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Background Methods Results Conclusion Equinovarus deformity correction was performed by soft tissue release and bone deformity correction, and tendon transfer to maintain deformity correction. Because of the high complication rate of tendon fixation methods, partial or total anterior tibial tendon or posterior tibial tendon transfer to the peroneus tertius tendon was reported. The purpose of this study was (i) to review the results of this tendon transfer technique after release and correction of talipes equinovarus, and (ii) to analyze the complication of this technique.Between February 2017 and May 2022, 176 patients (210 feet) with equinus and/or varus foot and ankle deformities underwent anterior or posterior tibial tendon transfer to the peroneus tertius in our institute. Preoperative and postoperative foot and ankle range of motion (passive and active) were checked. The postoperative radiographic assessment included antero‐posterior (AP), lateral, and hindfoot alignment radiographs. Preoperative and postoperative lateral tibio‐talar, talo‐calcaneal, talo‐first metatarsal, tibial‐sole angles, hindfoot alignment, and anterior subluxation of the talus were checked. The American Orthopedic Foot and Ankle Society (AOFAS) ankle‐hindfoot scale, and visual analog scale (VAS) were used to assess pain. Paired Student's t‐test was used to compare the clinical scores and radiographic angles before the operation and at the last follow‐up.The mean age of the patients was 23.27 ± 13.44 years (range, 3–69 years). The mean follow‐up time was 25.56 ± 16.37 months (range, 12–68 months). There were significant differences between the preoperative and postoperative measurements of the lateral tibio‐talar angle, lateral talo‐calcaneal angle, lateral talo‐first metatarsal angle, lateral tibial‐sole angle, and hindfoot alignment (p < 0.001). There was significant difference between the preoperative and postoperative AOFAS and VAS scores (p < 0.001). The early complications included infection in one patient, skin necrosis in two patients, and plantar numbness in three patients. The late complications included pin infection in three patients, tibio‐talar joint compression in four patients, forefoot pain in two patients, toe flexion in two patients, and plantar numbness in one patient. There were three cases of complications (1.43%) related to the transferred tendons.Tibialis anterior or posterior tendon transfer to the peroneus tertius is a safe and effective method for equinovarus deformity correction. It yielded excellent outcomes that produced high patient satisfaction and few complications. [ABSTRACT FROM AUTHOR]

The main aim of this study was to ultrasonographically analyse the thickness and the relationship between the Superomedial Bundle of the Spring Ligament and the Posterior Tibial Tendon in healthy subjects and its relationship with different epidemiological variables. Fifty-five healthy feet with a mean of 47 years old measuring the same ultrasound model and researcher. Demographic variables (age, sex, laterality, BMI, type of sports activity performed, and type of work activity) were collected from all participants. The thickness of the PTT and the Spring Ligament was measured in both longitudinal and transverse diameters. The intraclass correlation coefficient (ICC) was also analysed to assess the agreement of the measurements between a researcher and the ultrasound specialist radiologist. The mean thickness of the Spring ligament was 5.07 mm (95 % CI 4.75–5.38), while that of the PTT in its long axis was 3.58 mm (95 % CI 3.37–3.79). Regarding the interobserver agreement analysis, the intraclass correlation coefficient for measurements between observers was 0.91 (CI95 %: 0.698–0.977) which denotes a high degree of similarity between the clinician and the radiologist. This study describes the relationships between the thickness of the posterior tibial tendon and the superomedial Bundle of the Spring ligament in healthy subjects, as well as their variability according to certain epidemiological variables such as age, gender, occupation, and sport. On the other hand, the measurements taken by a researcher high agreement with those taken by a radiologist specialized in ultrasound. • There are differences between the thickness of the SMSL between men and women. • There are differences between age and the thickness of the PTT. • In healthy subjects the PTT was on average 0.7 times the size of the SMSL. • A high degree of agreement was found between the measurements taken by the investigators. [ABSTRACT FROM AUTHOR]

Purpose: To assess whether a correlation between the calcaneal pronation angle and the presence of internal plantar arch overload signs (such as upper-medial spring ligament lesion, posterior tibial tendon tenosynovitis, etc.) could lead to a better understanding of coxa pedis pathology. Material and methods: One hundred ankle MRIs of consecutive patients were retrospectively reviewed measuring the calcaneal pronation angle and either the presence or absence of internal plantar arch overload signs. Next, the association of overload signs with increasing pronation angle was evaluated to establish a cut-off point beyond which coxa pedis pathology could be defined. Results: The tibial-calcaneal angle values in patients with and without effusion proved to be significantly different (p < 0.0001). The tibial-calcaneal angle values in patients with and without oedema also demonstrated a significant difference (p < 0.0056). Regarding posterior tibial tendon, a significant difference was found between the two groups (p < 0.0001). For plantar fascia enthesopathy, the result was borderline significant (p < 0.054). A linear correlation was found between the value of pronation angle and the extent of spring ligament injury (p < 0.0001). In contrast, no correlation with age was found. Conclusion: In conclusion, the literature associates medial longitudinal plantar arch overload with posterior tibial tendinopathy and spring ligament complex injuries. Our data show that both injuries are highly correlated with increased calcaneal pronation angle, which could be considered a predictive sign of internal plantar arch overload, prior to the development of the associated signs. [ABSTRACT FROM AUTHOR]

Posterior tibial tendon insufficiency is the commonest cause of adult flexible flatfoot. Transfer of the flexor digitorum longus (FDL) has been described a therapeutic arsenal in flexible flat feet and posterior tibial tendon disorders. It is often combined with bony procedure (open or percutaneous calcaneal osteotomy). We describe a technique and the steps endoscopic approach of FDL transfer. The procedure is able to be performed safely and reproducible under perfect viewing In the future with a clinical study investigating, we purpose the results of such surgery in a cohort of patients with flexible flatfoot. Level IV Therapeutic study: case serie. No funding was received for this research project. [ABSTRACT FROM AUTHOR]

Purpose: The anatomy of the spring ligament complex, as well as its pathology, is not well known in daily clinical practice. The purpose of this study was to evaluate the shear-wave elastography properties of the spring ligament and the posterior tibial tendon in healthy adults, and to assess the reliability and reproducibility of these measurements. Methods: Shear-wave elastography was used to evaluate both ankles in 20 healthy patients (10 females/10 males) resting on a hinge support with their ankles in neutral, valgus 20° and varus 30° positions. The stiffness of the spring ligament and posterior tibial tendon was assessed by measuring the speed of shear wave propagation through each structure. Results: Posterior tibial tendon and spring ligament reach a maximum estimated stiffness in valgus 20° position (7.43 m/s vs 5.73 m/s, respectively). Flat feet were associated with greater spring ligament stiffness in the 20° valgus position (p = 0.01), but not for the posterior tibial tendon (p = 0.71). The physiologic weightbearing hindfoot attitude had no impact on the stiffness of the posterior tibial tendon or the spring ligament, regardless of the analysis position. Intra- and inter-observer agreements were all excellent for spring ligament stiffness, regardless of ankle position, and were good or excellent for posterior tibial tendon. Conclusions: This study describes a protocol to assess the stiffness of tibialis posterior and the spring ligament by shear-wave elastography, which is reliable, reproducible, and defines a corridor of normality. Further studies should be conducted to define the role of elastography for diagnosis/ evaluation of pathology, follow-up, or surgical strategies. [ABSTRACT FROM AUTHOR]

Ankle fractures with associated dislocation of the ankle joint are a common injury presenting to emergency rooms. The first step in successful management of these injuries is with closed reduction of the dislocation and splinting in as close to anatomic alignment as possible. Infrequently, closed reduction cannot be obtained due to interposed soft tissues. In the case of ankle dislocations, subluxation of the posterior tibial tendon into the tibiofibular syndesmosis is a rare associated injury that may prevent proper reduction of the ankle mortise and, if not identified and corrected, results in a poor long-term outcome. We present a rare case of a young, healthy male college athlete who sustained a closed ankle dislocation injury with subluxation of the posterior tibial (PT) tendon through the ankle joint and into the tibiofibular syndesmosis. Additionally, we present a brief literature review and technique guide on the reduction and relocation of the posterior tibial tendon to hopefully serve as a reference for management of this rare injury type.

The transfer of the posterior tibial tendon through the interosseous membrane is potentially an effective treatment to correct the deformity of the foot and ankle. Our study aimed to evaluate the anatomical feasibility of anterior transfer of the posterior tibial tendon through the interosseous membrane route using the musculotendinous junction (MTJ). Eighteen adult cadavers were used. The width and thickness of the tibial posterior MTJ, width of the interosseous membrane at the corresponding level, and the window size of the interosseous membrane were measured. Additionally, the distance between the distal end of the MTJ and the tip of the medial malleolus were recorded. The mean length of the posterior tibial tendon was 83.60 mm, the mean distance of the posterior tibial MTJ to medial malleolus tip was 45.48 mm and the mean length of MTJ was 31.74 mm. The mean width of distal end of MTJ was 7.76 mm, thickness of distal end of MTJ was 4.07 mm and the mean width of the interosseous membrane at the distal end of MTJ was 4.76 mm. We found the mean width of the proximal end of MTJ was 20.68 mm, the mean thickness of proximal end of MTJ was 5.52 mm, and mean width of interosseous membrane at the proximal end of MTJ was 8.76 mm. Our study has demonstrated that a 31 mm length incision made at approximately 45 mm from the proximal end of the medial malleolus can safely reach the MTJ. We recommend an opening length of the interosseous membrane of at least 20 mm. [ABSTRACT FROM AUTHOR]

Abstract Purpose Accessory navicular is accompanied by the deformity of valgus flexible flatfoot. The surgical treatment includes reconstruction of insertion of posterior tibial tendon following resection of the accessory navicular. However, this treatment could not correct completely the deformity of valgus flexible flatfoot. This study aimed to evaluate the efficacy of subtalar arthroereisis combined with medial soft tissue reconstruction in treating 8–14-year-old flexible flatfoot patients with accessory navicular. Methods Clinical data of 35 pediatric flatfoot patients (with 50 feet) with accessory navicular who underwent subtalar arthroereisis and medial soft tissue reconstruction between April 2013 and September 2018 were analyzed retrospectively. Anteroposterior, lateral, and hindfoot alignment radiological images were measured in the weight-bearing position, and visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and satisfaction degree were evaluated. Also, surgical complications were recorded. Results The average follow-up time of the patients was 30 ± 9.3 months. None of the patients presented wound complications, and no implant loosening was detected. The AOFAS and VAS scores improved significantly (P

Background: Spring ligament fulfills 2 main important functions: one, supporting the head of the talus and stabilizing the talonavicular joint, and the other, maintaining the longitudinal arch by acting as a static support. In this preliminary report, we describe an endoscopic repair for spring ligament injuries with modified portals. Methods: We performed a retrospective case series study from February 2019 to January 2022. Posterior tibial tendon and/or associated bone deformities were assessed at the same surgical procedure. All patients were ≥18 years old and they had more than 6 months of follow-up. The procedure was performed in 11 patients. Mean age was 46 years (range 18-63). Ten had concomitant bony realignment surgery, and 8 had posterior tibial tendon surgery. Results: In all patients, endoscopic spring ligament repair could be technically done. The modified portals were used in all procedures as described in the surgical technique. Three patients had a superficial lesion, 1 had a rupture <5 mm, 7 had a rupture >5 mm but not a complete rupture through the entire spring ligament. Most of the patients had good clinical results from the surgery that included endoscopic spring ligament debridement and/or repair at 2 years follow up Conclusion: In this small series we found that endoscopy may be an effective technique to diagnose and treat incomplete spring ligament injuries. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

Objective To present a novel approach for the anatomic reconstruction of the posterior tibialis tendon (PTT) in restoring plantar insertions and evaluate its efficiency in treating flexible adult‐acquired flatfoot deformity (AAFD) caused by PTT dysfunction. Methods For AAFD treatment, a novel PTT reconstruction method was presented. The current study involved 16 patients, including three men, and 13 women, from August 2017 to July 2019. The mean age was 43.2 ± 15.1 years (21–64 years). The innovative PTT repair method was used on all patients. The treatment involved performing a traditional Flexor Digitorum Longus (FDL) transfer in the navicular tuberosity and suturing the plantar insertions to FDL as tension was applied to tighten the plantar structures of the foot. The results were retrospectively analyzed. The clinical outcome was assessed using the pain visual analogue scale (VAS), the satisfaction VAS, and the American Orthopedic Foot and Ankle Society ankle–hindfoot scale (AOFAS‐AH). Isokinetic testing was performed using a dynamometer at 60°/s and 120°/s for inversion/eversion and plantarflexion/dorsiflexion, respectively, to determine the mean peak torque. Radiographic measurements were employed to assess the outcomes. Results Bone surgeries combined with the modified anatomic PTT reconstruction were performed on patients with medializing calcaneal osteotomy in 12 (75%) patients and subtalar joint fusion in four (25%) patients. The branch linking to the plantar insertions was detected in every case, with an average width of 3.5 ± 0.8 mm (3.1–4.3 mm). All patients were followed up for the mean of 16.8 ± 1.8 months (range, 15–20 months). The average postoperative functional scores, including pain VAS, satisfaction VAS, total AOFAS‐AH, and all AOFAS‐AH sub‐scales, steadily improved during the follow‐up. In the last follow‐up, isokinetic testing revealed no loss of plantarflexion strength (p = 0.350 and 0.098) and significant improvement in the inversion strength (p = 0.007 and 0.008) in the operated ankles at 60°/s and 120°/s. Radiographic outcomes, particularly the talar head uncovering, improved significantly after more than a year (p

Purpose: Accessory navicular is accompanied by the deformity of valgus flexible flatfoot. The surgical treatment includes reconstruction of insertion of posterior tibial tendon following resection of the accessory navicular. However, this treatment could not correct completely the deformity of valgus flexible flatfoot. This study aimed to evaluate the efficacy of subtalar arthroereisis combined with medial soft tissue reconstruction in treating 8–14-year-old flexible flatfoot patients with accessory navicular. Methods: Clinical data of 35 pediatric flatfoot patients (with 50 feet) with accessory navicular who underwent subtalar arthroereisis and medial soft tissue reconstruction between April 2013 and September 2018 were analyzed retrospectively. Anteroposterior, lateral, and hindfoot alignment radiological images were measured in the weight-bearing position, and visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and satisfaction degree were evaluated. Also, surgical complications were recorded. Results: The average follow-up time of the patients was 30 ± 9.3 months. None of the patients presented wound complications, and no implant loosening was detected. The AOFAS and VAS scores improved significantly (P < 0.001). Radiological parameters, such as the talar first metatarsal angle and talonavicular coverage angle on anteroposterior foot view, Meary's angle and calcaneal pitch angle on the lateral view, and calcaneus valgus angle on hindfoot alignment view improved significantly (P < 0.001). Postoperative complications were observed in three patients. Conclusion: Subtalar arthroereisis combined with medial soft tissue reconstruction significantly alleviated pain and improved the functions in pediatric and adolescent flexible flatfoot patients with accessory navicular; also, the radiological manifestations and functions improved. [ABSTRACT FROM AUTHOR]

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD. [ABSTRACT FROM AUTHOR]

Abstract Purpose The anatomy of the spring ligament complex, as well as its pathology, is not well known in daily clinical practice. The purpose of this study was to evaluate the shear‐wave elastography properties of the spring ligament and the posterior tibial tendon in healthy adults, and to assess the reliability and reproducibility of these measurements. Methods Shear‐wave elastography was used to evaluate both ankles in 20 healthy patients (10 females/10 males) resting on a hinge support with their ankles in neutral, valgus 20° and varus 30° positions. The stiffness of the spring ligament and posterior tibial tendon was assessed by measuring the speed of shear wave propagation through each structure. Results Posterior tibial tendon and spring ligament reach a maximum estimated stiffness in valgus 20° position (7.43 m/s vs 5.73 m/s, respectively). Flat feet were associated with greater spring ligament stiffness in the 20° valgus position (p = 0.01), but not for the posterior tibial tendon (p = 0.71). The physiologic weightbearing hindfoot attitude had no impact on the stiffness of the posterior tibial tendon or the spring ligament, regardless of the analysis position. Intra‐ and inter‐observer agreements were all excellent for spring ligament stiffness, regardless of ankle position, and were good or excellent for posterior tibial tendon. Conclusions This study describes a protocol to assess the stiffness of tibialis posterior and the spring ligament by shear‐wave elastography, which is reliable, reproducible, and defines a corridor of normality. Further studies should be conducted to define the role of elastography for diagnosis/ evaluation of pathology, follow‐up, or surgical strategies.

Medial ankle sprains have a very low incidence (5% of ankle ligament injuries), and most of the time, the first structure involved is the deltoid ligament complex. However, other structures, such as the spring ligament, posterior tibial tendon, and flexor retinaculum, can also get damaged. A 32-year-old man who had an ankle sprain while performing sports activities showed magnetic resonance imaging findings compatible with a detachment of the flexor retinaculum and medial dislocation of the posterior tibial tendon. Surgical intervention was suggested to this patient; deepening of the medial retromalleolar groove and reattaching of the retinaculum were performed. It is very important to consider this rare injury after a medial ankle sprain and to think out of the box, not always assuming a deltoid ligament lesion. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Background: Posterior Tibial Tendon (PTT) dysfunction is considered to have an important role in Progressive Collapsing Foot Deformity (PCFD). The objective of our study was to assess the relationship between PTT status and three-dimensional foot deformity in PCFD.Methods: Records from 25 patients with PCFD were included for analysis. The PTT was considered deficient in patients with a positive single heel rise test or a deficit in inversion strength. Three-dimensional foot deformity was assessed using the Foot and Ankle Offset (FAO) from Weight-Bearing-CT imaging. Hindfoot valgus, midfoot abduction and medial longitudinal arch collapse were assessed on X-Rays using hindfoot moment arm, talonavicular coverage angle and Meary's angle respectively. Deland and Rosenberg MRI classifications were used to classify PTT degeneration.Results: PCFD with PTT deficit (13/25) had a mean FAO of 7.75 + /- 3.8% whereas PCFD without PTT deficit had a mean FAO of 6.68 + /- 3.9% (p = 0.49). No significant difference was found between these groups on the hindfoot moment arm and the talonavicular coverage angle (respectively p = 0.54 and 0.32), whereas the Meary's angle was significantly higher in case of PCFD with PTT deficit (p = 0.037). No significant association was found between PTT degeneration on MRI and FAO.Conclusion: PCFD associated three-dimensional deformity, hindfoot valgus and midfoot abduction were not associated with PTT dysfunction. PTT dysfunction was only associated with a worse medial longitudinal arch collapse in our study. Considering our results, it does not appear that PTT is the main contributor to PCFD.Level Of Evidence: Level III, Retrospective Comparative Study. [ABSTRACT FROM AUTHOR]

Objectives: Posterior tibial tendon dysfunction (PTTD) affects the support of the medial longitudinal arch and stability of the hindfoot. The purpose of this study was to assess the relationships of PTTD with foot and ankle functions and foot deformities in patients with rheumatoid arthritis (RA). Methods: A total of 129 patients (258 feet) who underwent magnetic plain and contrast-enhanced magnetic resonance imaging were enrolled in this study. Positive magnetic resonance imaging findings were defined as tenosynovitis and incomplete and complete rupture of the posterior tibial tendon. Foot and ankle functions were assessed using the Japanese Society for Surgery of the Foot standard rating system for the RA foot and ankle scale (JSSF-RA) and self-administered foot evaluation questionnaire. Plain radiographs were examined for the hallux valgus angle, first metatarsal and second metatarsal angle, lateral talo-first metatarsal angle, and calcaneal pitch angle. Results: PTTD was associated with motion in the JSSF-RA (p=.024), activities of daily living in JSSF-RA (p=.017), and pain and pain-related factors in the self-administered foot evaluation questionnaire (p=.001). The calcaneal pitch angle was significantly lower in the feet with PTTD than in those without PTTD (median: 16.2° vs. 18.0°; p=.007). Conclusions: The present study shows that PTTD was associated with foot and ankle functions and flatfoot deformity. Thus, a better understanding of PTTD in patients with RA is important for the management of foot and ankle disorders in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: To present a novel approach for the anatomic reconstruction of the posterior tibialis tendon (PTT) in restoring plantar insertions and evaluate its efficiency in treating flexible adult‐acquired flatfoot deformity (AAFD) caused by PTT dysfunction. Methods: For AAFD treatment, a novel PTT reconstruction method was presented. The current study involved 16 patients, including three men, and 13 women, from August 2017 to July 2019. The mean age was 43.2 ± 15.1 years (21–64 years). The innovative PTT repair method was used on all patients. The treatment involved performing a traditional Flexor Digitorum Longus (FDL) transfer in the navicular tuberosity and suturing the plantar insertions to FDL as tension was applied to tighten the plantar structures of the foot. The results were retrospectively analyzed. The clinical outcome was assessed using the pain visual analogue scale (VAS), the satisfaction VAS, and the American Orthopedic Foot and Ankle Society ankle–hindfoot scale (AOFAS‐AH). Isokinetic testing was performed using a dynamometer at 60°/s and 120°/s for inversion/eversion and plantarflexion/dorsiflexion, respectively, to determine the mean peak torque. Radiographic measurements were employed to assess the outcomes. Results: Bone surgeries combined with the modified anatomic PTT reconstruction were performed on patients with medializing calcaneal osteotomy in 12 (75%) patients and subtalar joint fusion in four (25%) patients. The branch linking to the plantar insertions was detected in every case, with an average width of 3.5 ± 0.8 mm (3.1–4.3 mm). All patients were followed up for the mean of 16.8 ± 1.8 months (range, 15–20 months). The average postoperative functional scores, including pain VAS, satisfaction VAS, total AOFAS‐AH, and all AOFAS‐AH sub‐scales, steadily improved during the follow‐up. In the last follow‐up, isokinetic testing revealed no loss of plantarflexion strength (p = 0.350 and 0.098) and significant improvement in the inversion strength (p = 0.007 and 0.008) in the operated ankles at 60°/s and 120°/s. Radiographic outcomes, particularly the talar head uncovering, improved significantly after more than a year (p < 0.001 for all). Conclusions: The novel technique for PTT reconstruction in restoring the plantar insertions serves as an effective procedure in treating AAFD caused by PTT dysfunction in terms of delivering a consistent improvement in ankle inversion strength, medial longitudinal arch restoring, and satisfactory clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: A consensus group recently proposed the term progressive collapsing foot deformity (PCFD) and a new classification with 2 stages plus 5 classes to describe the complex array of flatfoot deformities. This study aimed to validate different diagnostic accuracy rates of the PCFD classification. Methods: This was a survey-based study distributed among 13 foot and ankle fellowship programs for 3 groups of participants with varied experience in practice (group 1: fellows in training, group 2: surgeons in practice for 1-4 years, and group 3: surgeons in practice for ≥5 years). Each participant was asked to assign 20 different cases of flatfoot deformity to the appropriate classes and stages using the PCFD classification. The overall diagnostic accuracy, class, and stage diagnostic accuracy rates for the 20 cases were calculated first for the entire cohort and then compared among the 3 groups. The misdiagnosis rate for each class of deformity (the sum of overdiagnosis and underdiagnosis rates) of the entire cohort was calculated and compared with the other classes. Mean and standard evidence were used to describe numerical data. One-way analysis of variance was used to compare values among the 3 groups and the 5 classes. P <.05 was considered statistically significant. Results: For the whole cohort, the overall diagnostic accuracy, class diagnostic accuracy, and stage diagnostic accuracy rates were 71.0%, 78.3%, and 81.7%, respectively There was a statistically significant difference between group 1 and 2, and group 1 and 3, in overall diagnostic accuracy and class diagnostic accuracy, with no significant difference among the 3 groups regarding stage diagnostic accuracy. Class B had a significantly higher overdiagnosis rate than the rest of the classes, whereas class D was significantly underdiagnosed than others. The misdiagnosis rates for classes A to E were 3.3%, 17.5%, 11.1%, 26.0%, and 3.7%, respectively. Conclusion: The PCFD classification showed overall fair diagnostic accuracy rates. The highest diagnostic accuracy was for "hindfoot valgus deformity" and "ankle instability." Further content validation of the PCFD classification is needed to examine the terminology and interpretation of those classes with low diagnostic accuracy including "midfoot/forefoot abduction deformity," "forefoot varus deformity/medial column instability," and "peritalar subluxation/dislocation." Level of Evidence: Level II, prospective comparative study. [ABSTRACT FROM AUTHOR]

Posterior tibial tendon subluxation in the setting of an ankle fracture is a rare occurrence and, to our knowledge, has not been reported in the trimalleolar ankle fracture subtype. We report a case of a 24-year-old male who sustained a right, closed trimalleolar ankle fracture and concomitant posterior tibial tendon anterior subluxation after a motor vehicle collision. The posterior tibial tendon was found to be incarcerated in the fracture. He underwent operative treatment to relocate the tendon and for open reduction and internal fixation for his fracture. It is imperative to assess for soft tissue entrapment in foot and ankle injuries as it may impede reduction by closed means and may lead to poor outcomes if not appropriately identified and addressed.

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD.

Background: Although surgical treatment for osteochondral lesion of the talus (OLT) can obtain good clinical outcomes, the rate of return to sports is variable. It is reported that medial OLT unrelated to trauma has abnormal structures in the medial aspect, which may induce the medial OLT due to the medial instability. The posterior tibial tendon (PTT) plays an important role in the stabilization of the foot, and high mechanical stress may be added to the PTT to compensate for medial instability in medial OLT. We investigated whether abnormal PTT findings on preoperative magnetic resonance imaging (MRI) in patients with OLT affect clinical outcomes after surgery.  Methods: Eighty-one ankles in 74 patients who were treated surgically for OLT were included in this study (41 men and 33 women; mean age, 26.0 years). Abnormalities of the PTT were evaluated using preoperative MRI. The Japanese Society for Surgery of the Foot (JSSF) scale, arch height, and ankle activity score (AAS) on standing plain radiogram were compared between patients with and those without preoperative PTT abnormalities., Results: Twenty-five ankles (30.9%) had PTT abnormalities on preoperative MRI. All patients with preoperative PTT abnormalities were medial OLT. There were no significant differences in the preoperative JSSF scale in the procedures for OLT. The postoperative JSSF scale and arch height were significantly lower in patients with preoperative PTT abnormalities than those without them. AAS in patients with preoperative abnormalities significantly decreased at the final follow-up.  Conclusion: PTT abnormalities on preoperative MRI may affect clinical outcomes even in preoperative asymptomatic patients in the medial OLT unrelated to trauma., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethical Committee of Hiroshima University issued approval E-879. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kawabata et al.)

Objective: To compare the effects of anchor reconstruction of posterior tibial tendon with the traditional Kidner's procedure for accessory navicular bone syndrome., Methods: A retrospective analysis was conducted on 40 young athletes diagnosed with accessory navicular bone syndrome who were admitted to our hospital from 2018 to 2021. Among them, 20 patients underwent the modified Kidner procedure for the anchor reconstruction of the posterior tibial tendon (Experimental group), while the remaining 20 patients were treated with the traditional Kidner's procedure (Control group). Regular follow-ups were conducted to evaluate the degree of relief of foot symptoms and functional recovery., Results: All patients were followed up for 12 to 24 months (mean duration: 18.6±3.7) after the operation. At the last follow-up, significant differences were observed in the function and symptom relief of the affected foot compared to the preoperative state. The experimental group had a mean operation time of 52.10 ± 3.41 minutes, significantly shorter than the control group's 61.25 ± 2.75 minutes. The mean time to return to normal activity was 12.65 ± 1.23 weeks for the experimental group, compared to 15.25 ± 1.16 weeks for the control group., Conclusion: The modified Kidner procedure demonstrates a higher patient satisfaction rate compared to the traditional Kidner procedure. This is attributed to its shorter duration, reduced trauma, and quicker recovery of normal activity., Competing Interests: The authors have no conflict of interest.

Background: Hindfoot arthrodesis is used in patients with advanced-stage acquired flatfoot, usually associated with degenerative joint disease. The objective of the present study was to evaluate the clinical and radiographic results of hindfoot arthrodesis using the single-incision medial approach. Methods: A case series of 18 consecutive patients undergoing surgical correction between 2015 and 2018 with hindfoot arthrodesis using the medial approach was evaluated. The clinical assessment used the visual analog pain scale, AOFAS hindfoot score, SF-36, and foot function index. Radiographs and personal satisfaction criteria were also analyzed. Results: All radiographic parameters evaluated showed a significant improvement (p <.05), except the calcaneal pitch. Pain decreased by 5.1 points (p <.001), and the mean final AOFAS score was 72.6. In three feet, a new surgery was required. Two feet developed talar necrosis. None of the cases presented surgical wound dehiscence, and two presented with superficial infection, which was resolved with the use of oral antibiotics. Conclusion: Double arthrodesis (subtalar and talonavicular) to correct adult-acquired valgus flatfoot using a medial approach has a low risk of soft tissue complications and presents satisfactory functional results. Avascular necrosis is a serious complication that was present in 11% of cases. [ABSTRACT FROM AUTHOR]

Background: Adult acquired flatfoot (AAFD) is commonly treated by foot and ankle surgeons. Despite how commonly this disease presents, its incidence and economic impact have yet to be defined. We hypothesized that the operative incidence of AAFD and its economic burden would increase over the time period 1996 to 2014. Methods: The South Carolina database was queried for data from acute care and ambulatory surgery centers. Bivariate descriptive statistics were used to analyze the data. Operative incidence was calculated and demographics and medical comorbidities of patients who progressed to operative intervention were analyzed. Costs associated with operative care episodes were calculated to determine the economic burden. Results: A total of 1299 patients underwent AAFD corrective surgery between 1996 and 2014. Patients who underwent surgery for AAFD were most likely to be white, female, and in their fourth, fifth, and sixth decade of life. Operative incidence for AAFD rose from 0.26 per 100 000 covered lives in 1996 to 3.04 in 2014. The total health care costs associated with patients who underwent surgery for AAFD increased from $57 395.33 in 1996 to $6 859 723.60 in 2014. Conclusions: This data demonstrate that patients most commonly undergoing operative intervention for AAFD were white, female, and in their fourth, fifth, or sixth decade of life. There has been a significant increase in operative incidence, which may help direct attention to further exploration of outcome data in these patient populations, associated treatment costs, and preventative treatment options. [ABSTRACT FROM AUTHOR]

Background: Spring ligament injury is an important cause for flatfoot deformity; however, reliability of magnetic resonance imaging (MRI) findings of spring ligament injury is still ambiguous. Purpose: To investigate the reliability of MRI findings for the diagnosis of spring ligament injury. Material and methods: Forty-three cases with spring ligament injury proven by surgery and 29 control cases were enrolled. The spring ligament complex was demonstrated on proton density-weighted images reconstructed from 3D-isotropic MRI data. The presence of waviness, discontinuity, and abnormally high signal intensity of the spring ligament complex was evaluated by two radiologists in cooperation. Also, injury of the posterior tibial tendon (PTT) on MRI and the lateral talo-1st metatarsal angles on weight-bearing X-rays were evaluated. Results: Discontinuity and abnormally high signal intensity of the superomedial calcaneonavicular ligament (SmCNL) on MRI were more frequently observed in patients with spring ligament injury than in controls (p < 0.001). Discontinuity and abnormally high signal intensity of the SmCNL were found more often in the PTT injury group than in those without (p < 0.001). The talo-1st metatarsal angle was greater in patients with discontinuity and abnormally high signal intensity of the SmCNL on MRI than in patients without these findings (p < 0.001). Conclusion: Discontinuity and abnormally high signal intensity are reliable MRI findings for spring ligament injury and related disorders, such as flatfoot deformity and PTT injury. [ABSTRACT FROM AUTHOR]

Common peroneal nerve dysfunction after a multiligament knee injury can be devastating. In patients with persistent foot drop, posterior tibial tendon transfer to the dorsum of the foot is a reliable and safe procedure to restore dorsiflexion. These authors favor passing the posterior tibial tendon through the interosseous membrane and docking it into the lateral/middle cuneiforms. A Strayer procedure or tendo-Achilles lengthening must be performed in patients unable to achieve at least 10° of passive dorsiflexion. Despite the operative limb having 30% to 40% of ankle dorsiflexion strength of the uninjured limb, short- and long-term functional outcomes are excellent. [ABSTRACT FROM AUTHOR]

Background: Posterior tibial tendon dysfunction (PTTD) is a pathological condition that can cause failure of the posterior tibial tendon (PTT). Initially, patients with PTTD are often asymptomatic, making early identification and treatment challenging. Certain ultrasound (US) characteristics have been implicated in the presence of tendinopathy, but their frequency has yet to be assessed in the PTT. The purpose of this study was to identify and report on the frequency of incidental, or potentially early subclinical, tendinopathic US characteristics in asymptomatic PTTs. Methods: Following institutional review board approval, 150 participants underwent a bilateral-comprehensive US assessment. The resulting images were reviewed and assessed to identify the presence of abnormalities demonstrated to represent tendinopathy. Results: Overall, 266 tendons were assessed and 128 (48.1%) were determined to have at least one tendinopathic trait. Specifically, 51 (19.2%) had circumferential fluid, 69 (25.9%) had noncircumferential fluid, 22 (8.3%) had thickening, 31 (11.7%) had heterogenicity, 19 (7.1%) had hyperemia, and 2 (0.8%) had calcification. Additionally, Caucasian participants were found to be nearly 3 times more likely to have tendinopathic findings when compared with African American participants. Conclusion: Sixty-seven percent of participants and 48.1% of PTTs evaluated had at least one tendinopathic feature identified on US. The prevalence rates of these findings, observed in participants, were as follows: noncircumferential fluid, circumferential fluid, heterogenicity, and thickening. Knowing the frequency of these traits may help clinicians to identify subclinical tendinopathy in the PTT before it progresses to PTTD. Level of Evidence: Level IV, case series. [ABSTRACT FROM AUTHOR]

Background: Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Debate continues on whether spring ligament attenuation or posterior tibial tendon (PTT) dysfunction is the initial driver for the deformity. Our comparative prospective study aimed to quantify the radiological and clinical outcomes of 2 techniques for spring ligament reconstruction using a hamstring graft or a synthetic ligament. Methods: Seventeen spring ligament reconstructions (SLRs) were performed in 17 patients using synthetic ligament augmentation and 16 SLRs were performed using hamstring allograft in 13 patients. Additional procedures such as gastrocnemius recession, PTT advancement, flexor digitorum longus transfer, and calcaneal osteotomy were performed as required. A minimum of 12 months of follow-up was available for all cases. Radiographic analysis was performed with standardized parameters. Results: Following SLR with synthetic ligament augmentation, all radiological parameters significantly improved (P <.05). Hamstring allograft SLR also demonstrated significantly improved radiographic parameters in all but Meary's line at final follow-up. At 12 months, patient outcome scores were significantly better in the synthetic ligament group. Conclusion: Reconstruction of the spring ligament using either hamstring allograft or synthetic ligament augmentation provided significant improvements in radiological alignment; however, superior patient-reported outcomes were found in the synthetic ligament augmentation group. Levels of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]

This case report describes posterior tibial tendon (PTT) tendinopathy, valgus deformity with tenosynovitis, and osteopenia at the medial malleolus as the primary symptoms of a young patient with celiac disease (CD) without gastrointestinal symptoms. CD is an autoimmune condition that is a chronic inflammatory disorder of the small intestine triggered by ingestion of gluten in individuals with a particular genetic background. Without typical gastrointestinal symptoms, CD patients are often misdiagnosed or undiagnosed. The patient was diagnosed with CD by duodenal biopsy. He underwent a surgical procedure, including medial displacement calcaneal osteotomy, tenosynovectomy of the PTT and flexor digitorum longus (FDL), FDL transfer to the navicular for a pes planovalgus deformity, and drilling of the medial malleolus for a stress reaction. The mechanism of the PTT tear and associated heel valgus deformity was assumed to be related to the fact that his heel alignment on the affected side changed gradually from normal to valgus and pes planus owing to CD and mechanical stress, because his normal-side heel alignment was neutral before surgery and at final follow-up. His operated ankle was pain-free, with full range of motion, 1.5 years after surgery. The patient was able to restart running and exercise gradually. Foot and ankle specialists should consider the possibility of CD in patients presenting with a PTT tear without injury or trauma and osteopenia with no obvious reason. [ABSTRACT FROM AUTHOR]

Accessory navicular (AN) is a developmental variation of the secondary ossification center of the navicular tuberosity. Ten percent of patients with AN will have pain symptoms that affect walking and life. As the AN changes the position of the posterior tibial tendon insertion, children with AN often have posterior tibial tendon function insufficiency and flexible flat foot. Surgical treatment is often required after failure of conservative treatment. This article reviewed the etiology, clinical manifestations, complications, and treatment methods of AN., Competing Interests: Conflict-of-interest statement: All the authors declare that they have no competing interests., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

We report the case of a 32-year-old basketball player who presented with an acute flatfoot deformity after performing a unipodal power jump. Rupture of the posterior tibial tendon within the foot was diagnosed and then treated by hamstring tendon transfer combined with application of autologous biologic preparations. The functional outcome at 18 months was good. To our knowledge, this is the first reported case of posterior tibial tendon rupture treated by hamstring tendon transfer. [ABSTRACT FROM AUTHOR]

Category: Ankle; Trauma Introduction/Purpose: The Tibialis Posterior tendon (TPT) is the only tendon to come into contact with the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle they often have been missed and present late. Aim: Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia i.e. Pilon (PLM) and posterior malleolar fractures (PMF). Methods: A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site this was denoted as a minor entrapment and if ≥50% of the tendon was present in the fracture site was denoted as major. Results: A total of 363 patients were identified for further analysis, 220 who had a PMF and posterior 143 with Pilon injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture entered the TPT sheath, there was a 45% (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath p <.001). There was no significant difference in TPT entrapment in PMF as compared to PML (p=0.353). Conclusion: In our assessment, there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider care pre-operative imaging and seek to identify the TPT intraoperatively where entrapment does occur. [ABSTRACT FROM AUTHOR]

Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot. Degenerative changes in this tendon, lead to pain and weakness and if not identified and treated will progress to deformity of the foot and degenerative changes in the surrounding joints. Patients will complain of medial foot pain, weakness, and a slowly progressive foot deformity. A "too many toes" sign may be present and patients will be unable to perform a single heal raise test. Investigations such X-ray, ultrasound and magnetic resonance imaging will help stage the disease and decide on management. The optimal manage may change based on the progression of deformity and stage of disease. Early identification and prompt initiation of treatment can halt progression of the disease. The purpose of this article is to examine the causes, signs, symptoms, examinations, investigations and treatment options for posterior tibial tendon dysfunction.

Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not universally accepted, although many have agreed that any displacement warrants anatomic reduction and fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention. The patient was treated with prompt open reduction and internal fixation and had an excellent functional outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough exploration of the zone of injury is required to identify and adequately address any surrounding pathologic features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never been previously reported and emphasizes the importance of understanding the local anatomy and how restoration of the distorted anatomy is vital to optimize patient function. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The treatment of progressive collapsing foot deformity (PCFD) typically begins with nonoperative management including physical therapy, bracing, nonsteroidal anti-inflammatory medications, and activity modifications. Surgical intervention is not typically performed until nonoperative treatment has failed. Corticosteroid injections into the posterior tibial tendon sheath (PTTS) is a burgeoning nonoperative treatment modality for PCFD. The purpose of our study was to assess the safety of ultrasound-guided corticosteroid injections into the posterior tibial tendon sheath for posterior tibialis tendon tendinopathy. Secondary outcomes include duration of pain relief, amount of pain relief, need for repeat injections and progression to surgery. Methods: We retrospectively reviewed all patients in our electronic medical record who underwent a PTTS steroid injection between 2015 to 2020 for the diagnosis of posterior tibial tendon dysfunction, and/or posterior tibialis tendon insufficiency, and/or ankle pain. Demographic information was obtained from the patient record in addition to MRI data, clinical response to injection based on follow up visits, number of total injections, and progression to surgery. Thirty-eight posterior tibial tendon sheath ultrasound-guided injections in 33 patients met criteria during the 5 year study period. Results: Thirty-three patients were included in the study with 38 injections. Two patients (6.1%) had 3 posterior tibial tendon injections, one patient (3%) had 2 injections, and the rest had only a single injection yielding a total of 38 injections included in the study. Eighteen of 38 (47%) injections yielded good or better pain relief. Seven of 33 patients (21%) progressed to surgery. There were no reported complications with the 38 performed injections. Conclusion: Ultrasound-guided corticosteroid injections into the posterior tibial tendon sheath is a safe nonoperative treatment modality for posterior tibialis tendon tendinopathy. The efficacy of the injection appears highly variable with 47% of injections yielding 'good' or better clinical results. When evaluating BMI, obese patients (BMI >= 30.0) were found to have a more sustained response to injection (P = 0.029) and more pain relief (P = 0.049) compared to non-obese patients. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Cerebral palsy (CP) provides challenges when treating congenital clubfoot (CF) due to the presence of aberrant muscle tone and motor dysfunction. Split anterior tendon transfer (SPATT) and split posterior tendon transfer (SPOTT) are two ubiquitous treatments in the surgical repair of CP CF. Kling et. al. developed a three-tier grading system for documenting SPOTT outcomes; assigning excellent, good, or poor based on postoperative ambulation and functional dorsiflexion, this system has also been applied to SPATT recovery. The purpose of this study is to elucidate any difference in the outcomes of CP CF patients who receive SPOTT vs SPATT treatment. Methods: Following PRISMA guidelines a comprehensive search was conducted of PubMed, Cochrane, CINAHL, Scopus, and Web of Science. Collected publications represent all available literature on clubfoot. Articles were then screened by two independent reviewers at the title, abstract, and full-text level; only articles that detailed tendon-transfer treatment of pediatric patients with CF, CP, and contained three or more human subjects were included. Publications were excluded from screening if found to be duplicate articles, historical reviews, professional opinions, case reports, or contained non-human subjects. Two independent reviewers verified that each article met predetermined inclusion criteria at each level of screening. SAS statistical software was used to determine the relationship between positive and negative interventions outcomes, as well as patent demographics. Results: An initial search yielded 6,469 articles; after review 17 articles remained which described surgical tendon transfer: 12 (70.59%) split posterior tendon transfer (SPOTT) articles (mean-age 9.30 +- 2.57 years, mean follow-up length 60.03 +- 37.64 months), 5 (29.41%) split anterior tendon transfer (SPATT) articles (mean-age 10.12 +- 3.40 years mean follow-up length 64.16 +- 34.35 months). SPOTT papers included a total of 391 patients and 446 feet with a post-operative excellent & good rate of 90.48% and failure rate of 8.70%. SPATT papers included a total of 136 patients and 151 feet with a post-operative excellent & good rate of 71.22% and failure rate of 9.73%. Conclusion: These results show that the publication frequency of CP CF treatment by split posterior tendon transfer is higher than that of split anterior tendon transfer. Additionally, results of this systematic review indicate that there is a greater predicted positive outcome in SPOTT vs SPATT while there is no significant difference in predicted negative outcomes between procedures. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Cerebral palsy (CP) can lead to various foot deformities, including equinovarus, or clubfoot position. Patients with CP present a challenge when treating clubfoot as there is aberrant muscle tone and motor dysfunction. Many interventions with variable outcomes are available for patients with clubfoot and cerebral palsy, however, no studies exist that compare existing treatments and outcome measures. The purpose of this study is to investigate the existing body of evidence surrounding the treatments and outcomes of clubfoot in cerebral palsy by way of a systematic review. Methods: Using PRISMA guidelines a comprehensive search was conducted of PubMed, Cochrane, CINAHL, Scopus, and Web of Science. Publications were collected which represent all available literature on clubfoot. Articles were screened at the title, abstract, and then full-text level. Only articles that detailed the treatment of pediatric patients with clubfoot, CP, and contained three or more human subjects were included. Publications were excluded from further screening if they were found to be duplicate articles, historical reviews, professional opinions, case reports, or if subjects were non-human. At each level of screening, articles were screened by two independent reviewers to verify that each paper met the predetermined inclusion criteria. Following this, data extraction from primary sources was conducted for; number of patients, age of patients, follow-up length, treatment modality applied, and outcome measures. T-tests were performed using SAS statistical software to determine the relationship between age and type of intervention. Results: An initial search yielded 6,469 articles, after review and cross selection, 32 remained as shown in Table 1. Of these, 53.13% (n=17) articles documented surgical tibial tendon transfer (TT): anterior TT (n=5) (mean-age 10.12 +-3.40yrs), posterior TT (n=12) (mean-age 9.30 +-2.57yrs). Botox & casting was referenced in 15.63% (n=5) articles (mean age 5.34 +-1.21yrs), lengthening of tendon or muscle procedures 12.50% (n=4) (mean age 6.30 +-1.69yrs), botox alone 12.50% (n=4) (mean age 6.83 +-1.72yrs), and osteotomy 6.25% (n=2) (mean age 10.94 +-1.51yrs). There was a difference in age for patients receiving TT versus those receiving botox & casting (9.54+-2.75 years old vs 5.34 +-1.21yrs years, p<.05). Conclusion: These results indicate the preferred modality of clubfoot correction in the setting of cerebral palsy is tibial transfer. The average age of patients receiving surgical treatments was higher than those with casting, Botox, or orthotics. Due to a lack of standardized outcome measurements reported across studies, we recommend further research aimed specifically at evaluating intervention selection based on patient desired functional outcomes. [ABSTRACT FROM AUTHOR]

The article discusses the use of spring ligament to support the talar head and prevent it from falling into plantarflexion and adduction in patients with adult-acquired flatfoot deformity.

Lateral column lengthening is a common procedure for correction of pes planovalgus. A tricortical bone graft has been a standard among foot and ankle surgeons. The purpose of the present study was to compare the union rates and complications between the 2 forms of fixation for lateral column lengthening. The present study was a retrospective medical record and radiograph review of 52 patients divided into 2 equal groups, allograft (group A) and opening wedge plate (group B). The radiographic analyses compared the preoperative, postoperative and long-term measurements of cuboid abduction and talonavicular angles. The outcome measures included nonunion, hardware removal, and infection. The median follow-up duration for each group was 34.5 (range 6.3 to 89.5) months and 12.6 (range 6.5 to 56.8) months for groups A and B, respectively. Group A had 4 nonunions (15.4%) and group B had 2 nonunions (7.7%). The mean radiographic measurements of cuboid abduction and talonavicular articulation for each group improved significantly. The incidence of hardware removal was greater for group A than for group B (30.8% versus 15.4%), although the difference was not statistically significant. The median time to osseous healing for group A was 12.0 (range 8.0 to 80.0) weeks and for group B was 10.0 (range 6.0 to 36.0) weeks. The interposition plating techniques for lateral column lengthening procedures had a lower nonunion rate and incidence of hardware removal compared with the traditional use of tricortical bone grafting. The findings from the present study will aid surgeons in alternative fixation for lateral column lengthening procedures. [ABSTRACT FROM AUTHOR]

The posterior tibial muscle is the main functional support of the plantar arch its dysfunction is the main cause of acquired flat foot. This is a 32 year old patient who consults for progressive pain of the inside of the ankle and right foot with a considerable decrease in its sporting and professional activity. Examination reveals a collapse of the plantar arch. The radiological assessment finds imprisonment of posterior tibial tendon in the internal retromalleolar bony canal. The patient received a release of the tendon with resection of the bony canal in full. The posterior tibial tendon showed longitudinal laceration was sutured and the internal retromalleolar canal was closed. The race and the freedom of the tendon were considered satisfactory by the end of surgery. The evolution was marked by the disappearance of pain, recovery of a satisfactory sport and professional activity and a progressive decrease in the collapse of the plantar arch.

Introduction/Purpose: Progressive collapsing foot deformity (PCFD) is a degenerative disorder of ligaments and tendons that encompasses a wide range of deformities, including arch height loss, hindfoot valgus, and forefoot abduction. The posterior tibial tendon (PTT) is the main active stabilizer of the arch. We hypothesize that it may become injured secondarily as it attempts to maintain foot stability when the ligaments, passive stabilizers, are attenuated. Several cadaveric studies have been conducted on the role of the PTT in PCFD, but the ability of the PTT to compensate for the loss of the ligamentous stabilizers has not been clearly characterized. We developed a high-fidelity finite element model of the foot to determine the PTT's ability to maintain foot stability when the principle ligamentous stabilizers are attenuated. Methods: The encapsulating soft tissue (EST), cartilage, and cortical and trabecular bones were reconstructed in Mimics from CT scan images of a female cadaveric foot weighing 60 kg. Tension-only spring elements were used to reflect all the ligaments in ANSYS. Bodyweight and tendon forces were applied using force vectors in the direction of their lines of action. The proximal tibia was fixed only in the vertical direction, allowing it to translate and rotate in all other degrees of freedom. Nonlinear frictional contacts were used between the EST and the ground, and between the cartilages. The flatfoot was simulated by removing all of the ligaments. We measured the foot alignment angles for the flatfoot and the foot with ruptured spring/deltoid ligament, while we gradually increased the force within the PTT. The measured angles were then compared to the intact foot to evaluate the ability of the PTT to restore foot alignment. Results: The models were validated by comparing the Meary's (MA), calcaneal pitch (CPA), hindfoot alignment (HAA), and talonavicular coverage angles (TCA) to clinically-derived values. In the flatfoot, an increase of the PTT force to approximately 700% of normal ('7 ×25.71 N=180 N') led to a nearly complete restoration of foot alignment (Fig. 1). The angles associated with arch height (MA/CPA) were restored to a lesser extent than those associated with hindfoot and forefoot alignment (HAA/TCA). For the foot with ruptured deltoid ligament, increasing force within the PTT by 500% led to a restoration of near normal hindfoot alignment (Fig. 1c). For the foot with ruptured spring ligament, the forefoot abduction was completely compensated only when the PTT force was increased to 1100% of normal (Fig. 1d). Conclusion: Almost seven times the normal PTT force is required to restore the foot to neutral alignment. Augmentation of PTT force to this extent is unrealistic. However, a lesser increase in PTT force provides partial alignment compensation. Furthermore, the restoration achieved by overloading the PTT primarily impacts the alignment of the hindfoot and forefoot rather than the arch. Because the PTT can partially restore foot alignment, it may become secondarily injured when the ligaments are torn. Strengthening of the PTT through therapeutic exercise can improve its ability to restore foot alignment and should be a cornerstone of non-operative treatment of PCFD. [ABSTRACT FROM AUTHOR]

Posterior tibial tendon dysfunction (PTTD) is an important cause of acquired pes planus that frequently observed in adults. Factors that play a role in the development of PTTD such as age-related tendon degeneration, inflammatory arthritis, hypertension, diabetes mellitus, obesity, peritendinous injections and more rarely acute traumatic rupture of the tendon. PTT is the primary dynamic stabilizer of medial arch of the foot. Plantar flexion and inversion of the foot occurs with contraction of tibialis posterior tendon, and arch of the foot becomes elaveted while midtarsal joints are locked and midfoot-hindfoot sets as rigid. Thus, during the walk gastrocnemius muscle works more efficiently. If the PTT does not work in the order, other foot ligaments and joint capsule would be increasingly weak and than pes planus occurs. We present a 10-yearold female patient diagnosed as PTTD and conservative treatment with review of the current literature.

Unlabelled: Dislocation of the posterior tibial tendon (PTT) is a rare pathological process that occurs most often as a result of acute trauma. The injury involves forced dorsiflexion and eversion of the foot against a contracted posterior tibialis. Diagnosis of the injury is often difficult secondary to the rarity of the injury and its similarity with other benign injuries of the medial ankle. Routine diagnostic imaging often does not reveal the injury, and advanced imaging with magnetic resonance imaging or ultrasound to confirm the diagnosis is often required. The injury can be a result of an abnormal retromalleolar groove or a tear of the flexor retinaculum. Because nonoperative treatment frequently results in poor outcomes with continuing pain and progressive flat foot, operative treatment with repair of the flexor retinaculum with correction of the retromalleolar groove is the most described intervention. We report an acute case of PTT dislocation in a collegiate gymnast during competition and offer our technique for surgical correction in the setting of a partially torn, attenuated flexor retinaculum with plate buttressing of the PTT into its native uncorrected groove.Levels Of Evidence: Therapeutic, Level IV: Case study. [ABSTRACT FROM AUTHOR]

The spring ligament complex is an important stabilizer of the medial ankle, together with the posterior tibial tendon (PTT) and the deltoid ligament complex. Lesions in these stabilizers result in acquired adult flatfoot deformity. The spring ligament complex includes three ligaments: the superomedial calcaneonavicular ligament, the medioplantar oblique calcaneonavicular ligament, and the inferoplantar longitudinal calcaneonavicular ligament. Normal MR imaging anatomy of the spring ligament complex and the PTT are described and illustrated in detail. Isolated lesions of the spring ligament complex are rare. In most cases, spring ligament complex lesions are secondary to PTT dysfunction. The best criteria for an injury of the clinically relevant superomedial calcaneonavicular ligament are increased signal on proton-density or T2-weighted sequences with thickening (> 5 mm), thinning (< 2 mm), or partial or complete discontinuity. A thickened ligament can be simulated by the gliding layer between the PTT and the superomedial calcaneonavicular ligament (thickness: 1-3 mm). The most common location of injury is the superior and distal portion of the superomedial calcaneonavicular ligament. A lesion seen by the orthopedic foot surgeon at the junction between the tibiospring ligament and the superomedial portion of the calcaneonavicular ligament is commonly classified as a spring ligament injury. In addition, an overview of MR imaging findings in different stages of the acquired adult flatfoot deformity is provided. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: The Kidner procedure is performed to treat the symptomatic accessory navicular that has failed nonoperative treatment. Classically, the Kidner procedure involves excision of the accessory navicular with detachment and advancement of the posterior tibial tendon to the base of the navicular tuberosity. Various modifications of the Kidner procedure have been reported in the literature in which the accessory navicular is excised but without complete detachment of the PTT. Typically, the PTT is reinforced back to the navicular tuberosity insertion, usually with a suture anchor. The standard postoperative protocol includes non weightbearing for six weeks. Early weight bearing is gaining popularity in the foot and ankle community. No study to date has evaluated outcomes with early weight bearing after a Kidner procedure. Methods: This is a retrospective comparative study of 34 patients who underwent a Kidner procedure involving excision of the accessory navicular with detachment and reattachment of the posterior tibial tendon with suture or a suture anchor. Surgery was performed by two fellowship trained foot & ankle surgeons from a single institution. A total of 16 patients (17 feet) were included in the early weightbearing protocol group (2 weeks). A set of matched patients (n=17) with a similar age and surgical date were used as the control group with standard weight bearing at 6 weeks postoperative. Postoperative function and complications were obtained from a retrospective chart review of prospectively collected data until final follow up (mean, 18 weeks). This was a qualitative assessment specifically looking at whether early weight bearing led to increased complications and/or decreased function compared to standard weight bearing at six weeks. Results: Of the 34 total patients, there were no cases of postoperative posterior tibial tendon rupture or failure of the repair. In the early weight bearing group, there was one complication. This patient had a chronic flatfoot and developed a posterior tibial tendonitis at 6 months postoperative after returning to routine activity. This required boot immobilization and physical therapy. The standard weight bearing group had four complications. Two patients had posterior tibial tendon weakness and prolonged rehabilitation at 4 and 6 months postoperative. One patient had stiffness and pain at 6 months postoperative. And one patient developed a deep vein thrombosis at 3 weeks postoperative. Otherwise, all patients had returned to routine shoewear and resumed their normal activities, including sports, at final follow up. Conclusion: Early weight bearing after foot and ankle procedures is becoming increasingly popular. This study found that early weight bearing at 2 weeks postoperative after the Kidner procedure has no increased complication rates compared to standard weight bearing at 6 weeks postoperative. Based on the complications that occurred in the standard weight bearing group, early weight bearing may actually be protective against complications that occur with prolonged immobilization, such as weakness, stiffness, and deep vein thromboses. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Flatfoot deformities are chronic debilitations that involve multiple ligament complexes that stabilize the hindfoot. No study has clearly evaluated the efficacy of utilizing the spring ligament internal-brace fibertape device as an adjunct through clinical and radiographic measures. The purpose of this study is to explore the diagnostic efficacy of 3T MRI to evaluate the spring ligament, and to compare operative failures, complications, and radiographic outcomes of patients who underwent procedures for posterior tibial tendon dysfunction (PTTD) that employed the internal-brace fibertape (IB) and those that did not in the non-internal-brace (NIB) group. Methods: Following IRB approval, patients that underwent flatfoot reconstruction by four surgeons at a single institution between 2015 and 2018 were queried from an institutional radiology database. A total of 44 cases were identified with procedures that utilized the IB, and those that underwent MRI preoperatively had spring ligament integrity compared to intraoperative findings. These 44 cases that utilized the IB were subsequently match paired 1:2 with an NIB group. Data was collected retrospectively for both clinical and radiographic outcomes. Clinical outcomes included failures leading to reoperation, complications, and additional procedures. Radiographic parameters involved pre- and post-operative comparisons. Inadvertent reoperations that implicated malunion or the need for a triple arthrodesis within 13 months of the initial procedure were compared. Patient complications were compared. Statistical analysis was performed to evaluate the relationship between the clinical outcomes of these patients and use of the IB as an additional source of stabilization. Results: A total of 132 cases were analyzed with 44 that employed the IB and 88 NIB. The average ages for each group were 46.7 and 46.5 years for the IB and NIB group respectively. Of the 44 IB patients, 0 out of the 10 (0.0%) who had received a preoperative MRI were correctly identified as having an attenuated or frankly torn spring ligament as determined intraoperatively. There were significant differences in failure rates between groups with 0.0% of IB procedures and 4.5% of NIB procedures resulting in failure (p=0.022). There were no significant differences among complications between groups. There were significant improvements between all pre- and post-operative radiographic measurements within each group. However, the improvements were not found to be significant between groups. Conclusion: The results of this systematic retrospective chart review demonstrate that the spring ligament internal-brace device may serve as an effective adjunct in PTTD procedures and suggest considering it when planning irrespective of preoperative MRI findings. The data suggest that failure rates may be reduced without increasing complications. Both methods of fixation can provide significant improvements in reconstructing the arch. However, the internal-brace may reduce the prevalence of postoperative malunion or the need for a triple arthrodesis. [ABSTRACT FROM AUTHOR]