom surgery was performed between 1990 and 1997. During this period of time, 148 patients were treated with surgery following failure of nonsurgical methods of treatment. The 129 patients (117 females, 12 males) with an average age of 53 years (range, 34–75 years) had been symptomatic for an average of 2.8 years (range, 0.5–7 years). The indication for surgery was the presence of foot pain, which was refractory to shoe modifications, orthoses, and brace support. All patients had a painful flexible flatfoot without a fixed forefoot supination deformity. The surgery performed included a medial translational osteotomy of the calcaneus and transfer of the flexor digitorum longus tendon into the navicular. There were additional surgeries performed in 49 patients including repair of a tear of the spring ligament, talonavicular capsule or deltoid ligament (45), lengthening of the Achilles tendon (26), correction of hallux valgus deformity (5), and arthrodesis of the first tarsometatarsal joint (4). All patients were examined, radiographs obtained, and isokinetic evaluation of both feet and lower limbs performed with the KinCom apparatus at a mean of 4.6 years following surgery (range, 3–8 years). The AOFAS hindfoot scale was used to evaluate each patient, although, due to the time elapsed from the initiation of treatment, preoperative AOFAS scores were not retrospectively determined. The mean AOFAS score at the time of the follow-up examination was 79 points (range, 54–93). There were 7 significant complications in 6 patients including: significant progressive hindfoot valgus deformity in 1 patient treated with a triple arthrodesis; overcorrection of the hindfoot in 2 patients necessitating revision with a lateral closing wedge calcaneus osteotomy; 3 patients with symptomatic sural neuritis, and 1 patient with weakness of the gastrocnemius resulting from overlengthening of the Achilles tendon. Isokinetic inversion and plantarflexion power and strength were compared with the contralateral limb for 121 patients, and were noted to be symmetric in 95, mildly weak in 18, and moderately weak in 8. Motion of the subtalar joint was normal in 44%, slightly decreased in 51%, and moderately decreased in 5% of patients. Anteroposterior and lateral radiographs were evaluated for the talonavicular coverage angle, talus-first metatarsal angle, talocalcaneal angle, and the height of the medial cuneiform to the floor. For 4 of these 5 parameters evaluated, the correction obtained was statistically significant (p < 0.05). Of the patients examined, 123 were entirely satisfied, 4 partially satisfied, and 2 were dissatisfied with the outcome of the procedure. Most patients experienced pain relief (97%), an improvement of function (94%), noted an improvement in the arch of the foot (87%), and were able to wear shoes comfortably without resorting to shoe modifications or orthotic arch support (84%). In conclusion, the surgical correction of stage II posterior tibial tendon rupture with medial translational calcaneus osteotomy and flexor digitorum longus tendon transfer to the navicular yielded excellent results with minimal complications, and a high patient satisfaction rate.
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Old 9th July 2010, 04:08 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Lateral Column Lengthening for Acquired Adult Flatfoot Deformity Caused by Posterior Tibial Tendon Dysfunction Stage II: A Retrospective Comparison of Calcaneus Osteotomy with Calcaneocuboid Distraction Arthrodesis.
Haeseker GA, Mureau MA, Faber FW.
J Foot Ankle Surg. 2010 July - August;49(4):380-384.
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In this study, clinical and radiological results after lateral column lengthening by calcaneocuboid distraction arthrodesis and calcaneus osteotomy were compared. Thirty-three patients (35 feet) treated with lateral column lengthening by distraction arthrodesis (14 patients, 16 feet; group I) or by calcaneus osteotomy (19 patients, 19 feet; group II) for adult-acquired flatfoot deformity caused by stage II posterior tibial tendon dysfunction were compared retrospectively. Mean follow-up was 42.4 months (range, 6-78 months) for group I and 15.8 months (range, 6-32 months) for group II (P < .001). The American Orthopaedic Foot & Ankle Society ankle-hindfoot score was determined, 4 variables were measured on preoperative and postoperative weight-bearing radiographs, and a number of independent and outcome variables, including patient satisfaction, were recorded. Group 2 had a significantly higher American Orthopaedic Foot & Ankle Society score compared with group I (mean, 85 vs. 72, respectively; P < .02) at time of last follow-up, and there were no dissatisfied patients in group I, whereas 2 patients in group II were dissatisfied with the result of the operation. All radiological results were significantly better at time of follow-up in both groups (except for talocalcaneal angle in group I), although no significant differences were noted in the amount of change in radiographic measurements between the groups. No significant correlation was found between follow-up time and radiographic improvement, indicating stable radiographic measurements over time. In group II, 13 mild calcaneocuboid subluxations were observed. In both groups, 1 nonunion and 1 wound complication occurred. Based on our experience with the patients described in this report, we recommend lateral column lengthening by means of calcaneus osteotomy rather than distraction arthrodesis of the calcaneocuboid joint, for correction of stage II posterior tibial tendon dysfunction.
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Old 30th August 2010, 12:32 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

The Modified Kidner-Cobb Procedure for Symptomatic Flexible Pes Planovalgus and Posterior Tibial Tendon Dysfunction Stage II: Review of 50 Feet in 39 Patients.
Giorgini R, Giorgini T, Calderaro M, Japour C, Cortes J, Kim D.
J Foot Ankle Surg. 2010 September - October;49(5):411-416.
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Symptomatic flatfoot is a prevalent disorder. We undertook a review of 50 feet in 39 patients with flexible flatfoot treated between August 2000 and January 2008 in order to evaluate the modified Kidner-Cobb procedure. Overall clinical results were rated as good in 48 (96%) feet and fair in 2 (4%) feet, and there were no poor results. Average follow-up was 4.6 years, and total recovery time was 5.7 months in older patients and 3.7 months in children. Manual muscle-strength testing revealed no difference in tibialis anterior strength between the operated and contralateral extremity. All patients visually demonstrated postoperative elevation of the medial longitudinal arch height. Complications included 2 feet with wound dehiscence and 1 foot with fractured hardware. The results of this review indicate that the modified Kidner-Cobb procedure is a useful treatment option for patients with symptomatic flexible flatfoot with posterior tibial tendon dysfunction stage 2.
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Old 15th February 2011, 02:20 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Effects of surgical correction for the treatment of adult acquired flatfoot deformity: A computational investigation.
Iaquinto JM, Wayne JS.
J Orthop Res. 2011 Feb 11. doi: 10.1002/jor.21379. [Epub ahead of print]
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Computational models of the foot/ankle complex were developed to predict the biomechanical consequences of surgical procedures that correct for Stage II adult acquired flatfoot deformity. Cadaveric leg and foot bony anatomy was captured by CT imaging in neutral flexion and imported to the modeling software. Ligaments were approximated as tension only springs attached at insertion sites. Muscle contraction of the gastrocnemius/soleus complex was simulated through force vectors and desired external loads applied to the model. Ligament stiffnesses were modified to reflect Stage II flatfoot damage, followed by integration of corrective osteotomies-medializing calcaneal osteotomy (MCO) and Evans and calcaneocuboid distraction arthrodesis (CCDA)-to treat flatfoot. Joint angles, tissue strains, calcaneocuboid contact force, and plantar loads were analyzed. The flatfoot simulation demonstrated clinical signs of disease evidenced by degradation of joint alignment. Repair states corrected these joint misalignments with MCO having greatest impact in the hindfoot, and Evans/CCDA having greatest effect in the mid- and forefoot. The lateral procedures unevenly strained plantar structures, while offloading the medial forefoot, and increased loading on the lateral forefoot, which was amplified by combining with MCO. The Evans procedure raised calcaneocuboid joint contact force to twice intact levels. Computational results are in agreement with clinical and experimental findings. The model demonstrated potential precursors to such complications as lateral tightness and arthritic development and may thus be useful as a predictor of surgical outcomes
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Old 1st March 2011, 03:42 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Radiographic Outcomes of Adult Acquired Flatfoot Corrected by Medial Column Arthrodesis with or without a Medializing Calcaneal Osteotomy.
Jordan TH, Rush SM, Hamilton GA, Ford LA.
J Foot Ankle Surg. 2011 Mar-Apr;50(2):176-81.
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Medial column arthrodesis and calcaneal osteotomies are commonly used for adult acquired flatfoot surgical reconstruction. In this retrospective study, 41 patients (47 feet) with a mean age of 55 ± 13.5 years underwent a medial column arthrodesis, with or without calcaneal osteotomy, between 1999 and 2007. The indication for surgery was a painful flatfoot deformity with peritalar subluxation, and a fault in the naviculocuneiform joint. At a mean of 9.6 (range 3-43) months postoperatively, in patients who underwent a medial column arthrodesis, radiographs showed a mean decrease in the talonavicular coverage angle of 10.2° ± 8.7° (P < .001), and mean increases in the lateral talometatarsal and calcaneal inclination angle of 10.7° ± 5.1° (P < .001) and of 3.2° ± 2.7° (P < .001), respectively. In patients who underwent a combined medial column arthrodesis and a medializing calcaneal osteotomy, the talonavicular coverage angle decreased by a mean of 12.1° ± 6.1° (P < .001), while the lateral talometatarsal angle and calcaneal inclination angle increased by a mean of 12.3° ± 6.1° (P < .001) and 3.1° ± 2.7° (P < .001), respectively, from preoperative values. Four nonunions (4 of 47, 8.51%) occurred at the naviculocuneiform joint and 1 nonunion (1 of 32, 3.13%) occurred at the tarsometatarsal joint. These findings demonstrate marked improvement of radiographic flatfoot parameters following a medial column arthrodesis with or without a medializing calcaneal osteotomy.
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Old 2nd March 2011, 01:14 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

I found this study of little practical value.

Steve
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Old 15th March 2011, 04:53 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Treatment of Posterior Tibial Tendon Dysfunction without Flexor Digitorum Tendon Transfer: A Retrospective Study of 34 Patients.
Didomenico L, Stein DY, Wargo-Dorsey M.
J Foot Ankle Surg. 2011 Mar 10. [Epub ahead of print]
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A retrospective study of patients who underwent gastrocnemius recession, double calcaneal osteotomy (Evans osteotomy and percutaneous calcaneal displacement osteotomy), and medial column fusion for the treatment of posterior tibial tendon dysfunction was conducted. The senior author performed the procedures between November 2002 and January 2009 on 34 patients who displayed at least Johnson and Strom stage II deformity and had undergone 12 months of failed conservative treatment. The coauthors evaluated the patients' radiographs before and after the operation. At a mean of 14 (range 3 to 44) months after surgery, radiographic measurements demonstrated statistically significant changes in the structural alignment of the feet. Based on our experience with these patients, we believe that a double calcaneal osteotomy combined with a gastrocnemius recession and stabilization of the medial column for the treatment of posterior tibial tendon dysfunction provides satisfactory correction, stability, and realignment of the foot. Furthermore, we feel that the use of flexor digitorum longus transfer, as well as triple arthrodesis, can be avoided without compromising the outcome when surgically treating posterior tibial tendon dysfunction.
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Old 16th April 2011, 07:32 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

Double calcaneal osteotomy and percutaneous tenoplasty for adequate arch restoration in adult flexible flat foot.
Basioni Y, El-Ganainy AR, El-Hawary A.
Int Orthop. 2011 Jan;35(1):47-51.
Quote:
Treatment of adult acquired flexible flat foot deformity can be problematic. Triple arthrodesis for structural correction has been the standard of care, thus sacrificing hind foot motion. The objective of this study was to assess the value of double calcaneal osteotomies in improving structural alignment while maintaining hind foot motion, which may further protect the function of adjacent motion segments. Double calcaneal osteotomies (Evans osteotomy and posterior calcaneal displacement osteotomy) were performed on 17 feet of 14 patients. Postoperative follow-up showed significant improvement in clinical foot and ankle scores.
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Old 2nd September 2011, 12:06 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Relationship of the Scarf valgus-inducing osteotomy of the calcaneus to the medial neurovascular structures.
Vermeulen K, Neven E, Vandeputte G, Van Glabbeek F, Somville J.
Foot Ankle Int. 2011 May;32(5):S540-4.
Quote:
BACKGROUND:
The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus deformity of the hindfoot. It is versatile with significant corrective power; however, the neurovascular structures are in close proximity on the medial side and thus may be harmed during the osteotomy. Moreover, because this type of osteotomy can cause a great lateral translation, traction of the medial neurovascular structures is possible. We performed an anatomic study to evaluate the medial soft tissues after a lateralizing Scarf-type calcaneal osteotomy.

MATERIALS AND METHODS:
The osteotomies were carried out on ten fresh-frozen cadaver specimens. We performed the osteotomy and induced valgus. Then we performed a medial dissection to identify the important medial structures: the medial and lateral plantar nerve (MPN , LPN) and the posterior tibial artery (PTA). We noted their relation to the osteotomy and their integrity.

RESULTS:
In several cases, one or more of the structures were sectioned. In five cases, all the structures crossed the osteotomy, four of which even a transection of one or both of the plantar nerves occurred. Although the PTA crossed the osteotomy in eight specimens, there was no transection of this structure.

CONCLUSION:
Scarf osteotomy of the calcaneus is a highly corrective osteotomy. However, caution must be exercised when performing as the medial neurovascular structures cross the osteotomy lines and transection can occur.

CLINICAL RELEVANCE:
When performing the osteotomy one should keep in mind that vigorous sawing and large displacement can cause damage to the medial neurovascular structures.
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Old 12th September 2011, 03:33 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Effect of Extra-osseous Talotarsal Stabilization on Posterior Tibial Tendon Strain in Hyperpronating Feet
Journal of Foot and Ankle Surgery; Article in Press
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Posterior tibial tendon dysfunction is considered one of the most common causes of progressive adult acquired flatfoot deformity. The etiology leading to the dysfunction of posterior tibial tendon remains controversial. The purpose of this study was to quantify strain on the posterior tibial tendon in cadaver feet exhibiting hyperpronation caused by flexible instability of the talotarsal joint complex. We hypothesized that posterior tibial tendon strain would decrease after a minimally invasive extra-osseous talotarsal stabilization procedure. A miniature differential variable reluctance transducer was used to measure the elongation of posterior tibial tendon in 9 fresh-frozen cadaver specimens. The elongation was measured as the foot was moved from its neutral to maximally pronated position, before and after intervention with the HyProCure® extra-osseous talotarsal stabilization device. The mean elongation of the posterior tibial tendon (with respect to a fixed reference point) was found to be 6.23 ± 2.07 mm and 3.04 ± 1.85 mm, before and after intervention, respectively (N = 27; variation is ± 1 SD). The average elongation reduced by 51% and was statistically significant with p < .001. Strain on the posterior tibial tendon is significantly higher in hyperpronating feet. An extra-osseous talotarsal stabilization procedure reduces excessive abnormal elongation of the posterior tibial tendon by minimizing excessive abnormal pronation. This minimally invasive procedure may thus provide a possible treatment option to prevent or cure posterior tibial tendon dysfunction in patients exhibiting flexible instability of the talotarsal joint complex.
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Old 11th July 2012, 05:48 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

Results of calcaneocuboid distraction arthrodesis.
Grunander TR, Thordarson DB.
Foot Ankle Surg. 2012 Mar;18(1):15-8
Quote:
BACKGROUND:
One powerful method of reconstructing an adult acquired flatfoot deformity is a calcaneocuboid distraction arthrodesis. We performed a retrospective review of a small series of patients who underwent a calcaneocuboid distraction arthrodesis with a femoral head allograft.

MATERIALS AND METHODS:
Sixteen feet (14 patients) were identified with an average follow up of 23 months (8-39 months) and an average age of 43 years (16-60 years). A calcaneocuboid distraction arthrodesis was performed with a femoral head allograft, secured with a 3 hole 1/3 tubular plate with 7 of the grafts being supplemented with platelet rich plasma (PRP). Patients were kept non-weight bearing for 6 weeks with an additional 6 weeks in a walking cast or boot. Plain radiographs and if necessary a CT or MRI were used to evaluate for union.

RESULTS:
Seven of the 16 feet developed a nonunion. Five of 9 patients without PRP developed a nonunion vs 2 of 7 patients where PRP was used.

CONCLUSION:
Due to the unacceptably high complication rate with this procedure, the authors have abandoned this procedure. If an allograft is to be used for a calcaneocuboid arthrodesis, the authors strongly recommend using rigid locking fixation with a longer period of protected immobilization
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Old 18th July 2012, 05:06 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Calcaneal osteotomy in the treatment of adult acquired flatfoot deformity.
Guha AR, Perera AM.
Foot Ankle Clin. 2012 Jun;17(2):247-58
Quote:
Calcaneal osteotomies are an essential part of our current armamentarium in the treatment of AAFD. Soft tissue correction or bony realignment alone have failed to adequately correct the deformity; therefore, both procedures are used simultaneously to achieve long-term correction. Medial displacement and lateral column lengthening osteotomies in isolation or in combination and the Malerba osteotomy have been employed along with soft tissue balancing to good effect by various authors. The goal is to create a stable bony configuration with adequate soft tissue balance to maintain dynamic equilibrium in the hindfoot. In “pronatory syndromes,” the relation of the osteotomy to the posterior subtalar facet modifies the biomechanics of the hindfoot in different ways. Anterior calcaneal osteotomies correct deformities in the transverse plane (forefoot abduction), whereas posterior tuberosity osteotomies result in “varization” of the calcaneus and correct the frontal plane deformity. The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, transverse plane movement is cancelled out and the frontal plane eversion–inversion is predominant. The patient presents with marked hindfoot valgus without significant forefoot abduction. Conversely, if the subtalar axis is more vertical than normal, transverse plane movement is predominant and the patient presents with forefoot abduction and instability of the medial midtarsal joints, although without significant hindfoot valgus. In this situation, a lateral column lengthening procedure is recommended to decrease the uncovering of the talar head and improve the height of the arch while correcting the forefoot abduction. With a predominant frontal plane deformity, medialization of the calcaneal tuberosity is used to displace the calcaneal weight bearing axis medially, aligning it with the tibial axis and restoring the function of the gastrosoleus as a heel invertor. An essential prerequisite for this is the absence of arthritis affecting the subtalar joint. The Achilles tendon may need to be lengthened at the same time.
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Old 6th September 2012, 04:18 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

Calcaneal osteotomy in the treatment of adult acquired flatfoot deformity.
Guha AR, Perera AM.
Foot Ankle Clin. 2012 Jun;17(2):247-58
Quote:
Calcaneal osteotomies are an essential part of our current armamentarium in the treatment of AAFD. Soft tissue correction or bony realignment alone have failed to adequately correct the deformity; therefore, both procedures are used simultaneously to achieve long-term correction. Medial displacement and lateral column lengthening osteotomies in isolation or in combination and the Malerba osteotomy have been employed along with soft tissue balancing to good effect by various authors. The goal is to create a stable bony configuration with adequate soft tissue balance to maintain dynamic equilibrium in the hindfoot. In “pronatory syndromes,” the relation of the osteotomy to the posterior subtalar facet modifies the biomechanics of the hindfoot in different ways. Anterior calcaneal osteotomies correct deformities in the transverse plane (forefoot abduction), whereas posterior tuberosity osteotomies result in “varization” of the calcaneus and correct the frontal plane deformity. The choice of osteotomy depends on the plane of the dominant deformity. If the subtalar axis is more horizontal than normal, transverse plane movement is cancelled out and the frontal plane eversion–inversion is predominant. The patient presents with marked hindfoot valgus without significant forefoot abduction. Conversely, if the subtalar axis is more vertical than normal, transverse plane movement is predominant and the patient presents with forefoot abduction and instability of the medial midtarsal joints, although without significant hindfoot valgus. In this situation, a lateral column lengthening procedure is recommended to decrease the uncovering of the talar head and improve the height of the arch while correcting the forefoot abduction. With a predominant frontal plane deformity, medialization of the calcaneal tuberosity is used to displace the calcaneal weight bearing axis medially, aligning it with the tibial axis and restoring the function of the gastrosoleus as a heel invertor. An essential prerequisite for this is the absence of arthritis affecting the subtalar joint. The Achilles tendon may need to be lengthened at the same time.
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Old 21st September 2012, 12:21 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Functional results of posterior tibial tendon reconstruction, calcaneal osteotomy, and gastrocnemius recession.
Kou JX, Balasubramaniam M, Kippe M, Fortin PT.
Foot Ankle Int. 2012 Jul;33(7):602-11.
Quote:
BACKGROUND:
This study aimed to assess and provide prospective outcome data following reconstruction of Stage II posterior tibial tendon insufficiency, as well as evaluate the effect of reconstruction with gastrocnemius recession on plantarflexion strength.

METHODS:
A prospective evaluation of 24 patients undergoing reconstruction for Stage II posterior tibial tendon insufficiency was granted IRB approval. The reconstructive procedures consisted of a flexor digitorum longus transfer, medial displacement calcaneal osteotomy, lateral column lengthening, and gastrocnemius recession. Patients were asked to complete multiple outcome measures preoperatively, 6 months, 1 year, and 2 years postoperatively. A dynamometer was utilized to evaluate peak torque plantarflexion preoperatively, 6 months, and 1 year postoperatively.

RESULTS:
In the study, 14 patients completed preoperative surveys, and 23 patients had 2-year followup. Patients were highly satisfied with the results of their surgery. All outcome measures showed statistically significant improvement. Improvement was seen at 6 months, but results continued to improve at the 1-year mark. By the second year, improvement largely reached a plateau. Biodex testing showed no loss of plantarflexion strength after reconstruction and gastrocnemius recession.

CONCLUSION:
Reconstruction of the flexible adult acquired flatfoot with FDL transfer, double calcaneal osteotomy, and gastrocnemius recession yielded excellent functional results for the treatment of Stage II posterior tibial tendon insufficiency. Plantarflexion weakness was not found to be a concern. A good functional outcome can be anticipated after the early postoperative period. However, it should be expected to take at least 1 year for maximal benefit.
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Old 28th September 2012, 02:10 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

From the latest Podiatry Today:
Current Concepts In Surgery For Adult-Acquired Flatfoot
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Old 12th October 2012, 12:30 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

PTT Functional Recovery in Early Stage II PTTD After Tendon Balancing and Calcaneal Lengthening Osteotomy.
Brilhault J, Noël V.
Foot Ankle Int. 2012 Oct;33(10):813-8.
Quote:
BACKGROUND:
The decision to offer surgery for Stage II posterior tibial tendon deficiency (PTTD) is a difficult one since orthotic treatment has been documented to be a viable alternative to surgery at this stage. Taking this into consideration we limited our treatment to bony realignment by a lengthening calcaneus Evans osteotomy and tendon balancing. The goal of the study was to clinically evaluate PTT functional recovery with this procedure.

METHOD:
The patient population included 17 feet in 13 patients. Inclusion was limited to early Stage II PTTD flatfeet with grossly intact but deficient PTT. Deficiency was assessed by the lack of hindfoot inversion during single heel rise test. The surgical procedure included an Evans calcaneal opening wedge osteotomy with triceps surae and peroneus brevis tendon lengthening. PTT function at follow up was evaluated by an independent examiner. Evaluation was performed at an average of 4 (range, 2 to 6.3) years.

RESULTS:
One case presented postoperative subtalar pain that required subtalar fusion. Every foot could perform a single heel rise with 13 feet having active inversion of the hindfoot during elevation.

CONCLUSIONS:
The results of this study provide evidence of PTT functional recovery without augmentation in early Stage II. It challenges our understanding of early Stage II PTTD as well as the surgical guidelines recommending PTT augmentation at this specific stage.
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Old 8th November 2012, 11:37 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

Outcome of medial displacement calcaneal osteotomy for correction of adult-acquired flatfoot.
Niki H, Hirano T, Okada H, Beppu M.
Foot Ankle Int. 2012 Nov;33(11):940-6.
Quote:
BACKGROUND:
The results of medial displacement calcaneal osteotomy (MDCO) with flexor digitorum longus (FDL) tendon transfer were reviewed, as well as postoperative radiographic changes, to determine quantitative x-ray-based indications for MDCO with FDL tendon transfer in cases of adult-acquired flatfoot.

MATERIALS AND METHODS:
Twenty-five patients, ages 42 to 71 years, underwent MDCO with FDL tendon transfer for stage II posterior tibial tendon dysfunction. Follow-up was 2.6 to 10.2 years. Preoperative and postoperative Japanese Society for Surgery of the Foot (JSSF), Foot Function Index, and SF-36 scores and physical and radiographic findings were compared. Eight measures of foot alignment were obtained from weight-bearing radiographs at 3, 6, 9, and 12 months after surgery and every 6 months thereafter. Differences in scores and values over time were analyzed statistically.

RESULTS:
Average JSSF scores improved from 59 preoperatively to 91.3 postoperatively (p < .001). The only x-ray parameters that improved significantly and showed maintenance of the surgical correction were the lateral talometatarsal (LTMT) and tibiocalcaneal (TBC) angles. With preoperative LTMT and TBC angles of >25° and >15°, respectively, correction was inadequate.

CONCLUSIONS:
It was concluded that indications for MDCO with FDL tendon transfer in cases of adult-acquired flatfoot are a preoperative LTMT angle of <25° and hindfoot coronal alignment (TBC angle) of <15°.
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Old 17th December 2012, 10:17 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Plantar Measurements to Determine Success of Surgical Correction of Stage IIb Adult Acquired Flatfoot Deformity
Matheis, Erika
VCU Digital Archives
Quote:
Adult Acquired Flatfoot Deformity (AAFD) is a progressive disease characterized by mechanical degeneration of the soft tissue structure in the arch of the foot that leads to changes in joint alignment. Surgical intervention commonly via tendon transfer and bony osteotomy is used to restore arch architecture, however there is a lack of quantitative assessments that measure the success of the surgical correction in vivo. Using plantar pressures via Tekscan® HR Mat and surveys (SF-36, FAOS), pre-operative and post-operative measures for six participants were defined, analyzed and compared. A paired t-test showed significant lateral shift for percent body weight during walking postoperativelyin the forefoot and midfoot regions. However, arch index measurement showed no significant change. The FAOS survey score also improved statistically postoperatively. The surgical correction was successful as deemed by some of these quantitative and qualitative measures.
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Old 11th January 2013, 12:09 AM
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Default Re: Surgery for posterior tibial tendon dysfunction

The Contribution of Medializing Calcaneal Osteotomy on Hindfoot Alignment in the Reconstruction of the Stage II Adult Acquired Flatfoot Deformity
Jeremy Y. Chan, Benjamin R. Williams, Pallavi Nair, Elizabeth Young, Carolyn Sofka, Jonathan T. Deland, Scott J. Ellis
Foot & Ankle International January 10, 2013 1071100712460225

Quote:
Background: Successful correction of hindfoot alignment in adult acquired flatfoot deformity (AAFD) is likely influenced by the degree of medializing calcaneal osteotomy (MCO) performed, but it is not known if other reconstruction procedures significantly contribute as well. The purpose of this study was to evaluate the correlation between common preoperative and postoperative variables and hindfoot alignment.

Methods: Thirty patients with stage II AAFD undergoing flatfoot reconstruction were followed prospectively. Preoperative and postoperative radiographs were reviewed to assess for correction in hindfoot alignment as measured by the change in hindfoot moment arm. Nineteen variables were analyzed, including age, gender, height, weight, body mass index (BMI), medial cuneiform-fifth metatarsal height, anteroposterior (AP) talonavicular coverage, AP talus-first metatarsal, lateral talus-first metatarsal and calcaneal pitch angles as well as intraoperative use of the MCO, lateral column lengthening (LCL), Cotton osteotomy, first tarsometatarsal fusion, flexor digitorum longus transfer, spring ligament reconstruction, and gastrocnemius recession or Achilles lengthening. Mean age was 57.3 years (range, 22-77). Final radiographs were obtained at a mean of 47 weeks (range, 25-78) postoperatively.

Results: Seven variables were found to significantly affect hindfoot moment arm. These were gender (P < .05), the amount of MCO performed (P < .001), LCL (P < .01), first tarsometatarsal fusion (P < .01), spring ligament reconstruction (P < .01), medial cuneiform-fifth metatarsal height (P < .001), and calcaneal pitch angle (P < .05). Multivariate regression analysis revealed that MCO was the only significant predictor of hindfoot moment arm. The final regression model for MCO showed a good fit (R2 = .93, P < .001).

Conclusion: Correction of hindfoot valgus alignment obtained in flatfoot reconstruction is primarily determined by the MCO procedure and can be modeled linearly. We believe that the hindfoot alignment view can serve as a valuable preoperative measurement to help surgeons adjust the proper amount of correction intraoperatively.
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Old 21st March 2013, 12:02 PM
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Default Re: Surgery for posterior tibial tendon dysfunction

Single-Incision Medial Approach for Double Arthrodesis of Hindfoot in Posterior Tibialis Tendon Dysfunction
Prashanth Anand, James A. Nunley, James K. DeOrio
Foot & Ankle International March 2013 vol. 34 no. 3 338-344
Quote:

Background: Triple arthrodesis through a 2-incision approach has been the primary salvage procedure for rigid hindfoot malalignment resulting from posterior tibialis dysfunction. However, complications like calcaneocuboid joint nonunion, lateral wound dehiscence, and adjacent joint arthritis have been reported after triple arthrodesis. Hence we adopted single-incision medial approach arthrodesis of subtalar and talonavicular joints, sparing the uninvolved calcaneocuboid joint and lateral skin.

Method: We report the results of a series of 18 feet with posterior tibialis dysfunction that had correction of malalignment by this approach. Mean age at surgery was 65 years. The mean follow-up was 24 months.

Results: There was statistically significant improvement in all the radiological parameters measured. There were no wound-related complications. The union rate was 89%. There were 2 malunions, and 2 feet developed valgus ankle deformity. The overall satisfaction rate among patients was 78%.

Conclusion: We present a case series of treatment of posterior tibialis tendon dysfunction by arthrodesis of the subtalar and talonavicular joints through an isolated medial approach. The results were not encouraging enough to recommend adopting this approach as an alternative to triple arthrodesis.
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