lecture 26 parekh pttd2
TRANSCRIPT
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Stage 2 – Posterior Tibial Tendon Dysfunction
Selene G. Parekh, MD, MBAAssociate Professor of Surgery
Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery
Adjunct Faculty Fuqua Business SchoolDuke University
Durham, NC919.471.9622
http://seleneparekhmd.comTwitter: @seleneparekhmd
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PTT Dysfunction
Most common cause acquired
adult flatfoot
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Adult Acquired Flatfoot Classification
Stage
Tendon Deformity
I Degenerated
None (mild)
II Elongated, partial tear
Flexible, ↑heel valgus, possible forefoot
abduction III Elongated,
Partial tearStiff/fixed: minimal heel
inversion
IV Elongated,partial tear
Valgus ankle tilt
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• A diverse constellation of deformity• Numerous names:
• PTTI, PTTD, Adult Acquired Flatfoot (AAFD), Adult Progressive Flatfoot, Collapsing Pes Valgus
Combined tendon/ligament failure
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Stage II
• Variability in 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.
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IIa
• Less than 30% medial talar head uncoverage (or no lateral incongruence)
• No clinical forefoot abduction
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IIb
• More than 30% medial talar head uncoverage or lateral incongruence
• Significant clinical forefoot abduction
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Lateral Incongruence
Congruent
IIa
Incongruent
IIb
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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
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Function/Biomechanics
• Initiates heel rise• 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
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Pathophysiology
• Unopposed pull of peroneal brevis• forefoot abduction• Attenuation in medial ligamentous structures
• Progressive collapse of arch• End stage
• Marked calcaneal valgus• Talus PF• Forefoot abduction
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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
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Etiology
• “Critical zone of hypovascularity”• Medial malleolus to navicular
• Diabetes• Hypertension• Obesity• Trauma
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Clinical Presentation
• Stage II: 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
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Physical Exam
• Observation (front & behind)• Deformity• Fullness behind medial malleolus
• Single toe raise• Evaluate TMT joints for
arthrosis/hypermobility (can mimic PTT dysfunction)
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Physical Exam
• Range of motion• Muscle strength testing• Swelling @ PTT• Tenderness @
PTT/sinus tarsi
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X-rays
• WB AP Foot• Talo-2nd MT angle• Lateral subluxation of
TN joint
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X-rays
• WB Lateral Foot• Sag of TN joint• Talo-1st MT angle (Meary’s angle)• Height of medial cuneiform or MT overlap
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X-rays
• WB Ankle Series• Hindfoot alignment view
• MRI • Controversial in its role
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Conservative Treatment
• Orthotic w/ 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
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Surgical Treatment
• Stage II: 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
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Equinus
Strayer
• Gastroc• Sural nerve• Larger incision• More time
TAL
• Quick• Atrophy of gastroc• Loss strength
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FDL Transfer
• Medial midline 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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FDL Transfer
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FDL Only
• Stage II (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
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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
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Medial Displacement Calcaneal Slide
•Supine•Incision
•1cm posterior to peroneals•Through skin only•SURAL
•Mosquito to bone•Score periosteum•TPS saw
•Bounce blade•Osteotome
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MCO
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MCO
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MCO
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MCO
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MCO
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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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PTT Dysfunction
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Failure Spring Ligament
• Superomedial Component• Abduction through
talonavicular joint
• Inferior Component• Plantar sag of
talonavicular joint
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LCL/ Evans Osteotomy
• Theory• Lateral column shortened
• Usage• Anterolateral impingement• Forefoot abduction
• TN subluxation > 30-50%
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LCL/ Evans Osteotomy
•Supine•Incision
•Lateral over 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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LCL
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LCL
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LCL
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LCL
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LCL
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LCL
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LCL
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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
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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
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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
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Other Ligaments• Other ligaments/joints likely fail: may be
combination• Flatfoot variants:
• Collapse through TMT joints
• Collapse through TN joints
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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, 1999
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Spring Ligament Tear
• Repair – primary
• Reconstruction• PTT• Allograft/Autograft
• TN fusion
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Spring Ligament Tear
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Spring Ligament Tear
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Spring Ligament Tear
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Spring Ligament Tear
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Surgical Treatment
• Stage II• 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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RE ECT
the ankle
the foot