Pes Planovalgus and posterior tibial tendinopathy · 2016-02-29 · Supple pes plano valgus Ø A :...
Transcript of Pes Planovalgus and posterior tibial tendinopathy · 2016-02-29 · Supple pes plano valgus Ø A :...
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Pes Planovalgus and posterior tibial tendinopathy:
Therapeutic choices in terms of staging the lesions
Dr de Halleux Jacques SPA, 2011 september 17
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TIBIALIS POSTERIOR TENDON
• Inversion of the heel• Adduction forefoot• Plantar flexion of the Ankle
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Tibialis posterior tendon
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PES PLANO VALGUS
Calcaneum valgusSubtalar joint tilted mediallyTalus medialy and downT-N and N-C subluxation Midtarsal joints Abduction + suppination
valgus hindfoot Achilles tendon = evertor
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DIAGNOSIS tibialis posterior dysfunction
flattening longitudinal archØ
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Ø valgus of the hindfoot
DIAGNOSIS tibialis posterior dysfunction
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Ø abduction of the mid and forefoot
Ø„too-many-toes sign“
DIAGNOSIS tibialis posterior dysfunction
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DIAGNOSIS tibialis posterior dysfunction
„single-heel-rise test“Normal Tib Post
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„single-heel-rise test“
Tib Post Dysfunction
DIAGNOSIS tibialis posterior dysfunction
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STAGEStibialis posterior dysfunction
stage 1 stage 2 stage 3 stage 4Ø retromalleolar pain + ++ ++ ++Ø hindfoot valgus (+/-) ++ ++ ++Ø arch flattening (+/-) ++ ++ ++Ø forefoot supination (+/-) (+) ++ ++Ø forefoot abduction (+/-) ++ ++ ++Ø deformity supple supple rigid rigidØ Ankle pain - - - ++
Stages 1, 2 , 3 = Johnson and Strom, Clin Orthop, 1989 Stage 4 = Myerson, JBJS Am, 1996
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Ø retromalleolar painØ X Ray NormalØ Stages A : inflammation, no deformation
B : partial PTT tear, no deformationC : partial PTT tear, little hindfoot valgus
Posterior Tibial Tendon Dysfunction Stage 1
Tenosynovitis or partial rupture
Haddad St, Myerson MS and al, Foot and Ankle Int, 2011,jan.
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Supple pes plano valgus
Ø A : valgus hindfoot ; (<50% uncovering TN)Ø B : forefoot suppination flexible (>50% uncovering TN)Ø C : A or B with forefoot suppination fixed)Ø D : Forefoot abductionØ E : medial colomn (TN, NC, CMT) instability
Stage 2Posterior Tibial Tendon Dysfunction
(partial) rupture
Elongation, tendinosis
Haddad St, Myerson MS and al, Foot and Ankle Int, 2011,jan.
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Posterior Tibial Tendon Dysfunction
Stage 3
Ø Rigid pes plano valgus
Ø A :Hindfoot valgusØ B :Forefoot abduction
More advanced course of tendon rupture
Haddad St, Myerson MS and al, Foot and Ankle Int, 2011,jan
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Posterior Tibial Tendon Dysfunction
Stage 4
Ø Rigid pes plano valgus Ø Lateral ankle pain
Ø A : reductible ankle valgusØ B : rigid ankle valgus (more common presentation)
ankle arthrosis
rupture
Talus valgus
Myerson MS and al, Foot and Ankle Int, 2011,jan
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conservative • physiotherapy• shoe corrections• medial support
Posterior Tibial Tendon Dysfunction TREATMENT
Ø Stage 1
Surgery? Ténosynovectomy?
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Posterior Tibial Tendon Dysfunction TREATMENT
Ø Stage 2
What to do?
• Valgus hindfoot?
• Forefoot abduction?
• Forefoot suppination?
• Medial column instability?
• Spring ligament ?
• Tibialis posterior?
• Achilles tendon ?
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PTT dysfunction St II
complex problem that has multiple treatment options *
* Hill K, Foot Ankle Clin.8(1):91-104, 2003 Mar
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Posterior Tibial Tendon Dysfunction Stage II
Treatment
SURGICAL
- Calcaneal osteotomy ( >< valgus :Koutsogiannis and others) ( >< abd forefoot : lateral column lenghtening)
- Arthrodesis (>< abd forefoot : lateral column lenghtening)(>< supp forefoot : medial colomn)
- Tendon reconstruction(suture, plasty, transfert FHL or FDC, Cobb)
- Ligament reconstruction(spring ligament)
- Others(Achilles tendon lenghtening, TN arthrodesis, subtalar arthrodesis, subtalar arthroeresis, medial
cuneiform osteotomy, 1st MT osteotomy)
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Line of weight-bearing transmitted through the talus medial to the calcaneus
CALCANEAL OSTEOTOMY(valgus correction)
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CALCANEAL OSTEOTOMY(valgus correction)
• 1893 : posterior fragment forwards, medially and downwards (Gleich)
• 1967: lateral opening wedge (Silver)
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CALCANEAL OSTEOTOMY(valgus correction)
• 1971: medial translation of the posterior fragment (Koutsogiannis) – JBJS, febr 1971-
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Surgical technique Koutsogiannis osteotomy
• Lateral incision (parallel and behind peroneal tendon) sural nerve!
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Surgical technique Koutsogiannis osteotomy
• Incision periostum parallel to the incision
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Surgical technique Koutsogiannis osteotomy
• MEDIAL TRANSLATION POSTERIOR PART CALCANEUM ( 1/3 to ½ of the width of the calcaneus; 1 cm)
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Surgical technique Koutsogiannis osteotomy
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Surgical technique Koutsogiannis osteotomy
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LATERAL OPENING WEDGE OSTEOTOMY
2005 : Z osteotomy(Malerba)
pictures from: Th Leemrijse, B Valtin, Pathologie du Pied et de la cheville, 2009
CALCANEAL OSTEOTOMY(valgus correction)
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MALERBA OSTEOTOMY Lateral opening wedge osteotomy
picture from: Th Leemrijse, B Valtin, Pathologie du Pied et de la cheville, 2009
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RESULTS CALCANEAL OSTEOTOMY(valgus correction)
• Correction of the valgus and the eversion force of the Achilles tendon
• Medial arch + forefoot abduction: deformation corrected only if no severe flatfoot
Calcaneal osteotomy alone not enough!
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CALCANEAL OSTEOTOMY(St IID : forefoot abduction) lateral column lenghtening
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CALCANEAL OSTEOTOMY: Lateral column lengthening
Hintermann B: Techniques in Orthopaedics and Traumatology 2000
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Lateral colomn lenghtening
Increasing of calcaneo-cuboidal arthrosis Evans : 65% at 13 years follow-upMosier-Laclair : 14% at 5 years follow-up *
Alternative = calcaneocuboïd distraction arthrodesis- less motion hindfoot, - increasing arthrosis hind and midfoot
(motion subtalar loss of 18 to 30% and TN loss of 40%**)
* Mosier-Laclair, Foot Ankle Clinic (6):95-119, 2001 Mar ** Deland J et al, Foot Ankle.16(11) , 1995
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Medial column restauration PTT dysfunction II C (rigid forefoot suppination)
- Arthrodesis naviculo-cuneiform 123 *
- Arthrodesis 1st tarso-metatarsal
- Cotton osteotomy (plantar flexion opening wedge cun 1)**
- Plantar flexion osteotomy MT1
• Alastair Younger, Foot Ankle Int. 32 (1) : 101-3, 2011** Hirose CB, Foot Ankle Int. 25 : 568-74, 2004
Stephen J Pinney, Foot Ankle Int, 27 (1) : 66-75, 2006 jan
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TENDON RECONSTRUCTION :suture
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TENDON RECONSTRUCTION:Z-lengthening
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TENDON RECONSTRUCTION : FHL or FDC transfert
Tibialis posterior
FDC
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TENDON RECONSTRUCTION:Transfert Tibialis anterior ( Cobb)
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Cobb Procedurerestore plantar flexion power of the 1st ray
( more distal insertion of the Tib Ant)
Knupp M, Hintermann B
- n = 22 PTT dysfunction st IIB- FU : 24 months- results : AOFAS score 53,2 to 88,5
excellent / good results : 95 %no decreasing Force of TA
- Cobb technique = apropriate alternative to arthrodesisin st II B PTT dysfunction ( in addition with other technique)
Knupp M, Hintermann B, Foot Ankle Int,. vol 28 (4) : 416-21, 2007
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LIGAMENT RECONSTRUCTIONspring ligament suture
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RESULTSFDL transfert + medial translation calcaneal osteotomy
Myerson M S *n:32 st II PTT dysfunctionmean age : 58 yFU : 20 months (14 to 48) results : AOFAS score 48 to 84
94% pain relief, improvement arch of the foot
Wacker J T **n : 44 st II PTT dysfunctionmean age 61 yFU : 51 months ( 38 to 62 )results : AOFAS score 48 to 88,5
95% pain relief80% improvement arch of the foot
* Myerson MS, Orthopedics. 19:383-8,1996** Wacker JT, JBJS. 84-B : 54-8, 2002
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RESULTSFDL transfert + medial translation calcaneal osteotomy
+ lateral colomn lenghtening ( Mosier-Laclair**)
Satisfaction rate highNo medial arch restauration in all patients
Cc arthrosis 14%
** Mosier-Laclair, Foot and Ankle Clinic, Mar 2001: (6):95-119;
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RESULTSCC arthrodesis + PTT repair + Achilles tendon
lenghtening ( Lauwerens, 2006)
N = 20; FU = 24 months85% complete relief of pain
10% nonunion
15% sural nerve dammage
Lauwerens, Acta Orthop, 2006 Feb; 77(1):156-63
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surgical • triple arthrodeses
Posterior Tibial Tendon Dysfunction
Treatment
ØStage 3
ØA : + Medial transl calc ost
ØB : + lenght lat column
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Surgical* A : ankle soft tissue repair + Triple ArthrodesisB : Panarthrodesis / TTC arthrodesis
Posterior Tibial Tendon Dysfunction Treatment
Ø Stage 4
*Bluman EM, Myerson MS, Foot Ankle Clinic, 12(2): 341-62, 2007
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I II II / III III / IV IV
conservative MTCO PTT repair spring Medial Lateral Triple Soft tissue Pantalar
synovectomy ligam column column arthrodesis ankle TTC desis
I pain A PTT nfllam; no deform
B parti PTT tear; no deform
C part PTT tear; little valgus
II supple PPV A calc valgus
B supple forefoot supp (COBB)
C rigid forefoot supp
D forefoot abd
E mdl column instabiliy
III rigid PPV A calc valgus
B forefoot abd
IV ankle valgus A supple
B rigid
Posterior Tibial Tendon Dysfunction TREATMENT
CONCLUSION
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Posterior Tibial Tendon Dysfunction CONCLUSION
• Good physical examination• Good treatment indication• Good results
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