Timothy C. Beals

Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon.

Dysfunction of the posterior tibial tendon is increasingly recognized as an etiology leading to acquired flatfoot in adults. Increased awareness of this condition during the past fifteen years has resulted in intensive study of the basic science and pathophysiology behind this clinical syndrome. New regimens for clinical assessment and treatment have been developed. Although much progress has been made in the recognition and treatment of this condition, many controversies and unanswered questions remain. This article will review the current thinking with regard to the pathophysiology, clinical evaluation, and decision-making process for the treatment of this common, debilitating condition. Kulowski, in 1936, was the first, to our knowledge, to describe tenosynovitis of the posterior tibial tendon39. Almost twenty years later, Fowler discussed tibialis posterior syndrome and described a series of patients who had had operative treatment of that condition19. In 1963, Williams described the operative treatment of tenovaginitis of the posterior tibial tendon73. In 1969, Kettelkamp and Alexander reported on repair of spontaneous rupture of the posterior tibial tendon35. Little else was written regarding the problems emanating from dysfunction of the posterior tibial tendon until others rekindled interest in this subject during the 1980s28,32,33,44-46. Many authors have described the progressive nature of acquired flatfoot that occurs following the onset of dysfunction of the posterior tibial tendon in an adult4,9,12,20,22,26,27, and a multitude of treatment regimens have been reported2,5,7,8,13,15,19,21,23,25,28,30,32,35,38,40,46,48,52,57,58 …

Postoperative complications of posterior ankle and hindfoot arthroscopy.

BACKGROUND Posterior ankle and hindfoot arthroscopy, performed with use of posteromedial and posterolateral portals with the patient in the prone position, has been utilized for the treatment of various disorders. However, there is limited literature addressing the postoperative complications of this procedure. In this study, the postoperative complications in patients treated with posterior ankle and hindfoot arthroscopy were analyzed to determine the type, rate, and severity of complications. METHODS The study included 189 ankles in 186 patients (eighty-two male and 104 female; mean age, 37.1 ± 16.4 years). The minimum duration of follow-up was six months, and the mean was 17 ± 13 months. The most common preoperative intra-articular diagnoses were subtalar osteoarthritis (forty-six ankles), an osteochondral lesion of the talus (forty-two), posterior ankle impingement (thirty-four), ankle osteoarthritis (twenty), and subtalar coalition (five). The most common extra-articular diagnoses were painful os trigonum (forty-six), flexor hallucis longus tendinitis (thirty-two), and insertional Achilles tendinitis (five). RESULTS The most common intra-articular procedures were osteochondral lesion debridement (forty-four ankles), subtalar debridement (thirty-eight), subtalar fusion (thirty-three), ankle debridement (thirty), and partial talectomy (nine). The most common extra-articular procedures were os trigonum excision (forty-eight), tenolysis of the flexor hallucis longus tendon (thirty-eight), and endoscopic partial calcanectomy (five). Complications were noted following sixteen procedures (8.5%); four patients had plantar numbness, three had sural nerve dysesthesia, four had Achilles tendon tightness, two had complex regional pain syndrome, two had an infection, and one had a cyst at the posteromedial portal. One case of plantar numbness and one case of sural nerve dysesthesia failed to resolve. CONCLUSIONS Our experience demonstrated that posterior ankle and hindfoot arthroscopy can be performed with a low rate of major postoperative complications.

Posterior tibial tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.

Subtalar Distraction Bone Block Fusion: An Assessment of Outcome:

Twenty-nine feet in 28 patients who underwent subtalar distraction bone block fusion for the treatment of subtalar deformities associated with symptomatic arthrosis were evaluated. All patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score. Eighteen men and 10 women with a mean age of 44 years were evaluated. The mean follow-up was 33 months. Subtalar arthrosis was secondary to trauma in 27 of 29 feet (93%) with os calcis fractures in 19, subtalar dislocations in 5, and talus fractures in 3. Eighteen of the 28 patients (64%) returned to either full- or part-time work. The change in the mean AOFAS Ankle-Hindfoot Scale score from 25 preoperatively to 75 postoperatively was statistically significant (P < 0.0001). The radiographic analysis of the pre- and postoperative standing lateral radiographs showed an average increase of 8 mm in hindfoot height, 9° in lateral talocalcaneal angle, and 11° in lateral talar declination angle that were statistically significant (P < 0.0001). All patients but one (96%) were satisfied. Complications included four nonunions, two varus malunions, one metatarsal stress fracture, and one medial plantar nerve paresthesia. Each nonunion occurred in patients who smoked.

Clinical outcome of arthrodesis of the ankle using rigid internal fixation with cancellous screws.

Thirty consecutive patients underwent arthrodesis of the ankle using rigid internal fixation with cancellous screws between 1992 and 1996. One patient died of causes unrelated to the surgery before bony union. Primary fusion occurred in 27 of the remaining 29 patients (93%). The average time to primary union was 9 weeks. Two patients developed a delayed union and were treated with an additional bone-grafting procedure. Ultimately, each of the 29 patients went on to fusion. Use of tobacco during the postoperative period had no apparent effect on the rate of fusion or time to fusion. Twenty-five patients were available for clinical evaluation at an average of 24 months after surgery. Subjective evaluation using questionnaires revealed a high level of satisfaction. All patients stated that they would undergo the procedure again. The mean postoperative score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale was 81 points, compared with 48 points preoperatively (of a possible 100). Constant pain was the reason given by all patients for seeking treatment. After the arthrodesis, pain was reported as absent in 13 and occasional in 12 patients. All patients noted less pain in the hindfoot after fusion of the ankle. Active litigation and Workers’ Compensation claims during the perioperative period had a significant negative effect on scores on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale and seemed to decrease patients’ perceived ability to return to work.

Plantarflexion torque following reconstruction of Achilles tendinosis or rupture with flexor hallucis longus augmentation.

Nine patients treated surgically for Achilles tendon rupture (7 patients) or tendinosis (2 patients) with primary repair or debridement and augmentation with the flexor hallucis longus muscle-tendon unit were evaluated at a mean of 19 months postoperative. Subjective evaluation revealed a high level of satisfaction. All patients returned to work and only two patients reported limitation in their recreational activities. The mean post-operative AOFAS Ankle-Hindfoot Score was 90 points. Four patients reported mild occasional pain and one patient complained of moderate daily pain. Motion assessment showed a 20% increase in the hallux MTP dorsiflexion compared to the non-operative side (p = 0.045). No difference in ankle motion was noted. Cybex II+ dynamic evaluation of plantarflexion peak torque was complete on both extremities. The torque deficit on the reconstructed extremity was 20% (p = 0.01) at 120 degrees per second and 26% (p = 0.003) at 30 degrees per second. There is no significant difference between the torque deficit recorded for patients with Achilles rupture and those with Achilles tendinosis. A trend toward improved torque production with longer follow up was observed.

The Effects of Medial and Lateral Displacement Calcaneal Osteotomies on Ankle and Subtalar Joint Pressure Distribution

We compared the pressure distribution in the ankle and posterior facet of the subtalar joint following 1 cm medial and lateral displacement calcaneal osteotomies to the pressure distribution in the intact foot. Six cadaver specimens were loaded in neutral alignment while pressure measurements were recorded. A 1-cm medial displacement osteotomy shifted the average center of force in the ankle 1.0 mm medially (p = 0.36) while a lateral displacement osteotomy shifted the center of force 1.1 mm laterally (p = 0.42). There was also a slight shift in the percentage of pressure toward the side of the talus to which the calcaneus was shifted. For the lateral displacement osteotomy, the pressure increased 4.0% in the lateral-most quadrant (p = 0.05), while the medial osteotomy increased the pressure 1.3% in the medial quadrant (p = 0.30). In the subtalar joint, a medial displacement osteotomy shifted the pressure distribution slightly medially (5.9%, p = 0.06) and more anteriorly (9.6%, p = 0.02) while the distribution was shifted laterally (5.9%, p = 0.17) and anteriorly (5.6%, p = 0.03) with a lateral displacement osteotomy. These shifts of percentage of pressure between quadrants of the joints were slight—less than 5% in the ankle and less than 10% in the subtalar joint. Significant translation of the calcaneal tuberosity appears to have only a small effect on pressure distribution in the ankle and posterior facet of the subtalar joint in a weighted cadaver model.

Functional outcome after modified Blair tibiotalar arthrodesis for talar Osteonecrosis

Background: Osteonecrosis of the talar body is a challenging problem for both patient and surgeon. One reconstruction option is an arthrodesis of the tibia to the talar neck, as described by Blair, 2 which has the theoretical advantages of salvaging some hindfoot height and motion of the subtalar joint. A few case series have been published describing outcome after modified Blair fusions, none with validated functional outcomes. The purpose of this article is to describe a modification of Blairs original technique, and report the functional outcomes in a series of patients undergoing this procedure. Method: A retrospective review of seven patients with talar osteonecrosis undergoing modified Blair tibiotalar arthrodesis was performed. The median patient age was 51 (range, 39–78). Median follow-up was 20 months (range, 12–112). Two patients required a repeat procedure for delayed/nonunion, with subsequent uneventful union. In all patients the procedure included compression screw fixation of the talar head to the anterior distal tibia, with the two repeat procedures and the most recent patient having an additional anterior compression plate and bone graft. Functional outcome measures using both the AOFAS ankle-hindfoot score and the SF-36® global health outcome measure were obtained at latest follow-up. In addition, radiographic assessment of bone union and time to union was determined. Results: Median SF-36® physical and mental component scores were 46 and 61, respectively. The median AOFAS ankle-hindfoot score was 67 out of 100. Median visual analog scales for postoperative pain and function were 7.1 and 6.0 respectively, out of a best possible score of 10. Conclusion: Functional outcome scores after modified Blair arthrodesis are lower than similar scores after conventional tibiotalar fusion, and much lower than “normal” values; however, the procedure has similar, if not lower, complication rates to alternative complex hindfoot reconstructions, and this procedure is a valuable alternative in the management of talar osteonecrosis with arthrosis.

New paradigm for patient-reported outcomes assessment in foot & ankle research: computerized adaptive testing.

Background: Accurately measuring, reporting and comparing outcomes is essential for improving health care delivery. Current challenges with available health status scales include patient fatigue, floor/ceiling effects and validity/reliability. Methods: This study compared Patient Reported Outcomes Measurement Information System (PROMIS)-based Lower Extremity Physical Function Computerized Adaptive Test (LE CAT) and two legacy scales -the Foot and Function Index (FFI) and the sport module from the Foot and Ankle Ability Measure (spFAAM) -for 287 patients scheduled for elective foot and ankle surgery. We documented the time required by patients to complete the instrument, instrument precision, and the extent to which each instrument covered the full range of physical functioning across the patient sample. Results: Average time of test administration: 66 seconds for LE CAT, 130 seconds for spFAAM and 239 seconds for FFI. All three instruments were fairly precise at intermediate physical functioning levels (i.e., Standard Error of Measurement < 0.35), were relatively less precise at the higher trait levels and the LE CAT maintained precision in the lower range while the spFAAM and FFIs had decreased precision. The LE CAT had less floor/ceiling effects than the FFI and the spFAAM. Conclusion: The LE CAT showed considerable advantage compared to legacy scales for measuring patient-reported outcomes in orthopaedic patients with foot and ankle problems. Clinical Relevance: A paradigm shift to broader use of PROMIS-based CATs should be considered to improve precision and reduce patient burden with patient-reported outcome measurement for foot and ankle patients.

Deltoid Ligament Abnormalities in Chronic Lateral Ankle Instability

Background: Treatment of patients with repeated ankle sprains and chronic lateral ankle instability tends to focus on the lateral collateral ligaments. We reviewed records to ascertain the prevalence of abnormalities of the deltoid ligament in this population. Methods: Retrospective review of MR images and surgical reports was performed for all patients during a 3-year period that underwent surgical treatment of chronic ankle instability at a single institution. Forty-seven ankles (46 patients) met inclusion criteria. None had medial ankle pain. Results: On MRI, all patients had anterior talofibular ligament tear, plus injury to one or more additional ligaments. Ninety-one percent had injury of calcaneofibular ligament. Injury to the posterior talofibular ligament was less common (49%). Deltoid ligament injuries were seen in 72% of cases (23% superficial deltoid only, 6% deep deltoid only, 43% both superficial and deep components). Of patients with injury to the superficial deltoid, 32% had an intact deep deltoid ligament. MRI correlated well to surgical findings. Conclusion: Deltoid ligament injuries were common in patients with lateral ankle instability who underwent reconstruction. Level of Evidence: IV, Retrospective Case Series