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OBSERVATIONS of four cases of posterior tibial tenosynovitis in which anomalies of the tendon were found at surgical exploration has prompted a review of this subject. The syndrome of noninfectious tenosynovitis was first described by Velpeau, in 1818, and again in 1825.1The work of de Quervain,2in 1895, and of many others since has served to emphasize the importance of this condition as a cause of painful symptoms, particularly about the wrist and ankle. Kulowski,3in 1936, was the first to mention tenosynovitis of the sheath of the posterior tibial tendon. This was also noted by Lipscomb,4who stated that it occurred in about 16% of cases of tenosynovitis and peritendinitis of the feet and ankles. Lapidus and Seidenstein5reported three cases of tenosynovitis with effusion involving the sheath of the posterior tibial tendon. Lipscomb noted anatomic variations of the tendons within the posterior

Summary 1. Anterior transplantation of the posterior tibial tendon between the tibia and fibula is described. 2. Application of this operative procedure in certain cases of congenital club foot and poliomyelitis is discussed. 3. This operation is considered effective in restoring muscle balance in selected cases of these two disabilities.

SUMMARY The paper presents two tests for evaluating the functional activity of the posterior tibial muscle in patients with spastic cerebral palsy. These tests help to determine whether or not the posterial tibial muscle is the deforming agent in the toe-in or adduction gait pattern. In addition, helpful information can be derived from these tests when planning a transfer of the posterior tibial tendon. RESUME Examen fonctionnel du muscle jambier posterieur dans la paralysie spastique L'auteur presente deux tests pour l'evaluation de l'activite fonctionnelle du muscle jambier posterieur chez des malades atteints de paralysie cerebrale spastique. Ces tests servent a determiner si ou non le muscle jambier posterieur est l'agent deformant dans la demarche avec adduction. En addition, on peut en tirer des precisions utiles si un deplacement du tendon jambier posterieur est envisagee. ZUSAMMENFASSUNG Funktionstest des M. tibialis posterior bei der Spastischen Paralyse Es werden zwei Tests zur Ermittlung der funktionellen Aktivitat des M. tibialis posterior bei Patienten mit spastischer cerebraler Lahmung beschrieben. Diese Untersuchungen helfen bei der Entscheidung, ob der M. tibialis posterior fur die Deformierung bei der Zeheneinwartsstellung oder beim Adduktorengang verantwortlich ist oder nicht. Auserdem kann von diesen Untersuchungen wertvolle Information gewonnen werden, wenn eine Verpflanzung der Tibialis posterior–Sehne geplant ist. RESUMEN Examen funcional del musculo tibial posterior en las paralisis espasticas Se exponen dos ‘tests’ para evaluar la actividad funcional del musculo tibial posterior en pacientes con paralisis cerebral espastica. Estos ‘tests’ ayudan a definir si el citado musculo es el agente deformante en la marcha con aduccion. Ademas estos ‘tests’ pueden facilitar information util cuando se trata de realizar un trasplante del tendon del tibial posterior.

A patient initially presented with pain in the instep and medial malleolar area swelling after an eversion injury. The pain was described as "fiery" and failed to resolve with conservative measures. Ankle and foot radiographs were normal. The patient returned several weeks later with complaints of continued pain and of disturbed gait, the latter due to unilateral flatfoot and a sensation of loss of control of the involved foot. At surgery an incompetent posterior tibial tendon was found and repaired.

Luxation of tibialis posterior tendon is rarely to be seen. In our case luxation is caused by direct traumatisation. Surgical deepening of tibial groove and trans-osseous suture of retinaculum are sufficient for good results after three months.

The Kidner procedure has been the most frequently recommended form of surgical treatment for the painful accessory navicular. This formal relocation of the posterior tibial tendon is said to restore the dynamic balance to the foot which is lost when the posterior tibial tendon gives an abnormal insertion into the accessory ossicle. The literature was reviewed to ascertain what is known or what is believed about the accessory navicular and the role of the posterior tibial tendon in the support of the longitudinal arch of the foot. Eighteen patients who had simple excision of the accessory navicular were reviewed to assess the success of such a procedure. In follow-up they all had very satisfactory results. A second group of 208 patients with non-traumatic foot complaints were reviewed to determine the incidence of accessory navicular and its association with the flat foot. Twenty-nine cases of previously undetected accessory navicular were identified in this group giving us a total of 179 patients without accessory navicular and 49 patients with accessory navicular available for study. There was no significant difference between the arch in these 2 groups of patients. Based on the findings in this study, the accessory navicular plays no role in the development of a flat foot. Simple excision of the prominent ossicle seems to be the surgical procedure of choice when conservative means of management fail.

In the treatment of equinovarus deformity of the foot in children with cerebral spastic paralysis, to supplement heel-cord lengthening, we split the posterior tibial tendon and transferred its posterior half laterally into the peroneus brevis tendon. Thirty-seven operations were performed on thirty-one hemiplegic, quadriplegic, and diplegic children who were followed for a mean of eight years postoperatively (range, four to fourteen years), at which time twenty-six of the thirty-one children were skeletally mature. There were thirty excellent, four good, and three poor results. The results did not deteriorate with time. Thirty-two of thirty-four children with good or excellent results had functioning dorsiflexors of the foot and were brace-free postoperatively. The children who had a poor result had recurrent deformity, but none had development of a calcaneal or calcaneovalgus deformity.

A modification of the transfer of the posterior tibial tendon anteriorly through the interosseous membrane for the correction of equinovarus deformity of the foot was carried out without complication on 44 extremities of 22 children age between 8 and 15.

Surgical management of the accessory navicular or navicular beak using the Kidner procedure was indicated in 29 feet. Pain was present in all feet; difficulty with shoe fit and flat feet were other complaints. The patients were followed up for two to ten years (mean, 4.5 years) after operation. Eleven results were excellent, 15 good, and 3 poor, all in boys with a navicular beak. Only one complication occurred. Excision of the accessory navicular or navicular beak, together with suturing the fibers of the posterior tibial tendon (inserting on the accessory navicular or navicular beak) to the inferior surface of the navicular, is effective treatment.

A previously unreported anomaly of a clubfoot in a 14-month-old boy was associated with an absent posterior tibial tendon and a tarsal coalition.

The Kidner operation is a successful method of treatment for symptomatic feet with Type II and Type III accessory tarsal scaphoids that do not respond to conservative methods of treatment. The success of this operation is related more to the elimination of the bony prominence on the medial aspect of the foot and its mechanical irritation than to the correction of the pronated foot by means of posterior tibial tendon transfer. The age of occurrence of symptoms can be correlated with the level of physical activity and ossification or growth of this accessory bone. Symptoms in older patients develop after injury. The pronated foot or mechanically insufficient foot increases the stress on the bony prominence of the accessory tarsal scaphoid bone and precipitates in symptoms.

The posterior tibial tendon was rerouted by the technique described by Baker and Hill in 35 feet of children with a dynamic varus deformity due to spastic cerebral palsy. The average follow-up period was 11.4 years. In ten of the feet, rerouting of the posterior tibial tendon was the only procedure performed. Eight of the ten feet obtained a satisfactory correction. There were no overcorrection problems in these ten feet. In the remaining 25 feet, the Baker-Hill procedure was done concurrently with other procedures, such as lengthening of the triceps surae (22 feet), calcaneal osteotomy (two feet), or plantar fascia release (two feet). The dynamic equinovarus deformity was corrected in all 25, but three subsequently developed a cavus deformity. This was probably caused by excessive weakening of the triceps surae rather than transposition of the posterior tibial tendon. Based on this study, anterior rerouting of the posterior tibial tendon seems to be a simple, safe, and generally effective procedure for correction of dynamic varus of the spastic hindfoot in children with cerebral palsy.

Redirecting the posterior tibial tendon has improved the function of symptomatic flat feet. A modification that appears to improve the final result by increasing the support and fixation of the tendon is reported.

In 1929 I1described an operation for the correction of certain cases of intractable flatfoot by the removal of the prehallux or accessory scaphoid and transplantation of the posterior tibial tendon. In that article the literature was reviewed and a bibliography given. It was stated that the prehallux is a common and frequently unrecognized anomaly which, by changes in leverage, interferes with the normal mechanics of the action of the posterior tibial muscle and thus produces weakness of the longitudinal arch and flatfoot of a type highly resistant to the usual conservative methods of treatment. It was also stated that in the presence of the prehallux, whether as a separate bone or as a prolongation inward of the scaphoid, there is an abnormal insertion of the tibialis posticus tendon. Instead of passing under the inner end of the scaphoid to insert in the lower surface of the two internal