Stage II: Posterior Tibial Tendonitis



- Discussion:
    - inflammation causes tenosynovitis and elongation;
    - hindfoot remains supple and is reducible;
    - pt has flexible flat foot, & w/ removal of weight, foot resumes its normal arch;
    - it is essential to distinguish the supple type II lesion from the type III lesion (fixed deformity), since the later cannot be corrected w/ tendon 
           transfers;

- Radiographs:
    - if there is medial and plantar subluxation of the talar head, then there must be failure/elongation of the spring ligament;


- Management:
    - generally deformity will progress during this stage, even with non operative treatment;
    - tendon transfer must be performed within weeks since fixed valgus deformity will occur w/ in several months;
    - furthermore, tendon transfers will not correct any flat foot deformity that has already taken place;
    - FDL tendon transfer:
           - if tendon is ruptured, joint is mobile, & no fixed deformity is present, a FDL tendon transfer to the navicular is performed 
                  (alternatively, the surgeon may use the FHL for transfer);
    - in the report by Johnson JE, et al (2000), the authors retrospectively reviewed the results of subtalar arthrodesis combined with spring 
           ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular;
           - there were 16 patients (17 feet) with an average follow-up of 27 months (9-52);
           - all deformities were passively correctable. The average age was 56 yrs (39-78).
           - 53% had lateral pain from subfibular impingement;
           - 2 patients were noted to have degenerative changes of the subtalar joint.
           - successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24).
           - standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees 
                  (24 degrees preoperative, 18 degrees postoperative);
           - talonavicular coverage angle improved an average of 17 degrees (34 deg preoperative, 17 deg postoperative).
           - lateral talo-1st metatarsal angle improved an average of 10 deg (18 deg preoperative, 8 degrees postoperative).
           - lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 deg postoperative);
           - distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively 
                  (avg. improvement 6mm).
           - this operative procedure allows correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the 
                  longitudinal arch;
    - in the report by Kitaoka HB, et al (2000),
           - 9 fresh-frozen foot specimens were studied to determine the mechanical behavior of the foot using calcaneocuboid distraction 
                  arthrodesis, an operation designed for treatment of posterior tibial tendon dysfunction with flatfoot deformity;
            - height arch increased after calcaneocuboid distraction arthrodesis an average of 3.2 ± 3.6 mm and was less than normal arch at 
                         an average of 2.1 ± 2.4 mm;
                  - calcaneotalar position improved after calcaneocuboid distraction arthrodesis in adduction and inversion;
                  - calcaneocuboid alignment compared with flatfoot improved after calcaneocuboid distraction arthrodesis in adduction,
                          plantar flexion, and eversion, but compared with an intact foot was overcorrected in all three planes of motion;
             - Calcaneocuboid Distraction Arthrodesis for Posterior Tibial Tendon Dysfunction and Flatfoot A Cadaveric Study
                 


Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency.
  
Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report.

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



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 10, 2012 5:06 pm