Treatment of Posterior Tibial Tendon Dysfunction With Flexor Digitorum Longus Tendon Transfer and Calcaneal Osteotomy

Abstract

We treated 32 patients with stage-II posterior tibial tendon dysfunction with calcaneal osteotomy and flexor digitorum longus tendon transfer. These 32 patients (29 women, 3 men) had an average age of 58 years (range, 46 to 73 years) and had been symptomatic for an average of 2.5 years (range, 1 to 8 years) before surgical correction. The indication for surgery was the presence of medial foot pain refractory to nonoperative treatments, including shoewear modifications, orthoses, and bracing. All patients were examined at a mean of 20 months (range, 14 to 48 months) after surgery. Functional and radiographic examinations were performed for each patient and the American Orthopaedic Foot and Ankle Society (AOFAS) foot rating scale was used. Of the 32 patients, 30 were satisfied with the outcome of surgery, had improved function, and exhibited radiographic correction of the foot deformity. The AOFAS score improved from a preoperative mean of 48 points (range, 23 to 76) to a postoperative mean of 84 points (range, 68 to 92). In one patient, treatment failed, necessitating a triple arthrodesis for worsening deformity. The short-term results of this procedure are encouraging. Most patients (94%) experienced pain relief, had improvement in the arch of the foot, and were able to wear regular shoes without orthotic support. In order to correct deformity and provide substantial relief of foot pain and dysfunction, a medial translational calcaneal osteotomy was performed in addition to a flexor digitorum longus tendon transfer for management of stage-II posterior tibial tendon dysfunction.

Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity

“…6,15,21,34 Failure of this initial approach leads to surgical treatment, aiming to an asymptomatic, aligned and stable foot. 3, 7,11,21,30,34…”

“…The flexible hindfoot valgus (stage IA) is a common presentation of progressive collapsing foot deformity (PCFD). 5,6,14,15,18,24,28,30,40 Clinical findings include swelling and tenderness over the posterior tibial tendon (PTT), diffuse symptoms as fatigue or strain over the foot or ankle joints or subtle equinus contracture caused by gastrocnemius tightness. 2,4,17,21,31,34 Conservative measures as insoles for medial arch support, analgesic medication, physical therapy, weight loss or temporary immobilization may provide symptomatic relief.…”

“…6,15,21,34 Failure of this initial approach leads to surgical treatment, aiming to an asymptomatic, aligned and stable foot. 3,7,11,21,30,34 PTT tendoscopy was first described by Wertheimer et al 41 in a case report of a tendon sheath opening through a 2-incision endoscopic approach, and was later supported by the report of a cadaveric and a clinical prospective study by van Dijk et al 38 This minimally invasive technique, performed in isolation or combined with other procedures, has been suggested as a useful and safe procedure in flexible PCFD, providing information regarding PTT status and at the same time allowing full tendon inspection and debridement. 9,13,20,25,29,39 Medializing calcaneal osteotomy (MCO) plays a central role on correction of a coronal plane deformity in PCFD, by restoring the axis of action of the gastrocnemius-soleus complex insertion medially to the axis of the ankle joint, providing correction of hindfoot valgus and improving inversion of the heel.…”

Endoscopic assisted posterior tibial tendon reconstruction for stage 2 posterior tibial tendon insufficiency

“…The treatment of stage 2 posterior tibial tendon insufficiency is still controversial. Different combination of open procedures of tendon transfer, calcaneal osteotomy and hindfoot arthrodesis has been described [3][4][5][6][7][8][9][10]. We describe an endoscopic approach to reconstruct the posterior tibial tendon.…”

Isolated Gastrocnemius Recession for Progressive Collapsing Foot Deformity

“…17 Postoperative protocols following PCFD reconstruction typically involve non-weight bearing (NWB) for 4 to 9 weeks depending on the procedures performed. [18][19][20] Yet many patients have difficulty maintaining NWB restrictions. 21 Studies evaluating elderly patients have reported a range of 0% to 22% ability to maintain compliance with weight-bearing restrictions after pelvis, hip, or femur fracture fixation.…”