pes planovalgus tibialis posterior tendon dysfunction ... · pes planovalgus tibialis posterior...
TRANSCRIPT
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Pes PlanovalgusTibialis Posterior Tendon Dysfunction
stadium II
Therapeutic choices
Medializing Calcaneal osteotomy
Versus
Lengthening Calcaneal Osteotomy
Dr de Halleux Jacques GENOA, december 2th 2015
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TIBIALIS POSTERIOR INSUFFICIENCY
Calcaneum valgus
Subtalar joint tilted medially
Talus medialy and down
T-N and N-C subluxation
Midtarsal joints Abduct + supination
valgus hindfoot Achilles T = Evertor
PLANO
ABDUCTO
VALGUS
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Ø Stage 1Ø A : inflammation, no deformation Ø B : partial PTT tear, no deformationØ C : partial PTT tear, little hindfoot valgus
Ø Stage 2 = SUPPLEØ A : valgus hindfoot ; (<50% uncovering TN)Ø B : forefoot supination flexible (>50% uncovering TN)Ø C : A or B with forefoot supination fixed)Ø D : Forefoot abductionØ E : medial column (TN, NC, CMT) instability
Ø Stage 3 = RIGIDØ A :Hindfoot valgusØ B :Forefoot abduction
Ø Stage 4Ø A : reductible ankle valgusØ B : rigid ankle valgus (more common presentation)
Myerson, JBJS Am, 1996
STAGEStibialis posterior dysfunction
complex problem that has multiple treatment options *
PLANUS VALGUS
ABDUCTUSSUPINATION
MEDIAL COLUMN
* Hill K, Foot Ankle Clin. 2003. 8(1):91-104
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BONE PROCEDURES
MEDIALIZATION CALCANEAL OSTEOTOMY (KOUTSOGIANNIS, MYERSON)MALERBA CALCANEAL OSTEOTOMYSILVER CALCANEAL OSTEOTOMY
LATERAL LENGHTENING OSTEOTOMY LATERAL LENGHTENING CALCANEO-CUBOIDAL ARTHRODESIS
SUBTALAR ARTHRODESISSUBTALAR ARTHROERESISTALO-NAVICULAR ARTHRODESIS
MEDIAL COLUMN RESTORATIONCOTTON CUNEIFORM 1 OSTEOTOMYPLANTAR FLEXION MT1 OSTEOTOMYARTHRODESIS NAVICULO-CUNEIFORM 123ARTHRODESIS TARSO-MT1
SOFT TISSUE PROCEDURES
TIBIALIS POSTERIOR RECONSTRUCTIONSUTURETRANSFER(TFDL OR FDC; COB TECHNIQUE)
SPRING LIGAMENT RECONSTRUCTIONACHILLES TENDON LENGHTENING
MENU A LA CARTE
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MEDIALIZING CALCANEAL OSTEOTOMYMCO
(valgus correction)
Koutsogiannis. JBJS. Febr 1971
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Line of weight-bearing transmitted through the talus medial to the calcaneus
MEDIALIZING CALCANEAL OSTEOTOMYMCO
(valgus correction)
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SURGICAL TECHNIQUE MCO
Lateral incision (parallel and behind peroneal tendon) sural n !
Osteotomy // skin incision
MEDIAL TRANSLATION POSTERIOR PART CALCANEUM (1/3 to ½ of the width of the calcaneus)
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2- LINEAR RELATIONSHIP between:
- amount of MCO displacement- correction hindfoot alignment
1- TREATMENT of AQUIRED FLATFOOT
= Association of different procedures that impact hindfoot alignment(MCO, LCL, TMT fusion, reconstruction PTT + spring ligament …)
Main Predictor of hindfoot valgus alignment correction = MCO(others: much lesser effect)
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3- HINDFOOT MOMENT ARM
- Help surgeon to titrate the amount of correction
- 0 - 5 mm varus = greatest clinical improvement *
PREOP POSTOP
MOST INFERIOR ASPECT CALCANEUM
* M Conti et al, F&A International, 2015. 36(8):919-927
VALGUS VARUS
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MCO FIXATION = 1 headless screw
- 2 headless screws : no better result- Headed screw : 30 -50% removal
- lateral plate : more non-union
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- Good results- No non-union- N = 30
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- Valgus
- Eversion force of the Achilles tendon
- Medial arch + Forefoot abduction
= only if no severe flatfoot
MCO alone
not enough!
MCO Correction of :
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Suture / Z lenghtening
Transfert FDL-FHLTib ant (Cobb)
RECONSTRUCTION SPRING LIGAMENT
RECONSTRUCTION PTT
OSTEOTOMY - ARTHRODESISLCL, Cotton, MT1 N-C, T-MT
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RESULTSMCO + FDL transfert
* Myerson MS, Orthopedics. 19:383-8,1996** Wacker JT, JBJS. 84-B : 54-8, 2002
Myerson M S *n:32 st II PTT dysfunctionmean age : 58 yFU : 20 months (14 to 48) results : AOFAS score 48 to 84
94% pain relief, improvement arch of the foot
Wacker J T **n : 44 st II PTT dysfunctionmean age 61 yFU : 51 months ( 38 to 62 )results : AOFAS score 48 to 88,5
95% pain relief80% improvement arch of the foot
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CALCANEAL OSTEOTOMY: Lateral column lengthening
St IID : forefoot abduction
picture from Hintermann B: Techniques in Orthopaedics and Traumatology 2000
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Correction of:
- Medial arch height *not because F Pl tightness ***
- Forefoot abduction*improve coverage Talar head by Navicular
- Hindfoot valgus*
Side effect:
- Lateral forefoot plantar pressure ** simultaneous procedure medially
* Evans D, Calcaneo-valgus deformity. JBJSBr. 1975;57-B(3):270-278** Benthien et al, Foot Ankle International.2007;28(1):70-77*** Horton, Myerson et al, Foot Ankle International.1998;19:370-373
EVANS PROCEDURE: Lateral column lengthening
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calcaneo-cuboidal osteoarthritis
Evans : 65% at 13 years follow-upMosier-Laclair : 14% at 5 years follow-up *
Alternative = calcaneocuboïd distraction arthrodesis
- less motion hindfoot, (loss subtalar motion of 18 to 30% and loss TN of 40%**)
- increasing arthritis hind and midfoot
•Mosier-Laclair, Foot Ankle Clinic (6):95-119, 2001 Mar ** Deland J et al, Foot Ankle.16(11) , 1995
LATERAL COLUMN LENGHTENING OSTEOTOMY LCL
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Cadaveric study
LCL with 8 mm trapezoidal grafts
CC joint pressure
CC joint Pressure
CC joint Pressure
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Linear relationship : - Graft size (Lenghtening LCL)- Correction forefoot abduction
(measured by the RX lateral incongruency angle)helpfull for surgeon to titrate the proper amount of correction
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Majority of publications = trapezoidal graft
Rectangular graft
Better bony realignment = Better flatfoot deformity correction(more graft volume medially)
(Intraarticular TN pressure : trapezoidal = rectangular)
Kind of graft shape?
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DOUBLE OSTEOTOMY : MCO + LCL
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- Performing MCO prior to the LCL osteotomy
Risk of overcorrection (cfr additional hindfoot inversion)
- Performing LCL osteotomy prior to MCO
Reduce risk of overcorrection
If double osteotomy performed : Prior MCO or Prior LCL?
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LCL without MCO
- LCL osteotomy
(autologous tricortical bone block, T-plate)
- Reinsertion Post. tib.
- FDL transfer to navicular
- Reconstruction Spring ligament
- Gastroc-slide/lengthening
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N=112 feetFU 2 years n101 feet58,2y
Talo-MT1 normalizedPost Tib insufficiency improvedVAS FA improvedPedography normalized
9% wound healing delay
Association- LCL- reconstructionTib Post + Spr
Lig
- Ach T lenghtening
safe and predictable technique Flatfoot correction
(Abducto-Plano-Valgus)
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- Posterior Tibialis Tendon Dysfunction St II=
Complex problemmultiple therapeutic options
- MCO or LCL = not to be used aloneNeed for Additional proceduresdepending on the deformations
CONCLUSION
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Thanks
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TIBIALIS POSTERIOR TENDON
� Inversion of the heel� Adduction forefoot� Plantar flexion of the
Ankle
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Tibialis posterior tendon
Inversion of the heelAdduction forefoot
Plantar flexion of the Ankle
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PLANO VALGO
ABDUCTUS
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DIAGNOSIS tibialis posterior dysfunction
flattening longitudinal archØ
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Ø valgus of the hindfoot
DIAGNOSIS tibialis posterior dysfunction
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Ø abduction of the mid and forefoot
Ø„too-many-toes sign“
DIAGNOSIS tibialis posterior dysfunction
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DIAGNOSIS tibialis posterior dysfunction
single-heel rise test
Normal Tib Post
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„single-heel-rise test“
Tib Post Dysfunction
DIAGNOSIS tibialis posterior dysfunction
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STAGEStibialis posterior dysfunction
stage 1 stage 2 stage 3 stage 4Ø retromalleolar pain + ++ ++ ++Ø hindfoot valgus (+/-) ++ ++ ++Ø arch flattening (+/-) ++ ++ ++Ø forefoot supination (+/-) (+) ++ ++Ø forefoot abduction (+/-) ++ ++ ++Ø deformity supple supple rigid rigidØ Ankle pain - - - ++
Stages 1, 2 , 3 = Johnson and Strom, Clin Orthop, 1989 Stage 4 = Myerson, JBJS Am, 1996
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Posterior Tibial Tendon Dysfunction St II TREATMENT
� Valgus hindfoot?
� Forefoot abduction?
� Forefoot supination?
� Medial column instability?
� Spring ligament ?
� Tibialis posterior?
� Achilles tendon ?
complex problem that has multiple treatment
options *
* Hill K, Foot Ankle Clin.8(1):91-104, 2003 Mar
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Ø retromalleolar painØ X Ray NormalØ Stages A : inflammation, no deformation
B : partial PTT tear, no deformationC : partial PTT tear, little hindfoot valgus
Posterior Tibial Tendon Dysfunction Stage 1
Tenosynovitis or partial rupture
Haddad St, Myerson MS and al, Foot and Ankle Int, 2011,jan.
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Supple pes plano valgus
Ø A : valgus hindfoot ; (<50% uncovering TN)Ø B : forefoot suppination flexible (>50% uncovering TN)Ø C : A or B with forefoot suppination fixed)Ø D : Forefoot abductionØ E : medial colomn (TN, NC, CMT) instability
Stage 2Posterior Tibial Tendon Dysfunction
(partial) rupture
Elongation, tendinosis
Haddad St, Myerson MS and al, Foot and Ankle Int, 2011,jan.
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Posterior Tibial Tendon Dysfunction
Stage 3
Ø Rigid pes plano valgus
Ø A :Hindfoot valgusØ B :Forefoot abduction
More advanced course of tendon rupture
Haddad St, Myerson MS and al, Foot and Ankle Int, 2011,jan
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1893 : medial closing wedge (Gleich)
1967: lateral opening wedge (Silver)
MEDIALIZING CALCANEAL OSTEOTOMYMCO (Koutsogiannis. JBJS. Febr 1971)
(valgus correction)
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CALCANEAL OSTEOTOMY(valgus correction)
� 1971 : medial translation of the posterior fragment (Koutsogiannis) –JBJS, febr 1971-
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MEDIAL TRANSLATION POSTERIOR PART CALCANEUM ( 1/3 to ½ of the width of the calcaneus; 1 cm)
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LATERAL OPENING WEDGE OSTEOTOMY
2005 : Z osteotomy(Malerba)
pictures from: Th Leemrijse, B Valtin, Pathologie du Pied et de la cheville, 2009
CALCANEAL OSTEOTOMY(valgus correction)
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MALERBA OSTEOTOMY Lateral opening wedge osteotomy
picture from: Th Leemrijse, B Valtin, Pathologie du Pied et de la cheville, 2009
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TIBIALIS POSTERIOR RECONSTRUCTION :suture
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TENDON RECONSTRUCTION:Z-lengthening
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TENDON RECONSTRUCTION : FHL or FDC transfert
Tibialis posterior
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TENDON RECONSTRUCTION WITH TIBIALIS ANTERIOR
COBB TECHNIQUErestore plantar flexion power of the 1st ray
( more distal insertion of the Tib Ant)supple forefoot supination St IIB
Knupp M, Hintermann B, Foot Ankle Int,. vol 28 (4) : 416-21, 2007
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COBB TECHNIQUE
Knupp M, Hintermann B
- n = 22 PTT dysfunction st IIB- FU : 24 months- results : AOFAS score 53,2 to 88,5
excellent / good results : 95 %no decreasing Force of TA
- Cobb technique = apropriate alternative to arthrodesisin st II B PTT dysfunction ( in addition with other technique)
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LIGAMENT RECONSTRUCTIONspring ligament suture
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RESULTSMCO + LCL + FDL transfert ( Mosier-Laclair**)
� Satisfaction rate high
� No medial arch restauration in all patients
� Cc arthritis 14%
** Mosier-Laclair, Foot and Ankle Clinic, Mar 2001: (6):95-119;
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Posterior Tibial Tendon Dysfunction
Stage 4
Ø Rigid pes plano valgus Ø Lateral ankle pain
Ø A : reductible ankle valgusØ B : rigid ankle valgus (more common presentation)
ankle arthrosis
rupture
Talus valgus
Myerson MS and al, Foot and Ankle Int, 2011,jan
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conservative • physiotherapy• shoe corrections• medial support
Posterior Tibial Tendon Dysfunction TREATMENT
Ø Stage 1
Surgery? Ténosynovectomy?
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LCL osteotomy correct
- Majority of the hindfoot valgus deformity
- While also correct the midfoot deformity
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Posterior Tibial Tendon Dysfunction Stage II
Treatment
SURGICAL
- Calcaneal osteotomy( >< valgus :MCO and others (Silver, Malherba...)) ( >< abd midfoot :LCL lateral column lenghtening)
- Arthrodesis(>< abd forefoot : lateral column lenghtening)(>< supp forefoot : medial colomn)
- Tendon reconstruction(suture, plasty, transfert FHL or FDC, Cobb)
- Ligament reconstruction(spring ligament)
- Others(Achilles tendon lenghtening, TN arthrodesis, subtalar arthrodesis, subtalar arthroeresis, medial cuneiform osteotomy, 1st MT osteotomy)
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RESULTSCC arthrodesis + PTT repair + Achilles tendon
lenghtening ( Lauwerens, 2006)
� N = 20; FU = 24 months
� 85% complete relief of pain
� 10% nonunion
� 15% sural nerve dammage
Lauwerens, Acta Orthop, 2006 Feb; 77(1):156-63
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� Arthrodesis naviculo-cuneiform 123 *
� Arthrodesis 1st tarso-metatarsal
� Cotton osteotomy (plantar flexion opening wedge cun 1)**
� Plantar flexion osteotomy MT1
• Alastair Younger, Foot Ankle Int. 32 (1) : 101-3, 2011** Hirose CB, Foot Ankle Int. 25 : 568-74, 2004
Stephen J Pinney, Foot Ankle Int, 27 (1) : 66-75, 2006 jan
RIGID FOREFOOT SUPINATION?STADIUM II C
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surgical • triple arthrodeses
Posterior Tibial Tendon Dysfunction
Treatment
ØStage 3
ØA : + Medial transl calc ost
ØB : + lenght lat column
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Surgical* A : ankle soft tissue repair + Triple ArthrodesisB : Panarthrodesis / TTC arthrodesis
Posterior Tibial Tendon Dysfunction Treatment
Ø Stage 4
*Bluman EM, Myerson MS, Foot Ankle Clinic, 12(2): 341-62, 2007
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I II II / III III / IV IV
conservative MTCO PTT repair spring Medial Lateral Triple Soft tissue Pantalar
synovectomy ligam column column arthrodesis ankle TTC desis
I pain A PTT nfllam; no deform
B parti PTT tear; no deform
C part PTT tear; little valgus
II supple PPV A calc valgus
B supple forefoot supp (COBB)
C rigid forefoot supp
D forefoot abd
E mdl column instabiliy
III rigid PPV A calc valgus
B forefoot abd
IV ankle valgus A supple
B rigid
Posterior Tibial Tendon Dysfunction TREATMENT
CONCLUSION
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Posterior Tibial Tendon Dysfunction CONCLUSION
• Good physical examination• Good treatment indication• Good results
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Linear relationship : - LCL graft size - Correction forefoot abduction
(measured by the RX lateral incongruency angle)helpfull for surgeon to titrate the proper amount of correction
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Rectangular graft ( no trapezoidal)
� better bony realignment = better flatfoot deformity correction(more graft volume medially)
� Intraarticular TN pressure :trapezoidal = rectangular
What kind of graft shape?
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- Tibialis Posterior Dysfunction St II=
Complex problem multiple therapeutic options
- MCO or LCL = not to be used aloneAdditional procedures mandatorydepending on the deformations
- Displacement : - MCO = Hindfoot moment arm = 0-5 mm varus- LCL = 0,8 cm
- Double Osteotomy: LCL prior to the MCOavoid overcorrection
CONCLUSIONS