SLR - October 2017 - Anthony M. Chesser
Reference: Ruffilli A, Traina F, Giannini S, Buda R, Perna F. Surgical Treatment of Stage II Posterior Tibialis Tendon Dysfunction: 10-Year Clinical and Radiographic Results. Eur J Orthop Surg Traumatol 2017 Jul doi: 10.1007/s00590-017-2011-z. [Epub ahead of print]Scientific Literature Review
Reviewed By: Anthony M. Chesser, DPM
Residency Program: The Western Pennsylvania Hospital, Pittsburgh PA
Podiatric Relevance: This paper discusses midterm radiographic and surgical outcomes for patients with stage II posterior tibial tendon disorder (PTTD). This paper was chosen because stage two PTTD has mixed treatment algorithms, and this paper had high AOFAS scores at a 10-year follow-up (89±10).
Methods: This is a retrospective review of 63 patients (102 feet) who underwent surgical correction of stage II PTTD. Patients who underwent bilateral surgical correction of PTTD were not done in succession. Patients with MRI confirmation of a partial tear of their tibialis posterior (PT) tendon underwent flexor digitorum longus tendon transfer into the navicular with a bone tunnel (49 patients). Salvageable PT tendons were repaired, and diseased portions were resected (53 cases). Additional procedures included a medial displacement calcaneal osteotomy (MDCO) and a lateral column lengthening (LCL) depending on clinical presentation of the foot (hindfoot valgus or forefoot abduction). Achilles lengthening was performed on patients with triceps surae contractures. Patients were reassessed clinically and radiographically at a final follow-up of 125.1 ± 41.9 months. Clinical evaluation was performed by hindfoot AOFAS score. Radiographic assessment included measurement of the lateral talus-first metatarsal angle (LTFMA) and the talo-navicular coverage angle (TNCA).
Results: AOFAS hindfoot scores were 89 ± 10 at the final follow-up. Eighty-six percent of the patients were satisfied or satisfied with minor reservation. Radiographic evaluation showed statistical significant decrease in both LTFMA and TNCA. The authors found better TNCA correction with cases that had associated LCL as opposed to MDCO. There were four failures, all of which required surgical revision and subtalar joint fusions.
Conclusion: The authors had relatively high midterm satisfaction rates with their PTTD stage II protocol. The authors concluded that when bony deformities are addressed with appropriate osteotomies (i.e., MDCO for heel valgus and LCL for forefoot abduction) patients had long-lasting good results in conjunction with soft-tissue work. This article reinforces that when addressing flexible flat feet, physicians should have prolonged success with joint-sparing osteotomies and soft-tissue repairs and transfers. Fusions should be spared as salvage procedures or for more severe pathology.