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Lecture 26 parekh pttd2
Stage 2 posterior tibial tendon dysfunction is characterized by an elongated and partially torn tendon, resulting in a flexible deformity with increased heel valgus and possible forefoot abduction. Treatment begins conservatively with orthotics but may progress to surgical procedures like flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening to restore the arch height and alignment. More advanced cases may require fusion of the talonavicular joint or additional medial column procedures to address deformity in the midfoot. The goal of surgical treatment is to correct all aspects of the flexible deformity through procedures on the hindfoot, midfoot and forefoot.
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Lecture 26 parekh pttd2
- 1. Stage 2 –Posterior Tibial Tendon Dysfunction Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 2. PTT Dysfunction Most common causeacquired adult flatfoot
- 3. Adult Acquired Flatfoot Classification StageTendon Deformity I Degenerated None (mild) II Elongated, partial tear Flexible, ↑heel valgus, possible forefoot abduction III Elongated, Partial tear Stiff/fixed: minimal heel inversion IV Elongated, partial tear Valgus ankle tilt
- 4. • A diverseconstellation of deformity • Numerous names: • PTTI, PTTD, Adult Acquired Flatfoot (AAFD), Adult Progressive Flatfoot, Collapsing Pes Valgus Combined tendon/ligament failure
- 5. Stage II • Variabilityin amount and types of flexible deformity • Two groups • IIa • IIb _________________________________ *J.T. Deland, et al. HSS Journal (2006) 2:157–160 *Vora, et al. JBJS Am.,2006; 88:1726 - 1734 *Bluman EM, et al. Foot Ankle Clin. 2007 Jun;12(2):233-49, v. Review.
- 6. IIa • Less than30% medial talar head uncoverage (or no lateral incongruence) • No clinical forefoot abduction
- 7. IIb • More than30% medial talar head uncoverage or lateral incongruence • Significant clinical forefoot abduction
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- 9. Anatomy & Function •PTT insertions • Navicular tuberosity, navicularcuneiform capsule, medial, middle & lateral cuneiforms, cuboid, bases of 2nd-5th MT’s, & sustantaculum tali (Sarrafian) • PTT function • Inversion of subtalar joint • Adduction of forefoot • Supination of forefoot • Antagonist • Peroneal brevis
- 10. Function/Biomechanics • Initiates heelrise • Invert subtalar joint • Locking transverse tarsal jts • GSC powerful inverter after inversion initiated by posterior tib • Patients w/ PTT dysfunction • Unable to initiate heel rise • Able to maintain heel rise once on their toes
- 11. Pathophysiology • Unopposed pullof peroneal brevis • forefoot abduction • Attenuation in medial ligamentous structures • Progressive collapse of arch • End stage • Marked calcaneal valgus • Talus PF • Forefoot abduction
- 12. Pathophysiology • Spring Ligament Complex •Integrity of TN joint • Superior medial calcaneonavicular ligament • Inferior calcaneonavicular ligament • Forefoot abd attenuation of spring ligament • Talus PF & equinus contracture
- 13. Etiology • “Critical zoneof hypovascularity” • Medial malleolus to navicular • Diabetes • Hypertension • Obesity • Trauma
- 14. Clinical Presentation • StageII: Flexible deformity • Postural changes • Heel valgus • Loss of arch • Forefoot abduction/varus • Tendinosis • Weakness • Normal subtalar motion • Pain • Initially medial lateral pain later • Able to perform single toe rise early • Unable to perform single toe rise late
- 15. Physical Exam • Observation(front & behind) • Deformity • Fullness behind medial malleolus • Single toe raise • Evaluate TMT joints for arthrosis/hypermobility (can mimic PTT dysfunction)
- 16. Physical Exam • Rangeof motion • Muscle strength testing • Swelling @ PTT • Tenderness @ PTT/sinus tarsi
- 17. X-rays • WB APFoot • Talo-2nd MT angle • Lateral subluxation of TN joint
- 18. X-rays • WB LateralFoot • Sag of TN joint • Talo-1st MT angle (Meary’s angle) • Height of medial cuneiform or MT overlap
- 19. X-rays • WB AnkleSeries • Hindfoot alignment view • MRI • Controversial in its role
- 20. Conservative Treatment • Orthoticw/ medial heel lift, longitudinal arch, medial forefoot post • MAFO/Arizona brace • For more severe flexible deformities • UCBL to block abduction of forefoot • Difficult to make Chao & Wapner, CORR, 1999
- 21. Surgical Treatment • StageII: controversial • Early • FDL transfer • Medial displacement calcaneal osteotomy • Late • Add • Lateral column • Lengthening/Evans • CC fusion • TAL • Medial column procedure • Cotton, Lapidus, PF osteotomy • Spring ligament • Repair vs reconstruction vs TN fusion
- 22. Equinus Strayer • Gastroc • Suralnerve • Larger incision • More time TAL • Quick • Atrophy of gastroc • Loss strength
- 23. FDL Transfer • Medialmidline incision • Retract addHal • Knot of Henry • Formal tenodesis • Transfer through drill hole in navicular • Tie at end of case • Foot maximal inversion
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- 25. FDL Only • StageII (flexible deformity) • FDL transfer • Results (Mann & Thompson) • 88% satisfied • 7/11 not satisfied had fixed hindfoot or forefoot deformity • No significant improvement in arch height radiographically
- 26. Medial Displacement Calcaneal Slide •Theory • Change the mechanical axis of the Achilles • Improves inversion power • Shifts weight bearing axis towards long axis of tibia • Usage • Hindfoot valgus deformity
- 27. Medial Displacement Calcaneal Slide •Supine •Incision •1cmposterior to peroneals •Through skin only •SURAL •Mosquito to bone •Score periosteum •TPS saw •Bounce blade •Osteotome
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- 33. Medial Displacement Calcaneal Slide •Shift in plantar flexion, lock in dorsiflexion • 5-10mm • Fixation options • 6.5, 7.0 screws • 1 or 2 • Edgelock • IO Fix
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- 35. Failure Spring Ligament •Superomedial Component • Abduction through talonavicular joint • Inferior Component • Plantar sag of talonavicular joint
- 36. LCL/ Evans Osteotomy •Theory • Lateral column shortened • Usage • Anterolateral impingement • Forefoot abduction • TN subluxation > 30-50%
- 37. LCL/ Evans Osteotomy •Supine •Incision •Lateralover ant process •SURAL, PERONEALS •Find CC joint •Retract peroneals inferiorly •Measure 1.5cm proximal to CC joint •Score periosteum •TPS saw •Bounce blade
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- 45. LCL/ Evans Osteotomy •Distract • Lamina spreader • Hintermann distractor • Check TN reduction • Distract and measure • Autograft, allograft, biofoam wedges • Fixation options • > 4.0 screws • Laterally, axially • Plates • Biofoam wedges
- 46. Lateral Column Procedures •Lateral column lengthening • Restores arch height & talar head coverage • Evans procedure • Opening wedge calcaneal osteotomy • CC joint fusion • Loss 30-50% subtalar motion • Complete loss transverse tarsal motion Courtesy of Chi, et. al., CORR, 1999
- 47. Lateral Column Pain •Thomas RL, et al. Preliminary results comparing two Methods of lateral column lengthening. Foot Ankle Int. 2001; 22(2):107-19. • 3/34 (9%) feet w persistent lateral pain • J.T. Deland, et al. Posterior Tibial Tendon Insufficiency Results at Different Stages. HSSJ (2006) 2:157–160 • 8% w pain • 45% (10 feet of 22) w discomfort
- 48. Other Ligaments • Otherligaments/joints likely fail: may be combination • Flatfoot variants: • Collapse through TMT joints • Collapse through TN joints
- 49. Medial Column Procedures •Stage II • Medial column procedures • Correct forefoot supination • Options • PF cuneiform/Cotton osteotomy • PF 1st MT-cun arthrodesis • Nav-cun arthrodesis Pictures courtesy of Chi, et. al., CORR,
- 50. Spring Ligament Tear •Repair – primary • Reconstruction • PTT • Allograft/Autograft • TN fusion
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- 55. Surgical Treatment • StageII • Correct all deformity • FDL transfer • Medial displacement calcaneal osteotomy • Add • Lateral column • Lengthening/Evans • CC fusion • TAL • Medial column procedure • Cotton, Lapidus, PF osteotomy • Spring ligament • Repair vs reconstruction vs TN fusion
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