2017 AOFAS Specialty Day. Posterior Tibial Tendon Dysfunction: Stage III Getting the Most Out of Your Triple Arthrodesis

Transcription

1 2017 AOFAS Specialty Day Posterior Tibial Tendon Dysfunction: Stage III Getting the Most Out of Your Triple Arthrodesis Jeffrey E. Johnson, M.D. Professor, Dept. of Orthopaedic Surgery Chief, Foot and Ankle Service Director, Foot and Ankle Fellowship Barnes-Jewish Hospital at Washington University School of Medicine in St. Louis, Missouri I. Understanding the Flatfoot Deformity with PTTD A. Stages of Clinical Presentation 1. Stage I a. activity pain b. swelling, tenderness along PTT c. single limb heel rise (+/-) d. no deformity 2. Stage II a. tendon disrupted/elongated with attritional failure of static hindfoot stabilizers (spring lig., long plantar ligament, interosseous T-C lig., deltoid) b. swelling, tenderness along PTT c. acquired asymmetric pes planovalgus d. single limb heel rise (+) e. (+/-) lateral impingement pain f. wide variability in presentation: Type 2A: mild deformity, primarily medial pain Type 2B: mod.-severe deformity, lateral impingement 3. Stage III a. tendon disrupted/elongated with attritional failure of static hindfoot stabilizers (spring lig., long plantar ligament, interosseous T-C lig., deltoid lig.) b. stiff, fixed deformity of subtalar or transverse tarsal joints (not passively correctable) c. lateral abutment pain(calcaneofibular, talo-calcaneal) d. DJD hindfoot 4. Stage IV PTTD deformity assoc. with valgus deformity of ankle a. Deltoid insufficiency b. Lateral ankle joint wear or collapse

2 B. Physical Exam 1. Standing exam assess heel valgus/forefoot abduction 2. Seated exam assess gastroc/soleus and forefoot varus 3. Which components are flexible or fixed? C. Radiographic Evaluation 1. Standing Anteroposterior (AP) x-ray o Abducted/adducted forefoot o Lateral/medial subluxation talonavicular joint (TN coverage) o DJD talonavicular/ calcaneocuboid o Evaluate for bone loss/deficiency that may require interposition bone graft 2. Standing lateral x-ray o Midfoot sag (T-N, N-C, C-MT joints) o Evaluate hindfoot and ankle DJD o If significant sag/cavus at midfoot, may require additional arthrodesis (medial column, 1st TMT)/osteotomy (midtarsal) 3. Standing Anteroposterior ankle x-ray o Demonstrate calcaneofibular abutment o Rule out valgus tilt at tibiotalar joint(stage IV) II. III. Stage III Treatment Indications Stage III (fixed deformity, DJD) = arthrodesis 1. subtalar 2. double (CC and TN) 3. triple - usually required Adjunctive Procedures for Restoring Foot Alignment A. Concept of the foot tripod B. Medial column procedures for correction of residual forefoot varus.procedure depends on location of deformity and status of involved joints: 1. First TMT joint fusion (for severe TMT instability or DJD) 2. Plantarflexion opening wedge cuneiform-1 osteotomy with bone graft interposition (for normal or mild instability of TMT-1) 3. Reduction and arthrodesis naviculocuneiform joints. C. Medial Displacement Calcaneal Osteotomy (MDCO) for residual heel valgus following reduction of the lateral peritalar subluxation deformity at the subtalar joint. 1. First, internally rotate the calcaneus back under the talus to correct heel valgus and pin the subtalar joint. 2. Then assess congruity of the subtalar joint to determine if it has been over corrected in order to achieve the desired positional correction of the heel.

3 3. Consider adding a MDCO if when the subtalar joint is adequately reduced, the heel is still in excessive valgus. 4. Patients with congenital underlying pes planovalgus are more likely to need a MDCO than patient that initially had a neutral heel prior to PTTD. 5. Make incision for MDCO parallel to subtalar joint incision, leave 4 cm skin bridge if possible and limit undermining of skin flaps or self retaining retractors to limit wound healing complications. D. Soft-tissue reconstructions 1. FDL tendon transfer to navicular or distal PTT stump for mild valgus talar tilt (Stage IV) 2. Deltoid reconstruction for mild valgus tilt without significant ankle DJD: imbrication of ligament with suture construct reinforcement vs. allograft tendon reconstruction 3. Lateral ankle ligament reconstruction.not uncommon to have attritional degeneration of lateral ligaments with longstanding hindfoot valgus IV. Reduction maneuvers for stiff valgus hindfoot deformity correction and fusion A. Key is to understand the anatomy of deformity (See Schon and Hansen ref.) B. Manual Technique: With hands, stabilize talus with one hand while internally rotating calcaneus in relation to talus. C. Lamina Spreader Technique 1. Place lamina spreader between anterior superior process of calcaneus and anterior process of talus (not in the posterior facet). 2. Open lamina spreader to increase distance between anterior calcaneus and lateral process talus. 3. Avoid over-reduction causing incongruity at TN joint. D. Transverse midfoot handle bar maneuver a. Place 1/8 steinman pin across cuboid and cuneiforms b. Use pin protruding out each side of foot as a handle bar to reduce the transverse tarsal joint by forceful adduction and rotation of foot to correct forefoot varus. E. Beware of overcorrection carefully evaluate post reduction intraoperative images a. Evaluate lateral radiograph for subtalar congruency should still have some overlap of the anterior calcaneus on the talar neck b. Evaluate AP radiograph for talonavicular congruency often there is some gapping on medial side of TN joint due to erosion of medial side of the navicular or developmental changes of the joint over time.

4 V. Correction of all components of the deformity is critical to success. A. Ask yourself these questions before you leave the OR: 1. Is talus reduced? 2. Is forefoot abduction corrected? 3. Is Meary s line restored? 4. Is calcaneal pitch increased? 5. Is height of hindfoot increased? 6. Is Tripod of foot restored with a plantigrade forefoot and full correction of the forefoot varus? 7. Is the ankle stable? VI. Results of Operative Treatment A. Results of Stage 3 Treatment - Triple Arthrodesis 1. Graves, Mann & Graves (JBJS, Mar. 1993) 18 feet (17 pts) with variety of Dx (PTT rupture, RA, neuropathic arthropathy, trauma, polio, stroke), average age 66 y/o 3.5 yrs average follow-up Average radiographic change Pre Post Talus-1st metatarsal angle: 22 9 Lateral talocalcaneal angle: AP talus 2nd metatarsal angle: Complications 3 feet with nonunions 7 feet with progressive degenerative ankle disease 7 feet with progressive degenerative foot disease 2 feet with infections 1 foot collapse 2 /2 pre-mature, unauthorized WB 1 foot subtalar joint staple impingement on tip of fibula staple removal Patient satisfaction Satisfied: 15 feet Dissatisfied: 3 feet All 17 patients had less pain postoperatively 11 patients still had some discomfort Conclusions Use only as salvage operation because of technical difficulty and postoperative complications 2. Fortin & Walling (CORR, Aug. 1999) 32 feet with Stage III or IV adult acquired flatfoot, average age 63 y/o Standardized technique with BG and rigid internal fixation 4.3 yrs average follow-up

5 Average radiographic improvement Lateral talus-1st metatarsal angle: 18 Lateral talocalcaneal angle: 13 AP talus-1st metatarsal angle: 15 Navicular height increase: 17mm Complications 1 nonunion & 2 residual varus malunions 4 patients postoperative varus heel position 2 treated with shoe modification 2 Dwyer closing wedge osteotomy 1 patient progressive N-C joint sag no Tx 2 patients plantar heel pain screw removal 1 of 2 Stage IV feet progression of ankle Sxs subsequent ankle arthrodesis AOFAS hindfoot score 36 points Patient satisfaction Satisfied: 22 feet Satisfied with reservations: 2 feet Dissatisfied: 2 feet All but one patient would undergo procedure again Conclusions Acceptable treatment for late stage deformities Must be aware of long-term compensatory/degenerative arthritic changes of the ankle and midfoot 3. Pell, Myerson, & Schon (JBJS, Jan. 2000) 132 feet with a variety of deformities and preoperative diagnoses (95/132 feet planovalgus or pes planus Triple arthrodesis with rigid screw fixation and joint realignment without wedge resections 5.7 yrs average follow-up Average radiographic improvement Lateral talus-1st metatarsal angle: 14 Talocalcaneal coverage angle: 26 AP talus-1st metatarsal angle: 14 Complications 4 superficial wound problems 3 nonunions 1 superficial peroneal neuritis 1 Charcot-like neuroarthropathy 1 Achilles tendon rupture 1 peroneal tenosynovitis

6 Patient satisfaction Average AOFAS postoperative ankle-hindfoot score 60.7 points Significant increase in postoperative ankle arthritis though not associated with patient satisfaction 91% stated they would have the procedure again Overall patient satisfaction 8.3 (10 = completely satisfied) significant association with postoperative alignment 20% required modified shoes or AFO at follow-up Conclusions Effective in relieving pain and improving functional deficits High prevalence of subsequent ankle arthritis REFERENCES 1. Astion DJ, Deland JT, Otis JC, Kenneally S. Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg 79A(2):241-6, Bednarz PA, Monroe MT, Manoli A. Triple arthrodesis in adults using internal fixation: an assessment of outcome. Foot Ankle Int 20(6):356-63, Clain MR and Baxter DE: Simultaneous calcaneocuboid and talonavicular fusion: long-term follow-up study. J. Bone Joint Surg. [Br] 76: , Coetzee JC, Hansen Jr ST. Surgical management of severe deformity resulting from posterior tibial tendon dysfunction. Foot Ankle Int 22(12):944-9, Deland J, Otis JC, Lee KT, et al.: Lateral column lengthening with calcaneocuboid fusion: range of motion in the triple joint complex. Foot Ankle, 16(11): , Easley ME, Trnka HJ, Schon LC, et al. Isolated subtalar arthrodesis. J Bone Joint Surg 82A:613-24, Fortin PT, Walling AK. Triple Arthrodesis. Section I: Symposium: Adult Acquired Flatfoot. CORR 1(365):91-99, Graves S, Mann R, Graves K: Triple arthrodesis in older adults. J Bone Joint Surg, 75A, , Haddad SL, Myerson MS, Pell IV RF, et al. Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot Ankle Int 18(8):489-99, Hansen ST, Jr. Triple arthrodesis in Functional Reconstruction of the Foot and Ankle., Philadelphia, PA: Lippincott Williams & Wilkins, 2000, pp Horton GA, Olney BW. Triple arthrodesis with lateral column lengthening for treatment of severe planovalgus deformity. Foot Ankle Int 16(7): , Johnson JE, Cohen BE, DiGiovanni BF, Lamdan R: Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency. Foot Ankle Int 21(9): 722-9, Johnson JE. Plantarflexion opening wedge cuneiform-1 osteotomy for correction of fixed forefoot varus. Techniques in Foot and Ankle Surgery 3(1):2-8, Johnson JE, Yu JR: Arthrodesis Techniques in the Management of Stage-II and III Acquired Adult Flatfoot Deformity. J Bone Joint Surg Aug; 87-A(8): Johnson KA, Strom DE: Tibialis posterior tendon dysfunction. Clin Orthop 239: , Kitaoka HB, Patzer GL. Subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus. Clin Orthop 345:187-94, 1997.

7 17. Maenpaa H, Lehto MU, Belt EA. What went wrong with triple arthrodesis. Clin Orthop 391: , Mangone PG, Fleming LL, Fleming SS, et al. Treatment of acquired adult planovalgus deformities with subtalar fusion. Clin Orthop 341:106-12, Mann RA, Thompson FM: Rupture of the posterior tibial tendon causing flat foot -surgical treatment. J Bone Joint Surg 67-A: , Myerson MS: Adult Acquired Flatfoot Deformity. J Bone Joint Surg 78-A(5): , O Malley MJ, Deland JT, Lee KT. Selective hindfoot arthrodeses for the treatment of adult acquired flat foot deformity: an in vitro study. Foot Ankle Int 16(7):411-7, Pell RF, Myerson MS, Schon LC. Clinical outcome after primary triple arthrodesis. J Bone Joint Surg 82A:47-57, Pedowitz WJ and Kovatis P: Flatfoot in the adult. J. of AAOS 3(5): , Romash MM. Triple arthrodesis for treatment of painful flatfoot, Grade III posterior tibial tendon dysfunction. Techniques in Foot and Ankle Surgery 2(2): , Russotti JM, Cass JR, Johnson KA. Isolated talocalcaneal arthrodesis: a technique using moldable bone graft. J Bone Joint Surg 70A:1472-8, Saltzman CL, Fehrle MJ, Cooper RR, Spencer EC, Ponseti IV. Triple arthrodesis: twenty-five and fortyfour-year average follow-up of the same patients. J Bone Joint Surg 81A(10): , Sangeorzan BJ, Mosca V, Hansen ST,Jr: Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot and Ankle 14: , Schon LC. Derotational triple arthrodesis for severe pes plano valgus corrections in Browner, B.D. (ed.): Techniques in Orthopaedics. Philadelphia, PA: Lippincott-Raven Publishers, 1996, 11(4): Southwell RB, Sherman FC. Triple arthrodesis: a long term study with force plate analysis. Foot and Ankle 2:15-24, Stephens HM, Walling AK, Solmen JD, et al. Subtalar repositional arthrodesis for adult acquired flat foot. Clin Orthrop 365:69-73, Toolan BC, Sangeorzan BJ, Hansen Jr ST. Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. J Bone Joint Surg 81A: , Wilson Jr FC, Fay GF, Lamotte P, et al. Triple arthrodesis: a study of the factors affecting fusion after three hundred and one procedures. J Bone Joint Surg 47A:340-8, 1965.