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Isolated posterior tibial tendon dislocation is a rare condition. Diagnosis can be challenging, especially in the acute clinical setting. Predisposing factors include shallow posterior tibial tendon groove and tear of the flexor retinaculum. We report the case of traumatic subluxation of the posterior tibial tendon, illustrating imaging findings and surgical technique. Posterior tibial tendon dislocation was detected using dynamic ultrasound, while magnetic resonance was essential for a comprehensive evaluation that included underlying predisposing anatomic abnormalities and associated pathologic conditions. Conservative treatment is often unsuccessful thus surgical approach was needed. Under ampliscopic guidance, a bone tunnel was created behind the retromalleolar groove. The posterior tibial tendon was located into the new groove and the retinaculum was re-attached and tightened by anchors and absorbable sutures at the anterior margin of the sulcus. At 12-month follow-up, the patient did not complain any residual pain and he was able to perform normal daily activities without any limitations and with no further tendon dislocations.

INTRODUCTION Bluman et al., flatfoot classification is based on posterior tibial tendon (PTT) dysfunction leading to a chronological appearance of several foot deformities. An expert consensus recently proposed a new classification named Progressive Collapsing Foot Deformity (PCFD) in which the focus was shifted to five different independent foot and ankle deformities and their flexibility or rigidity. The aim of this study was to compare Bluman and PCFD classifications. We hypothesize that both classifications will be reliable and that the PCFD classification will allow a larger distribution of the different types of foot deformity. MATERIALS AND METHODS We performed a retrospective IRB-approved study including 92 flatfeet. Three foot and ankle surgeons reviewed patient files and radiographs to classify each foot using both classifications. Bluman classification was performed one time as initially described and a second time after removing the Angle of Gissane sclerosis sign. Interobserver reliabilities were determined with Fleiss' kappa values. RESULTS Interobserver reliabilities of Bluman and PCFD classifications were, respectively, substantial 0.67 and moderate 0.55. PCFD Class C and D reliabilities were, respectively, slight 0.07 and fair 0.28. The 276 readings were spread into 10 substages in Bluman and 65 subclasses in PCFD. The progressivity of the Bluman classification prevented the combination of flexible hindfoot valgus (II Bluman, 1A PCFD), midfoot abduction (IIB, 1B) and medial column instability (IIC, 1C) which was frequent in our study (112/276 readings, 40.6%). By removing the Angle of Gissane sclerosis sign from the Bluman classification, the prevalence of stage III decreased from 44.2 to 10.1%. CONCLUSIONS Bluman and PCFD classifications were reliable. The PCFD classification showed a larger distribution of different types of flatfeet but Classes C and D need better definition. The progressivity of Bluman classification causes inconsistencies and Gissane angle sclerosis sign is inappropriately used and might lead to incorrect surgical indications.

Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders. Most common foot and ankle tendoscopies are for the Achilles, peroneals, and posterior tibial tendon. Tendoscopy may be used as an adjacent procedure to other techniques, such as calcaneal osteotomies. The technique allows for an unrivalled view of the entire length of tendons while also providing a dynamic evaluation of their movement inside the sheath. Therefore, it is a useful tool both for the diagnosis and the minimally invasive treatment of different tendon disorders around the foot and ankle. In this paper we will review the techniques, indications, results, and existing evidence and outcomes and complications of foot and ankle tendoscopies. The original techniques will be presented together with tips and tricks to optimize the tendoscopic experience. We will also conducted a search of the biomedical literature to look for results and outcomes of posterior tibial tendoscopy, peroneal tendoscopy, and Achilles tendoscopy.

The spring ligament is the main static supporter of the medial longitudinal arch. Identifying every detail of the pathophysiology of each condition in which these structures are involved is the key to an appropriate approach and treatment. Isolated reconstruction of the posterior tibial tendon present long-term results with a high failure rate. It is important to diagnose spring ligament injuries because of the probable consequences if not treated, such as acquired flatfoot deformity and loss of correction of treated flatfoot. The option of surgical treatment is discussed in this article.

The therapeutic outcome of the local arthrodesis surgery for type 2 accessory navicula (AN) is rarely reported. This study aimed to compare the clinical outcomes between Kidner and arthrodesis procedures for type 2 AN.Sixteen patients (20 feet) with symptomatic type 2 AN receiving surgical treatment in our hospital between November 2013 and December 2015 were retrospectively included. Ten patients (13 feet) underwent the Kidner surgery (Kidner group) and 6 patients received local arthrodesis procedure (arthrodesis group). Radiographic indices before/after surgery were compared between the two groups. Patient's satisfaction with surgery outcome was evaluated by patient self-assessment questionnaire.The calcaneal pitch angle was significantly increased after surgery in both groups (bothp0.01), while the talocalcaneal coverage angle and lateral talo-first metatarsal angle were not significantly changed after surgery. There was no significant difference regarding the postoperative changes in the three radiographic indices between the two groups. In the arthrodesis group, 3 patients (4 feet) had an excellent outcome, 2 patients (2 feet) a good outcome, and 1 patient (1 foot) had a fair outcome. In the Kidner group, 6 patients (8 feet), 2 patients (3 feet), 1 patient (1 foot) and 1 patient (1 foot) had excellent, good, fair, and poor treatment outcomes, respectively. The rate of good-to-excellent outcomes was comparable between the arthrodesis group and Kidner group (83% vs. 80%, p=0.696).Our results suggested that both the Kidner surgery and arthrodesis surgery were an effective treatment for symptomatic type 2 AN.

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.

A posterior tibial tendon (PTT) rupture associated with ankle fractures is a very rare condition. Ankle pronation and external rotation (PER) movement are the typical traumatic mechanism. This injury is frequently overlooked preoperatively. Early diagnosis and treatment are very important to prevent the serious consequences related to functional PTT insufficiency on biomechanics of the foot. Few cases have been described in the literature that highlight the relationship between PTT rupture and PER type ankle fracture with a medial malleolar fracture. We present a case of a complete PTT rupture in a closed atypical ankle fracture in which a medial malleolar fracture was associated with a very large fragment from the anterolateral distal tibia (Tillaux-Chaput fragment) and a concomitant avulsion fracture from the anteromedial portion of the fibula (Lefort-Wagstaffe fragment), with a novel pattern never described before.

Background The accessory navicular (os tibiale externum, prehallux) is a frequent skeletal variation. However, a bipartite os tibiale externum is extremely rare and so far has only be reported in radiologic studies. Methods We report on a 30-year old female patient with flexible flatfoot and a bilateral accessory navicular. On the more painful side, a bipartite accessory navicular was resected. The posterior tibial tendon was fixed to the medial aspect of the navicular proper after levelling the prominent tuberosity. Results and conclusions The patient was completely pain free after 6 weeks and there was no remaining functional deficit. Bipartite accessory navicular is a very rare variant of a rather frequent accessory bone at the foot. Resection of the ossicle with debridement of the medial aspect of the navicular and attachment of the posterior tibial tendon to the navicular body (modified Kidner procedure) seems to lead to an excellent result also in these cases. In the presence of more severe deformities, treatment has to be adapted to the individual case.

Objective: The aim of this study was to present a case series of patients undergoing posterior tibial tendoscopy, assess their clinical outcome, and describe surgical findings and treatment complications. Methods: This is a clinical, retrospective, observational study of 11 consecutive cases of tenosynovitis of the posterior tibial tendon. All 11 patients underwent tendoscopy of the posterior tibial tendon. All procedures were performed by the same surgeon in 2 different hospitals. Minimum follow-up was 2 years. Results: All patients had their preoperative and postoperative AOFAS and VAS scores assessed. Both scores had an important improvement at 12 months that persisted at 24 months. Moreover, 72.72% of the patients were very satisfied with the procedure, and no patient reported to be dissatisfied. Additionally, 90.91% of the patients had no postoperative complications. The present results are consistent with those previously reported in the literature. Conclusion: Endoscopic or tendoscopic repair of the posterior tibial tendon is a simple and reproducible procedure that provides good functional and cosmetic outcomes with a low complication rate. It is important to increase the number of patients in this series in order to expand our conclusions. Level of Evidence IV; Therapeutic Studies; Case Series.

The posterior tibial tendon (PTT) is the principal dynamic stabilizer of the medial longitudinal arch of the foot. The basic goal of surgically reconstructing PCFD is to restore the foot's medial longitudinal arch, often through a combination of bony and soft tissue procedures. While the FDL transfer has long been the gold standard for reconstruction, allograft reconstruction of the PTT has recently been increasing in popularity.

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.

Active individuals can experience exercise-induced pain along the medial, plantar central, and plantarmedial proximal arch. In many cases, these symptoms are consistent with conditions involving the plantar fascia, posterior tibial tendon, or entrapment of branches of the posterior tibial nerve. Unlike these other conditions, chronic exertional compartment syndrome (CECS) of the foot can be aggravated by interventions that impart any pressure or compression to the foot. Practitioners should have a high index of suspicion for CECS when classic treatments tend to aggravate patient's symptoms.

Introduction: An accessory navicular is a plantar medial enlargement of the navicular bone of the foot. The accessory navicular is incorporated with the posterior tibial tendon which inserts into the navicular tuberosity. Patients with an accessory navicular present with a foot bump. This condition occurs in up to 12% of the population. Only some patients are symptomatic. The purpose of this study is to report the surgical outcomes in a consecutive series of adolescent athletes with symptomatic accessory navicular. Methods: The study was approved by the College of Medicine IRB. …

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.

Arthroscopic subtalar arthrodesis is a safe and reproducible surgical technique in intractable subtalar pain or instability secondary to post-traumatic, rheumatic arthritis, or talocalcaneal coalitions. Other less frequent indications are primary osteoarthritis and gross instability. In neuropathic pathologies and chronic posterior tibial tendon ruptures, it can be taken into account only if subtalar pathology is not associated with deformities in other neighboring joints that need surgical fusion. Combined ankle and subtalar arthroscopic arthrodesis have been recently described with the patient in a prone position.

Sustentaculum tali fractures are rare injuries seen following a fall onto a varus-placed hindfoot or as part of a constellation of peritalar fracture/dislocations. In isolation, these fractures are often missed or diagnosed late. Frequently, an axial (Harris) X-ray view of the calcaneus and/or computed tomography (CT) scan is needed for diagnosis. Operative intervention is recommended as the sustentaculum plays a key role in maintaining medial column architecture. Additionally, sustentaculum fractures often involve the middle facet of the calcaneus. As such, a fracture of the sustentaculum can cause incongruity of the middle facet and should be treated as an intra-articular fracture. The preferred approach for operative fixation is a medial longitudinal incision centered over the course of the posterior tibial tendon. The outcomes of operative intervention are limited to case reports and case series but demonstrate a preservation of function.

This chapter provides an overview of the anatomy, patient history, clinical examination, and diagnostics of posterior tibial tendon pathologies and proposes a technique for posterior tibial tendoscopy and its indications.

Background To report on the functional, biomechanical, and radiographic results of patients who had undergone arthroereisis plus tensioning of the posterior tibial tendon for flexible flatfoot. The hypothesis is that arthroereisis associated to a tensioning of the posterior tibial tendon give a good correction with great satisfaction in patients with flexible flatfoot in grade IIA. Methods We evaluated 29 patients (31 feet), mean age of 46.4 years, who had been surgically treated for adult flatfoot grade IIA according to Myerson. Mean follow-up was 34.15 months. For clinical evaluation, the AOFAS hindfoot and VAS-FA scores were used. Results Postoperative results showed significant increases in both AOFAS and VAS-FA scores: 54.2–81.9 and 61.5–83.2 points, respectively. For the X-ray parameters, we observed a significant variation in the talo-first metatarsal angle, from 13.8° in pre-op to 7.4° in post-op. In lateral view, Djian Annonier angle was improved from 146.6° to 134.1°. The Meary’s angle, compared to an average of 8.8° in pre-operative stage improved to 4.3° in the post-operative stage. Postoperative satisfaction was excellent-good according to 23 patients (79.4%). Pain in the tarsal sinus was reported in 5 out of 31 feet (16.1%) for the first three months after surgery. Conclusions Arthroereisis and tensioning of the posterior tibial tendon provided good functional outcomes for patients under 60 years of age having stage IIA flexible flatfoot without arthritic manifestations.

The adult acquired flatfoot deformity resulting from posterior tibial tendon dysfunction is the result of rupture of the posterior tibial tendon as well as key ligaments of the ankle and hindfoot. Kinematic studies have verified certain levels of deformity causing hindfoot eversion, lowering of the medial longitudinal arch and forefoot abduction. The condition is progressive and left untreated will cause significant disability. Bracing with ankle-foot orthoses has shown promising results in arresting progression of deformity and avoiding debilitating surgery. Various types of ankle-foot orthoses have been studied in terms of effects on gait as well as efficacy in treatment.

Introduction and importance Irreparable sciatic nerve palsy is a cause of foot drop and resulting in absent or weak most of the muscles in leg. There may be dysfunctions of all tendons in the leg excepting Achilles tendon and plantaris tendon. The treatment of this atypical neurologic injury has not been defined. Case presentation I reported a case of foot drop following irreparable sciatic nerve palsy in which there was a dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon. The medial gastrocnemius tendon and plantaris tendon were transferred into the anterior tibialis tendon, the extensor digitorum longus tendon and extensor hallucis longus tendon. The lateral gastrocnemius tendon was transferred into the peroneus brevis. Four months post-operative, he reported no pain and became capable of walking without the assistance of an orthosis or a crutch and without steppage gait. Clinical discussion Anterior transfer of the tibialis posterior tendon was the preferred procedure. If no posterior tibial tendon function was presented, then in order of preference, the extensor hallucis longus, extensor digitorum longus, peroneal, flexor hallucis longus tendon, medial gastrocnemius, lateral gastrocnemius and plantaris tendon would be used. Conclusion The atypical dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy was presented. Tendon transfer using medial gastrocnemius tendon, lateral gastrocnemius tendon and plantaris tendon seemed to be a good choice for treatment of this injury. It allowed reconstruction of a stable, painless, plantigrade foot. Level of evidence Case report., Highlights • Irreparable sciatic nerve palsy is one of the causes of foot drop. • It may be resulting in dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon. • The treatment of this atypical neurologic injury has not been defined. • Tendon transfer using gastrocnemius tendon, plantaris tendon was a good choice for treatment of this injury.

Die Degeneration der Tibialis-posterior-Sehne entsteht meist auf der Basis einer kongenitalen Valgusfehlstellung des Kalkaneus. Weitere assoziierte Pathologien sind eine Vorfussupination und -abduktion sowie eine Verkurzung des M. gastrocnemius. Belastete Aufnahmen des Fuses in 3 Ebenen und eine Ruckfusachsaufnahme erlauben die Beurteilung der Achsen unter statischer Belastung. Die Tibialis-posterior-Sehne kann sonographisch und im MRT dargestellt werden. Informationen zu einer fettigen Degeneration des M. tibialis liefert das MRT. Eine mechanische Entlastung der Tibialis-posterior-Sehne kann durch ruckfusfassende Einlagen oder Orthesen erfolgen. Die alleinige Therapie der Tibialis-posterior-Sehne hat sich nicht bewahrt. Zentrales Element ist die Korrektur des Ruckfusvalgus durch eine medialisierende Kalkaneusosteotomie. Eine laterale Kalkaneusverlangerungsosteotomie und eine dorsale Open-wedge-Osteotomie des Os cuneiforme mediale (Cotten-Osteotomie) konnen zusatzlich indiziert sein. Die Augmentation der Tibialis-posterior-Sehne erfolgt durch eine Transposition der Sehne des M. flexor digitorum longus auf das Os naviculare. Rupturen des Pfannenbandes werden rekonstruiert, zusatzlich kann ein Sinus-tarsi-Spacer verwendet werden. Eine Verkurzung des M. gastrocnemius wird durch ein Release des Sehnenspiegels adressiert. Erste Arbeiten beschreiben den Einsatz biologisch aktiver Substanzen wie Platelet Rich Plasma. Die Beseitigung der Ruckfusfehlstellung und das konsequente Adressieren der verschiedenen Komponenten fuhren zu einer signifikanten Verbesserung der Fusfunktion. Limitierend wirken sich vorbestehende degenerative Veranderungen aus.

To objectively compare outcomes of nonoperative management and posterior tibial tendon (PTT) transfer for peroneal nerve injury due to multiligament knee injury (MLI).Retrospective cohort study with prospective follow-up.Tertiary care institution.Ten patients with peroneal nerve injury due to MLI (5 managed nonoperatively, 5 with PTT transfer) were evaluated and a control group of 4 patients without peroneal nerve injury.Clinical examination, subjective questionnaires, and 3-D motion capture gait analysis during flat-ground walking and stair descent.The primary outcome measure was the result of gait analysis. The results of subjective questionnaires were a secondary outcome measure.Dorsiflexion was significantly reduced at initial contact and mid-late swing phase in the nonoperative cohort. The PTT transfer cohort demonstrated increased dorsiflexion at each of these time intervals compared with patients managed nonoperatively, restoring symmetry between limbs. The PTT transfer cohort demonstrated similar gait patterns to controls but tended to be more everted. Ground reaction force was increased in the uninvolved limb in the PTT transfer group during gait and step down. There were no statistically significant differences in AOFAS, FAAM, IKDC, or Lysholm results.Posterior tibial tendon transfer is an option to restore dorsiflexion and eliminate the need for an orthosis in patients with foot drop due to MLI. Gait analysis demonstrates a significant improvement in sagittal plane ankle kinematics after PTT transfer. The trade-off is subtle instability, highlighting the dynamic stability that the PTT provides.

We report 2 cases where blood-pool SPECT/CT had a high added value compared with standard 3-phase bone scintigraphy with only delayed SPECT/CT for the etiological diagnosis of painful ankles. Two men, aged 48 and 62 years, were referred for suspicions of medial and lateral malleoli stress fractures, respectively. Although standard planar blood-pool imaging and delayed SPECT/CT were inconclusive, blood-pool SPECT/CT showed markedly increased uptake along posterior tibial tendon and peroneal tendon, respectively, leading to diagnose tendonitises. These cases illustrate that blood-pool SPECT/CT can extend the diagnostic yield of bone scintigraphy to extraosseous origin, particularly in chronic lower extremities pain.

With the aim to determine the importance of considering the contact between bodies, in this work, has been developed a numerical three dimensional model of the foot, which includes 28 bones, 504 thin ligaments, 48 plantar ligaments and the posterior tibial tendon; to find the values of the pinball region contact between each pair of bones, which at the same time, helps to achieve a correct distribution of body weight and, thus, highlight the importance of taking into account the configuration of the contact parameters between two bodies, to perform a correct characterization of the biomechanical effect of the foot. First, the validation of the model was carried out, determining the reaction forces of the metatarsals with the ground, and comparing them with the experimental reaction forces, subsequently, this validation was used to compare the variation of the reaction force once the contacts were modified. It was observed that by varying the value of the pinball region the reaction forces with the ground (GRF) can achieve significant changes (up to 159% in the fifth metatarsal into this work) and generates a wrong or a better prediction.

Posterior tibial tendon (PTT) dysfunction is a common disorder in adults and is also known as posterior tibial tendon deficiency (PTTD) and adult acquired flatfoot deformity. Flatfeet in the pediatric and the adult population are often regarded as different entities as they both have different etiologies; this chapter will focus on the adult population where the posterior tibial tendon plays a major role [1–4].

Background: The current techniques for medial malleolar osteotomy may lead to posterior tibial tendon injury and have a high rate of malunion. Purpose: To describe a novel partial step-cut medial malleolar osteotomy technique and evaluate its technical feasibility and its advantages compared with traditional methods. Study Design: Case series; Level of evidence, 4. Methods: The novel technique consisted of osteotomy of the anterior one-third to two-thirds of the medial malleolus. A total of 19 ankles (18 patients) with osteochondral lesions of the talus underwent the novel osteotomy technique before osteochondral reconstruction. All patients were evaluated for more than 2 years. Radiographs were analyzed for postoperative displacement and malunion, and postoperative ankle function was evaluated according to the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and the visual analog scale (VAS) for pain. Results: The partial step-cut osteotomy technique was able to provide adequate intra-articular exposure without disturbing the posterior tibial tendon. The 19 ankles healed at a mean of 7.3 ± 1.5 weeks (range, 6-12 weeks). There was slight incongruence in 4 ankles, with a displacement of 1.0 ± 0.1 mm proximally and 0.3 ± 0.1 mm medially. The mean postoperative AOFAS and VAS scores improved compared with preoperatively, from 54.2 ± 12.1 to 84.6 ± 6.6 and from 6.4 ± 1.0 to 1.8 ± 1.3, respectively ( P < .001 for both). No intraoperative tendon injuries were observed. Conclusion: Results indicated that partial step-cut osteotomy is a reliable and effective method for providing enough exposure, avoiding displacement after reduction, and not disturbing the anatomic structures behind the medial malleolus.

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. Level of Evidence: Level III, retrospective comparative study.

Level of Evidence: Level IV, case series.

A 42-year-old man, who is the first author of this article, presented with pain and left ankle swelling during a 100-km running race. He experienced a sharp pain and popping sensation while running upstairs 15 days after the race. He had previously received a steroid injection around the medial malleolus. Foot inversion was impossible; left toe gait was difficult. Magnetic resonance imaging revealed posterior tibial tendon discontinuity. Although the tendon was found to be discontinued 2-cm proximally to the medial malleolus on surgery for reconstruction, the history of steroid injection could also be responsible for the degeneration of the cut ends. Because of the degeneration, the debrided cut ends showed a gap that could not be directly sutured. Some researchers have reported good tendon transfer results using the flexor digitorum longus, which is situated along the posterior tibial tendon below the medial malleolus. However, loss of function of the flexor digitorum longus can cause a loss of the toe grip power, resulting in an inability to run. Therefore, we adopted the gracilis muscle tendon for tendon transfer. The degenerated cut ends were debrided and reconstructed using a gracilis muscle tendon of the same side. Active range-of-motion exercises were initiated after 3 weeks of below-knee casting. Jogging was permitted at 12 weeks after surgery. He completed a 100-km run at 11 months after surgery. Following one-and-half year, the function was restored. The case warrants publication because this novel tendon transfer technique has not been reported and was effective for a runner.

Acute compartment syndrome (ACS) is a devastating condition related to increased pressures within fascial compartments. Common etiologies include high energy trauma and extravasation or bleeding events. Rarely, walking or low impact, highly repetitive activities are implicated. In this paper we review 3 consecutive patients that presented with acute compartment syndrome after performing walking events during training in the United States Army. Two of these patients had myonecrosis of the anterior and lateral compartments, requiring posterior tibial tendon transfers. The final patient had no myonecrosis, but continued to have superior peroneal nerve irritation. We compare these patients to others with acute exertional compartment syndrome previously reported in the literature. Overall, patients with upper extremity, hand, foot and paraspinal acute exertional compartment syndrome have a good prognosis, while those with acute exertional compartment syndrome of the leg have a poor prognosis regardless of the timing of surgery.

This study is to draw attention to a relatively common anatomical anomaly and its possible operative treatment in dancers. The accessory navicular, or os tibiale externum, is an accessory bone on the medial side of the navicular of the foot at the insertion of the posterior tibial tendon (PTT). It can cause obvious hyperpronation, medial foot pain, and a limited and painful relevé in dancers. To the best of our knowledge, this is the first report on the operative treatment of the accessory navicular exclusively in dancers. Six dancers (10 feet) were treated in our clinic for a symptomatic accessory navicular Type II. Five of them (eight feet) underwent surgery, two unilaterally and three bilaterally (at the same time). All five had an excellent result at mean follow-up of 4.7 years, given that they fully resumed their professional dance activities without restriction, discomfort, or residual symptoms. One patient stopped dancing for unrelated reasons and became symptom free without further (surgical) treatment. Although no conclusions can be drawn from a retrospective case series and other treatment modalities were not considered, simple excision of a symptomatic accessory navicular Type II seems to be a good choice in dancers.

Category: Hindfoot; Ankle; Other Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a three-dimensional (3D) and complex pathology that is characterized by peritalar subluxation (PTS) of the hindfoot. Measuring the amount of subluxation of the subtalar joint at the posterior facet was described and utilized for many years as a marker of PTS. The subluxation of the middle facet was recently proposed as possibly a more accurate and reliable early marker of pronounced deformity, with almost 100% sensitivity and specificity for symptomatic AAFD. The objective of this study was to compare the amount of subluxation of both the medial and posterior facets in patients with increased hindfoot valgus and controls. Methods: In this IRB-approved retrospective comparative study, we included a total of 91 patients with AAFD (108 feet) who underwent standing weightbearing CT (WBCT) as a standard baseline assessment of their foot deformity. One blinded Fellowship- Trained Orthopedic Foot and Ankle Surgeon with more than 10 years of experience performed WBCT measurements regarding the amount of subluxation of the subtalar joint (percentage of uncoverage) at the posterior and middle facet, as previously described in the literature (Please see attached Figure). Measurements were performed at the sagittal midpoint of the articular facets using Coronal Plane WBCT images. The inter-method agreement between the posterior and middle facet subluxation was assessed using Spearman’s Correlation and Bivariate Analysis. A paired comparison of the measurements was performed using Wilcoxon. P-values of Results: The inter-method Spearman’s correlation between the subluxation of posterior and middle facets was measured 0.69. In a bivariate analysis, both measurements were found to be significantly and linearly correlated (PConclusion: This study is the first to compare measurements of the amount of subluxation of the posterior and middle facets of the subtalar joints as markers of peritalar subluxation in patients with AAFD. We found a positive and linear correlation between the measurements, with the middle facet subluxation being significantly more pronounced than the posterior facet by an average of almost 13%. Our results are consistent with the idea that the middle facet subluxation might represent an earlier sign of pronounced and progressing peritalar subluxation in patients with adult acquired flatfoot deformity. [Figure: see text]

Tendinopathy of the foot and ankle is common and can lead to pain or functional limitations. The most frequently affected tendons in the foot and ankle are the posterior tibial, peroneal, and Achilles. We used ultrasound to determine normal values for these tendons. From 2015 to 2016, a prospective, standardized bilateral lower extremity ultrasound examination protocol was performed by a musculoskeletal ultrasonographer of the 4 tendons and above and below the malleoli as appropriate. A total of 199 patients with 398 extremities were identified, consented, and participated in the study. Most tendons were normally distributed. The average size of the tendons was as follows: Achilles 5.0 mm (range 2.8-11.2 mm); peroneus long above the malleolus 2.1 mm (range 0.7-3.6 mm), below the malleolus 2.9 mm (range 0.8-6.3 mm); peroneus brevis above the malleolus 1.2 cm (range 0.3-4.0 mm), below the malleolus 1.3 mm (range 0.5-4.8 mm); posterior tibial tendon above the malleoli 3.7 mm (range 1.9-8.1 mm), below the malleolus 4.6 cm (range 1.8-11.8 mm). Standard deviations and distribution curves were similarly calculated for each tendon. This baseline data can assist clinicians in their diagnostic ability with ultrasound. Given its low cost, lack of ionizing radiation and dynamic ability along with an improved understanding of normative data it may become an increasingly used diagnostic modality. Levels of Evidence: Level II: Diagnostic

Background Posterior tibial tendon involvement is common in rheumatoid arthritis. Ultrasound has an important place in the examination of this tendon. Objectives Evaluate the prevalence of ultrasound signs of posterior tibial tendon involvement in rhumatoid arthritis. Methods This is a cross-sectional study that included fourteen consecutive patients (100% female, mean age 55.3 years) with rhumatoid arthritis (median duration of progression of 13.5 years, mean specialised care of 2.1 years). A grey and Doppler ultrasound study was performed on affected feet, looking for effusion, thickening or corporal thinning, hypoechoic aspect, fissures, and Doppler activity in the posterior tibial tendon. Results 28 feet were studied with ultrasound evaluation of the posterior tibial tendon. Figure 1 illustrates the prevalence of the pathological aspects of the posterior tibial found on ultrasound examination. Conclusions This study illustrates the different pathological aspects of the posterior tibial tendon. It highlights the high prevalence of this tendinopathy in the rheumatoid foot. Ultrasound allows accurate assessment of this tendon in RA patients. A large-scale study compared with a control group is necessary to better interpret and complete these preliminary results. Disclosure of Interest None declared

Objectives: To evaluate radiographic findings of medial longitudinal arch decreases of the foot based on examinations performed before and after posterior tibial transfer surgery to treat motor deficits caused by complete lesions of the peroneal nerve. Methods: A descriptive and analytical study was conducted based on information collected from medical records. Patients with at least two years of follow-up after surgery were included, and their radiographs were evaluated before and after the procedure. In the radiographs with the anteroposterior incidence of the foot, the talocalcaneal, talometatarsal and talonavicular congruence angles were evaluated. In the lateral view, the talocalcaneal, Meary’s and calcaneal pitch angles were analyzed. Data were collected regarding patient profiles, trauma mechanisms and follow-up times. Results: One patient had radiographic results suggestive of a decrease in the plantar arch after posterior tibial tendon transfer. Angular variation among the patients, which was within the normal range, was not significant. Conclusions: No significant decreases in the longitudinal arch of the foot were observed in the studied patients. Level of Evidence III; Retrospective Comparative Study.

Background We report a rare case of calcific tendinopathy in the posterior tibial tendon (PTT) at the navicular insertion. Case Conservative treatments other than extracorporeal shock wave therapy (ESWT) were ineffective. Calcium deposition disappeared from the PTT on plain radiographs at 6 months after ESWT. Discussion In this case, a 14-year-old boy with calcific tendinopathy of the PTT who had not benefited from conservative treatments was effectively treated using ESWT.

The purpose of this study was to evaluate a technique of transfer of the posterior tibial tendon (PTT) to a rerouted anterior tibial tendon (ATT) and transfer of the flexor digitorum longus (FDL) to the extensor hallucis longus (EHL) through four limited incisions in cases of drop foot. This is a prospective case series study in which the new technique was done on ten patients with drop foot. Preoperative and postoperative functional evaluation was performed according to Stanmore grading system, and the muscle power of dorsiflexion was assessed using the Medical Research Council grading system but modified using Seddon’s method. After a mean follow up of 29.4 months (range 24–42 months), the results were excellent in five patients (50 %), good in one patient (10 %), and fair in four patients (40 %). The average Stanmore grading system score in the last follow-up was 77 (range from 62 to 90) compared to an average preoperative score of 22.8 (range from 18 to 24). The power of the transferred PTT was graded 4 in six patients (60 %) and 3 in four patients (40 %). The technique is an option for treating cases of drop foot. It avoids the problems of insufficient tendon length and uses limited incisions. The anterior transfer of the FDL to the EHL prevents drop big toe and adds to the dorsiflexion power of the PTT. However, further studies are needed to compare the technique to the conventional PTT transfer techniques.

Purpose Posterior tibial tendon dysfunction is the most common cause of acquired asymmetric flatfoot deformity. The purpose of this study was to determine and compare the diagnostic value of MRI and high-resolution ultrasound (HR-US) in posterior tibial tendon dysfunction (PTTD), and assess their correlation with intraoperative findings. Materials and methods We reviewed 23 posterior tibial tendons in 23 patients with clinical findings of PTTD (13 females, 10 males; mean age, 50 years) with 18 MHz HR-US and 3 T MRI. Surgical intervention was performed in nine patients. Results HR-US findings included 2 complete tears, 6 partial tears, 10 tendons with tendinosis, and 5 unremarkable tendons. MRI demonstrated 2 complete tears, 7 partial tears, 10 tendons with tendinosis, and 4 unremarkable tendons. HR-US and MRI were concordant in 20/23 cases (87%). Image findings for HR-US were confirmed in six of nine patients (66.7%) by intraoperative inspection, whereas imaging findings for MRI were concordant with five of nine cases (55.6%). Conclusion Our results indicate that HR-US can be considered slightly more accurate than MRI in the detection of PTTD.

The posterior tibial tendon (PTT) helps the triceps surae to work more efficiently during ambulation. Disorders of the PTT include tenosynovitis, acute rupture, degenerative tears, dislocation, instability, enthesopathies, and chronic tendinopathy with dysfunction and flat foot deformity. Open surgery of the PTT has been the conventional approach to deal with these disorders. However, tendoscopy has become a useful technique to diagnose and treat PTT disorders. This article focuses on PTT tendoscopy and tries to provide an understanding of the pathomechanics of the tendon, indications for surgery, surgical technique, advantages, complications, and limitations of this procedure. Sin financiación 0.794 JCR (2015) Q4, 58/74 Orthopedics UEM

Adult-acquired flatfoot deformity results from insufficiency of the posterior tibial tendon. Often, it is multifactorial in origin. The classification system takes into account the clinical signs and symptoms as well as the radiographic findings and guides treatment options.

A case of acute, traumatic, lateral dislocation of the posterior tibial tendon is presented as a unique pattern of posterior tibial tendon dislocation. Several attempts at both closed and open reduction were required to relocate the tendon and reduce the fracture-dislocation. This case is being presented to demonstrate the use of cross-sectional imaging to both recognize the initial bony injury and to identify tendon anatomy and pathology that may not be seen in the operating room with limited visualization.

Zusammenfassung In dieser Ubersichtsarbeit werden Art, Anwendung, Operationstechnik und Auswirkung der in der Literatur beschriebenen Osteotomien zur Therapie des flexiblen und erworbenen Plattfuses des Erwachsenen, Stadium II, im Detail erlautert. Das Update stellt auch die aktuellen Ergebnisse hinsichtlich Beschwerderuckgang und Funktionsverbesserung dieser Operationstechniken zusammen.

Isolated dislocation of the posterior tibial tendon is an uncommon pathologic entity that typically occurs in the setting of acute trauma. The diagnosis remains challenging and is often delayed second to the rarity of the injury and symptoms similar to that of medial ankle sprains and other routinely diagnosed injuries about the ankle. The factors that predispose this tendon to dislocation include a hypoplastic retromalleolar groove, flexor retinaculum insufficiency, chronic repetitive trauma, and a structural abnormality from a previous medial malleolar fracture, or a combination thereof. Dislocation has also been cited as a complication of multiple local steroid injections and tarsal tunnel release. The mechanism of injury appears to involve forced dorsiflexion and eversion of the ankle when the posterior tibial tendon is contracted. Most cases do not respond well to conservative treatment and will require surgery to restore function and eliminate symptoms. We report a case of posterior tibial tendon dislocation related to a snowboarding injury and offer our technique for surgical correction.