Tendoscopic treatment of acute posterior tibial tendon dysfunction: case report

We present a case of a rheumatoid patient presenting with acute signs of posterior tibial tendon dysfunction (PTTD). Magnetic resonance imaging (MRI) results were inconclusive regarding the grade of posterior tibial tendon (PTT) tear. We performed posterior tibial tendoscopy, releasing all tendon adherences, and accomplished complete synovectomy. By the end of the procedure, we observed PTT integrity, normal excursion, and mild tendinosis. At 24-month follow-up, the Visual Analog Scale for pain (VAS-Pain) decreased from 9 (preoperatively) to 1. The Foot and Ankle Outcome Score (FAOS) increased from 16% (preoperatively) to 94%. Clinically, the patient had a symmetric bilateral heel rise test and no pain over the course of the PTT. A standard radiographic assessment demonstrated a normal foot arch and hindfoot alignment. This report illustrates how posterior tibial tendoscopy can simultaneously provide accurate diagnosis and surgically address acute PTTD on a rheumatoid patient, relieving symptoms and improving midterm clinical scores. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Combined Transfibular and Anterior Approaches Increase Union Rate and Decrease Non-Weight-Bearing Periods in Ankle Arthrodesis: Combined Approaches in Ankle Arthrodesis

The transfibular approach is a widely used method in ankle arthrodesis. However, it is difficult to correct coronal plane deformity. Moreover, it carries a risk of nonunion and requires long periods of non-weight-bearing because of its relatively weak stability. We hypothesized that the transfibular approach combined with the anterior approach in ankle arthrodesis wound yield a higher fusion rate and shorter non-weight-bearing period. This study was performed to evaluate the clinical and radiographic results and postoperative complications in ankle arthrodesis using combined transfibular and anterior approaches in end-stage ankle arthritis. Thirty-five patients (36 ankles) with end-stage ankle arthritis were consecutively treated using ankle arthrodesis by combined transfibular and anterior approaches. The subjects were 15 men and 20 women, with a mean age of 66.5 years (46–87). Clinical results were assessed using the visual analog scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) scores, and the ankle osteoarthritis scale (AOS) preoperatively and at the last follow-up. Radiographic results were assessed with various radiographic parameters on ankle weight-bearing radiographs and hindfoot alignment radiographs. All clinical scores significantly improved after surgery. Union was obtained in all cases without additional surgery. Talus center migration (p = 0.001), sagittal talar migration (p < 0.001), and hindfoot alignment angle (p = 0.001) significantly improved after surgery. One partial skin necrosis, two screw penetrations of the talonavicular joint, and four anterior impingements because of the bulky anterior plate occurred after surgery. In conclusion, combined transfibular and anterior approaches could be a good method to increase the union rate and decrease the non-weight-bearing periods in ankle arthrodesis.

Hindfoot motion analysis by subtalar compensation and ankle osteoarthritis stage using a multi-segment foot model

Background The biomechanics of the hindfoot in ankle osteoarthritis (OA) are not yet fully understood. Here we aimed to identify hindfoot motion in a gait analysis using a multi-segment foot model (MFM) according to ankle OA stage or hindfoot alignment by the presence of subtalar compensation. Methods We retrospectively reviewed the medical records, simple radiographs, and gait MFM data of 54 ankles admitted to our hospital for the treatment of advanced ankle OA. Spatiotemporal gait parameters and three-dimensional motions of the hindfoot segment were analyzed according to sex, age, body mass index, Takakura classification, and presence of subtalar compensation. Results No spatiotemporal gait parameters differed significantly according to the presence of subtalar compensation or ankle OA stage. Only normalized step width differed significantly (P = .028). Average hindfoot motion (decompensation versus compensation) did not differ significantly between the sagittal and transverse planes. Graphing of the coronal movement of the hindfoot revealed collapsed curves in both groups that differed significantly. Compared with Takakura stages 3a, 3b, and 4, cases of more advanced stage 3b had a smaller sagittal range of motion than those of stage 3a (P = .028). Coronal movement of the hindfoot in cases of Takakura stage 3a/3b/4 showed a relatively flat pattern. Conclusions The spatiotemporal parameters were not affected by the alignment state of the heel resulting from subtalar compensation. The sagittal range of hindfoot motion decreased in patients with advanced ankle OA. Once disrupted, the coronal movement of the subtalar joint in ankle OA did not change regardless of ankle OA stage or hindfoot compensation state.

Assessment of Progressive Collapsing Foot Deformity Using Semiautomated 3D Measurements Derived From Weightbearing CT Scans

Background: In progressive collapsing foot deformity (PCFD), hind- and midfoot deformities can be hard to characterize based on weightbearing plain radiography. Semiautomated 3-dimensional (3D) measurements derived from weightbearing computed tomography (WBCT) scans may provide a more accurate deformity assessment. In the present study, automated 3D measurements based on WBCT were used to compare hindfoot alignment of healthy individuals to patients with PCFD. Methods: The WBCT scans of 20 patients treated at our institution with either a flexible (N = 10) or rigid (N = 10) PCFD were compared with the WBCT scans of a control group of 30 healthy individuals. Using semiautomated image analysis software, from each set of 3D voxel images, we measured the talar tilt (TT), hindfoot moment arm (HMA), talocalcaneal angle (TCA; axial/lateral), talonavicular coverage (TNC), and talocalcaneal overlap (TCO). The presence of medial facet subluxation as well as sinus tarsi/subfibular impingement was additionally assessed. Results: With the exception of the TCA (axial/lateral), the analyzed measurements differed between healthy individuals and patients with PCFD. The TCA axial correlated with the TNC in patients with PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. Conclusion: Using 3D measurements, in this relatively small cohort of patients, we identified relevant variables associated with a clinical presentation of flexible or rigid PCFD. An increased TCO combined with sinus tarsi impingement raised the probability of predicting a deformity as rigid. Such WBCT-based markers possibly can help the surgeon in decision-making regarding the appropriate surgical strategy (eg, osteotomies vs realignment arthrodesis). However, prospective studies are necessary to confirm the utility of the proposed parameters in the treatment of PCFD. Level of Evidence: Level III, case-control study.

Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy

Background There have been debates on the necessity of fibular osteotomy (FO) in supramalleolar osteotomy (SMOT) for the treatment of varus ankle osteoarthritis. The purpose of the current study was to compare the clinical and radiological outcomes between SMOT with and without FO in the treatment of varus ankle osteoarthritis. Methods The SMOT group included 39 patients, and the SMOT with FO group included 24 patients. The basic information reached no significant difference between groups. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS), modified Takakura stage and range of motion (ROM) were used for the functional evaluation. The radiologic parameters were assessed at the last follow-up to compare the degree of talar reduction between the two groups. Results Both groups achieved significant improvements in AOFAS scores, modified Takakura stage, as well as AOS pain and functional scores (P < 0.001). The ROM of the ankle joint in the SMOT group was significantly decreased (P = 0.022). In both groups, all of the radiological parameters were significantly improved (P < 0.01). The tibiofibular clear space (TFCS) was significantly widened in the SMOT group (P < 0.001). No significant difference was found between the two groups according to the functional outcomes. However, the talar tilt angle (TT) and hindfoot alignment angle (HFA) in the SMOT with FO group were significantly smaller than those in the SMOT group (P < 0.05). The TFCS was significantly widened in the SMOT group (P = 0.001). The medial displacement of the talus (MDT) was better reduced in the SMOT with FO group (P = 0.006). Conclusion SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. If SMOT is combined with FO, talar tilt and medial displacement will be better reduced.

Fibular osteotomy is helpful for talar reduction in the treatment of varus ankle osteoarthritis with supramalleolar osteotomy

Background There have been debates on the necessity of fibular osteotomy (FO) in supramalleolar osteotomy (SMOT) for the treatment of varus ankle osteoarthritis. The purpose of the current study was to compare the clinical and radiological outcomes between SMOT with and without FO in the treatment of varus ankle osteoarthritis. Methods The SMOT group included 39 patients, and the SMOT with FO group included 24 patients. The basic information reached no significant difference between groups. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Ankle Osteoarthritis Scale (AOS), modified Takakura stage and range of motion (ROM) were used for the functional evaluation. The radiologic parameters were assessed at the last follow-up to compare the degree of talar reduction between the two groups. Results Both groups achieved significant improvements in AOFAS scores, modified Takakura stage as well as AOS pain and functional scores (P༜0.001). The ROM of the ankle joint in the SMOT group was significantly decreased (P = 0.022). In both groups, all of the radiological parameters were significantly improved (P༜0.01). The tibiofibular clear space (TFCS) was significantly widened in the SMOT group (P༜0.001). No significant difference was found between the two groups according to the functional outcomes. However, the talar tilt angle (TT) and hindfoot alignment angle (HFA) in the SMOT with FO group were significantly smaller than those in the SMOT group (P༜0.05). The TFCS was significantly widened in the SMOT group (P = 0.001). The medial displacement of the talus (MDT) was better reduced in the SMOT with FO group (P = 0.006). Conclusion SMOT is a promising procedure for functional improvement and malalignment correction in varus ankle osteoarthritis but reduces ankle range of motion. If SMOT is combined with FO, talar tilt and medial displacement will be better reduced.

Association Between Hindfoot Alignment and First Metatarsal Rotation

Background: The association between forefoot and hindfoot position for planus and cavus feet is fundamental to the treatment of these deformities. However, no studies have evaluated the association between hindfoot alignment and first metatarsal (M1) axial rotation. Understanding this possible relationship may help to understand the deformity and improve patient care. The purpose of this study is to determine a correlation between hindfoot alignment and metatarsal rotation as assessed by weightbearing computed tomography (WBCT). Methods: Patients who underwent weightbearing plain radiography (WBPR) and WBCT between 2015 and 2018 were evaluated. Hindfoot alignment was measured with the calcaneal moment arm (CMA). M1 rotation was measured using the Kim and Saltzman angles. Patient subgroups were created according to the severity of valgus/varus hindfoot alignment. Statistical analyses were performed to evaluate for association between variables. Results: Among the 196 patient feet included in the study, the average CMA was 6.0 ± 16.2 mm. The average Kim and Saltzman angles were 7.7 ± 12.9 degrees and 2.8 ± 13.1 degrees, respectively. The average Meary angle was 182.0 ± 11.9 degrees. A moderately strong association was found between the CMA and the Saltzman ( r = 0.641, P < .01) and Kim angles ( r = 0.615, P < .01). Hindfoot valgus was associated with M1 pronation and hindfoot varus with M1 supination. Additionally, inverse relationships between the Meary angle and the Saltzman ( r = −0.600, P < .01) and Kim angles ( r = −0.529, P < .01) were identified. Conclusion: In this well-defined cohort, we found substantial correlation between hindfoot alignment and M1 rotation. Hindfoot valgus was associated with M1 pronation, and hindfoot varus was associated with M1 supination. Surgeons correcting cavovarus/planovalgus deformities should be aware of this association and evaluate the need for first-ray derotation. Level of Evidence: Level III, retrospective cohort study.