Tendoscopy in stage I posterior tibial tendon dysfunction

Ultrasound assessment of the spring ligament and posterior tibial tendon in healthy subjects: A descriptive study

BACKGROUND

The main aim of this study was to ultrasonographically analyse the thickness and the relationship between the Superomedial Bundle of the Spring Ligament and the Posterior Tibial Tendon in healthy subjects and its relationship with different epidemiological variables.

METHODS

Fifty-five healthy feet with a mean of 47 years old measuring the same ultrasound model and researcher. Demographic variables (age, sex, laterality, BMI, type of sports activity performed, and type of work activity) were collected from all participants. The thickness of the PTT and the Spring Ligament was measured in both longitudinal and transverse diameters. The intraclass correlation coefficient (ICC) was also analysed to assess the agreement of the measurements between a researcher and the ultrasound specialist radiologist.

RESULTS

The mean thickness of the Spring ligament was 5.07 mm (95 % CI 4.75-5.38), while that of the PTT in its long axis was 3.58 mm (95 % CI 3.37-3.79). Regarding the interobserver agreement analysis, the intraclass correlation coefficient for measurements between observers was 0.91 (CI95 %: 0.698-0.977) which denotes a high degree of similarity between the clinician and the radiologist.

CONCLUSION

This study describes the relationships between the thickness of the posterior tibial tendon and the superomedial Bundle of the Spring ligament in healthy subjects, as well as their variability according to certain epidemiological variables such as age, gender, occupation, and sport. On the other hand, the measurements taken by a researcher high agreement with those taken by a radiologist specialized in ultrasound.

Outcomes of Combined Posterior Tibial Tendon Tendoscopy and Medializing Calcaneal Osteotomy for Stage IA Progressive Collapsing Foot Deformity

BACKGROUND

Posterior tibial tendon (PTT) tendoscopy and medializing calcaneal osteotomy (MCO) are among the available techniques for patients presenting with symptomatic flexible hindfoot valgus (stage IA) progressive collapsing foot deformity (PCFD). The aim of this study was to determine clinical and radiographic outcomes of combined PTT tendoscopy and MCO for patients presenting with symptomatic stage IA PCFD.

METHODS

A retrospective cohort study was performed in order to determine clinical and radiographic outcomes of 30 combined PTT tendoscopies and MCO on 27 patients presenting with symptomatic stage IA PCFD, with a minimum follow-up of 24 months. Patient satisfaction was assessed at last available follow-up as very satisfied, satisfied, and unsatisfied. Clinical assessment was performed evaluating preoperative and last available follow-up visual analog scale for pain (VAS-P), Foot and Ankle Outcome Score (FAOS), and the 36-Item Short Form Health Survey (SF-36). Magnetic resonance imaging (MRI) was performed preoperatively on all patients. Standard weightbearing anteroposterior, lateral, and long axial view radiographs of the foot and ankle were taken preoperatively, immediate postoperatively, at 6 weeks, 3 months, 6 months, 1 year postoperatively, and last follow-up evaluation available for each patient.

RESULTS

The mean follow-up was 38.6 (range, 26-62) months. We registered 27 very satisfied, 1 satisfied, and 2 unsatisfied patients. There was statistically significant improvement on all clinical scores (VAS-P, FAOS and SF-36), as well as on lateral talo-first metatarsal and hindfoot alignment angles. We found low-grade PTT tears in 5 patients (16.67%) in whom preoperative MRI documented PTT tenosynovitis alone.

CONCLUSION

We found that combined PTT tendoscopy and MCO provide significant clinical and radiographic improvement for patients presenting with symptomatic stage IAB PCFD. PTT tendoscopy should be considered in the treatment of all surgically addressed flexible valgus feet as it detects tendon tears which are frequently missed on an MRI.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

In-Office Needle Tendoscopy of the Tibialis Posterior Tendon with Concomitant Intervention

Tendoscopy has been recognized to be a useful technique in the diagnosis and treatment of early tibialis posterior tendon (TPT) dysfunction. Although open surgical procedures for advanced TPT disease have led to excellent outcomes, disagreement persists concerning the correct management algorithm for early TPT dysfunction. Recent developments in needle tendoscopy have provided a minimally invasive option for direct evaluation and intervention throughout the forefoot, midfoot, and hindfoot. The goal of this manuscript is to describe the technique for performing in-office needle tendoscopy targeting the TPT with a discussion of indications and opportunities afforded by an in-office procedure over the traditional operating room suite.

Progressive Collapsing Foot Deformity. Is There Really a Johnson and Strom Stage I?

Johnson and Strom stage I posterior tibialis tendon dysfunction presents with pain and swelling but preserved function and no deformity. Diagnosis is clinical. Pathomechanics explains the overloading of the tendon that may be worsened by a tight gastrocnemius, but systemic inflammatory disease may also be responsible for a stage I condition. Medial heel wedged orthoses are effective in most patients. Surgery usually consists of an open/endoscopic tenosynovectomy. In cases of complete tendon rupture, flexor digitorum longus tendon transfer may be considered. Stage I patients with a higher risk of progression-inflammatory conditions, excessive laxity, obese-may benefit from a "prophylactic" medializing calcaneal osteotomy.

Role of Minimally Invasive Surgery in Adult Flatfoot Deformity

Adult acquired flatfoot deformity (AAFD) as a consequence of posterior tibial tendon dysfunction is commonly divided in flexible (stages I and II) and fixed (stages III and IV) deformities. The aim of this article is to summarize the evidence available for minimally invasive surgical techniques that can be used in the treatment of flexible AAFD, including tibialis posterior tendoscopy, subtalar arthroereisis, minimally invasive calcaneal osteotomy, and medial proximal gastrocnemius recession. A treatment algorithm and technical tips have also been provided.

Effect of extensive tenosynovectomy on diffuse flexor hallucis longus tenosynovitis combined with effusion

OBJECTIVE

The objective of this study was to examine the clinical and magnetic resonance imaging (MRI) outcomes of extensive tenosynovectomy on patients with diffuse flexor hallucis longus tenosynovitis combined with effusion (DFHLT-E).

METHODS

Consecutive patients undergoing extensive tenosynovectomy for DFHLT-E in the same foot and ankle center from January 2013 to December 2016 were selected; a total of 14 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, MRI, American Orthopaedic Foot and Ankle Society (AOFAS) clinical midfoot scale, and visual analog scale (VAS) pain scores.

RESULTS

The 14 patients were followed up for an average of 15.0 ± 2.3 months (12-18 months). There were no recurrences in all clinical examinations at the final follow-up. The AOFAS score was improved from 61.57 ± 10.70 before surgery to 90.28 ± 9.41 at the final follow-up. The difference was statistically significant (p = 0.001). The VAS score was improved from 4.00 ± 0.82 before surgery to 0.43 ± 0.53 at the final follow-up (p < 0.001). MRI examination revealed two patients with small residual and limited effusion with no clinical symptoms. Superficial pin infection was observed in one patient, and two patients had transient neurostimulation.

CONCLUSIONS

Extensive tenosynovectomy is an effective alternative for the treatment of DFHLT-E with less complications or recurrence.

Tendoscopy of Achilles, peroneal and tibialis posterior tendons: An evidence-based update

BACKGROUND

Tendoscopy has been proposed in treating several conditions affecting tendons around the ankle. We reviewed literature to investigate the efficacy of Achilles, peroneal and tibialis posterior tendoscopy.

METHODS

Following the PRISMA checklist, the Medline, Scopus and EMBASE databases were searched, including studies reporting patients affected by disorders of Achilles, peroneal and tibialis posterior tendons and treated by tendoscopy (or tendoscopic-assisted procedures). The tendoscopic technique, rehabilitation protocol, clinical scores, patient satisfaction, success and failure rates and complications were evaluated.

RESULTS

Sixteen studies (319 procedures) dealt with Achilles tendoscopy, nine (108) and six (78) about peroneal and tibialis posterior, respectively. Wound healing, cosmetic results, complication rate, work and sport resumption delay were satisfactory. Clinical scores, classification methods and rehabilitation protocols adopted were heterogeneous.

CONCLUSIONS

The recent scientific evidence suggests that tendoscopy and endoscopic-assisted percutaneous procedures are a safe and effective treatment in chronic and acute disorders of tendons around the ankle.

Role of Tendoscopy in Treating Stage II Posterior Tibial Tendon Dysfunction

BACKGROUND

Stage II tibialis posterior tendon dysfunction (PTTD) resistant to conservative therapies is usually treated with invasive surgery. Posterior tibial tendoscopy is a novel technique being used in the assessment and treatment of posterior tibial pathology. The aims of this study were (1) to clarify the role of posterior tibial tendon tendoscopy in treating stage II PTTD, (2) to arthroscopically classify spring ligament lesions, and (3) to compare the arthroscopic assessment of spring ligament lesions with magnetic resonance imaging (MRI) and ultrasonographic (US) data.

METHODS

We reviewed prospectively collected data on 16 patients affected by stage II PTTD and treated by tendoscopy. We report the reoperation rate and functional outcomes evaluated by comparing pre- and postoperative visual analogic scale for pain (VAS-pain) and the Short-Form Health Survey (SF-36; with its physical [PCS] and mental [MCS] components). Postoperative satisfaction was assessed using a VAS-satisfaction scale. One patient was lost to follow-up. Spring ligament lesions were arthroscopically classified in 3 stages. Discrepancies between preoperative imaging and intraoperative findings were evaluated.

RESULTS

At a mean of 25.6 months' follow-up, VAS-pain ( P < .001), SF-36 PCS ( P = .039), and SF-36 MCS ( P < .001) significantly improved. The mean VAS-satisfaction score was 75.3/100. Patients were relieved from symptoms in 80% of cases, while 3 patients required further surgery. MRI and US were in agreement with intraoperative data in 92% and 67%, respectively, for the tendon assessment and in 78% and 42%, respectively, for the spring ligament.

CONCLUSIONS

Tendoscopy may be considered a valid therapeutic tool in the treatment of stage II PTTD resistant to conservative treatment. It provided objective and subjective encouraging results that could allow continued conservative therapy while avoiding more invasive surgery in most cases. MRI and US were proven more useful in detecting PT lesions than spring ligament tears. Further studies on PT could use this tendoscopic classification to standardize its description.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series.

Posterior Tibial Tendon Endoscopic Debridement for Stage I and II Posterior Tibial Tendon Dysfunction

Adult acquired flatfoot deformity (AAFD), formerly known as posterior tibial tendon (PTT) dysfunction, is one of the most common problems of the foot and ankle. It was first described as tendon failure but has since been revealed as ligamentous failure in addition. AAFD is a spectrum of deformities that ranges from tenosynovitis (stage I) to AAFD (stages II-IV). Regarding mild stage I and stage II disease, it was once standard to perform an open synovectomy completely removing the inflamed synovium; this procedure required a large 6-cm medial ankle incision. Postoperative management included plaster cast immobilization for 3 weeks, followed by a boot with controlled ankle movement for another 3 weeks. Now, the standard is shifting to PTT endoscopy, which has proved to be an efficient way to treat tenosynovitis in stage I and II AAFD with a shorter postoperative period. Using this technique, we can achieve 360° visualization of the PTT within the tendon sheath, allowing for a complete exploration and debridement. We hope that by using this video description, practitioners could avoid the increased morbidity associated with open procedures, as well as help patients return to activity sooner after surgery.

Adult-acquired flatfoot deformity

Adult-acquired flatfoot deformity (AAFD) is a known and recognized cause of pain and disability. Loss of PTT function is the most important contributor to AAFD, and its estimated prevalence is thought to be over 3%. This review aims to summarize the current literature and encompass recent advances regarding AAFD.

Foot and ankle tendoscopies: current concepts review

Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders.The most common foot and ankle tendoscopies are: Achilles; peroneal; and posterior tibial tendon.Tendoscopy may be used as an adjacent procedure to other techniques.Caution is recommended to avoid neurovascular injuries.Predominantly level IV and V studies are found in the literature, with no level I studies still available.There are many promising and evolving endoscopic techniques for tendinopathies around the foot and ankle, but studies of higher levels of evidence are needed to strongly recommend these procedures. Cite this article: EFORT Open Rev 2016;1:440-447. DOI: 10.1302/2058-5241.160028.

Ultrasound Guidance in Performing a Tendoscopic Surgery to Treat Posterior Tibial Tendinitis: A Useful Tool?

A 25-year-old man with a pronation-external rotation type of fracture was surgically treated using a fibular plate. Five years later, he underwent resection of bone hyperplasia because of the ankle pain and limitation of range of motion. Thereafter, the left ankle became intermittently painful, which persisted for about one year. He presented at the age of 43 with persistent ankle pain. Physical and image analysis findings indicated a diagnosis of posttraumatic posterior tibial tendinitis, which we surgically treated using tendoscopy. Endoscopic findings showed tenosynovitis and fibrillation on the tendon surface. We cleaned and removed the synovium surrounding the tendon and deepened the posterior tibial tendon groove to allow sufficient space for the posterior tibial tendon. Full weight-bearing ambulation was permitted one day after surgery and he returned to his occupation in the construction industry six weeks after surgery. The medial aspect of the ankle was free of pain and symptoms at a review two years after surgery. Although tendoscopic surgery for stage 1 posterior tibial tendon dysfunction has been reported, tendoscopic surgery to treat posttraumatic posterior tibial tendinitis has not. Our experience with this patient showed that tendoscopic surgery is useful not only for stage 1 posterior tibial dysfunction, but also for posttraumatic posterior tibial tendinitis.

Posterior Tibial Tendoscopy: Endoscopic Synovectomy and Assessment of the Spring (Calcaneonavicular) Ligament

A tear of the spring ligament is frequently associated with posterior tibial tendon dysfunction. Repair of the damaged spring ligament is an important component of surgical reconstruction in the treatment of posterior tibial tendon dysfunction because it is a major anatomic contributor to the integrity of the medial longitudinal arch, particularly if the dynamic support of the posterior tibial tendon is compromised. Extensive dissection is required for exposure and repair of the ligament because it is a deep-seated structure. It is beneficial to confirm the presence of ligament tears before surgical exploration to avoid unnecessary dissection. Preoperative magnetic resonance imaging and ultrasound studies have moderate sensitivity in the detection of these tears. We report an arthroscopic technique for assessment of the integrity of the spring ligament during endoscopic or open reconstruction of the posterior tibial tendon. This allows the surgeon to confirm the presence of a ligament tear before additional dissection to explore and repair the ligament.

Stage I and II Posterior Tibial Tendon Dysfunction: Return to Running?

Posterior tibial tendon dysfunction can be a difficult entity to treat in the athletic population. Understanding the deformity components allows the physician to maximize nonoperative intervention with orthotics and physical therapy. Not all patients improve with nonoperative treatment, and surgical intervention can be successful in minimizing symptoms. Although return to full athletic activity is not universally possible, an active lifestyle is possible for many after surgical reconstruction.

Functional Outcomes of Tibialis Posterior Tendoscopy With Comparison to Magnetic Resonance Imaging

BACKGROUND

The purpose of the current study was to report functional outcomes of tendoscopy for treatment of tibialis posterior tendon pathology as well as compare its diagnostic capability with magnetic resonance imaging (MRI).

METHODS

Clinical records and MRI of 12 patients who underwent tendoscopy of the tibialis posterior tendon (TPT) were retrospectively reviewed. Mean follow-up was 31 months (range, 26-43 months). Preoperative MRI findings were compared with tendoscopic findings to assess the diagnostic agreement between each modality. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) General Health Questionnaire pre- and postoperatively. Mean patient age was 43 years (range, 17-63 years). Mean duration of preoperative symptoms was 15.5 months (range, 3-36 months).

RESULTS

Pathologies addressed via tendoscopy included tenosynovitis, tendinosis, stenosis, tendon subluxation, and partial thickness tear (via mini-arthrotomy). Preoperative MRI findings were in agreement with tendoscopic findings in 8 of 12 cases (67%). Tendoscopy diagnosed and allowed access for treating pathology that was missed on MRI in the remaining four cases. The FAOS improved from a mean preoperative score of 58 (range, 36-78) to a mean postoperative score of 81 (range, 44-98) (P < .01). The SF-12 score improved from a mean preoperative score of 34 (range, 13-51) to a mean postoperative score of 51 (range, 21-76) (P = .01).

CONCLUSIONS

Although MRI is considered an effective imaging technique for tendon pathology, tendoscopy may be a more sensitive diagnostic tool. Tendoscopy was an effective minimally invasive tool to diagnose and treat tibialis posterior tendon pathology resulting in functional improvements in the short-term for early stage TPT dysfunction. Further studies comparing tendoscopy with traditional open approaches are warranted.

LEVEL OF EVIDENCE

Level IV case series.

Posterior tibial tendon dysfunction: an overlooked cause of foot deformity

Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot. Degenerative changes in this tendon, lead to pain and weakness and if not identified and treated will progress to deformity of the foot and degenerative changes in the surrounding joints. Patients will complain of medial foot pain, weakness, and a slowly progressive foot deformity. A “too many toes” sign may be present and patients will be unable to perform a single heal raise test. Investigations such X-ray, ultrasound and magnetic resonance imaging will help stage the disease and decide on management. The optimal manage may change based on the progression of deformity and stage of disease. Early identification and prompt initiation of treatment can halt progression of the disease. The purpose of this article is to examine the causes, signs, symptoms, examinations, investigations and treatment options for posterior tibial tendon dysfunction.

Arthroscopic treatment for posterior tibial tendon lesions with a posterior approach

PURPOSE

To evaluate clinical results of arthroscopic treatment for posterior tibial tendon (PTT) lesions using a posterior approach.

METHODS

Sixteen patients with PTT lesions underwent arthroscopic treatment using a posterior approach. After routine posterior arthroscopy to expose the posterior tibiotalar compartment, the posterior subtalar compartment, and the flexor hallucis longus tendon, the shaver was then moved through the flexor hallucis longus tendon to detect and treat the PTT lesion, including synovectomy, debridement, and repair of the PTT. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot (AOFAS) scale and visual analog scale (VAS) for subjective satisfaction were used to evaluate pre- and post-operative clinical results.

RESULTS

Fifteen patients (94 %) (15 ankles) were followed for a mean of 26 ± 10 months. No patients experienced vascular or nerve complications during or after the operation. Mean AOFAS score improved from 49 ± 12 points preoperatively to 84 ± 8.5 points post-operatively (p = 0.000). Mean VAS improved from 6.2 ± 1.7 preoperatively to 2.4 ± 1.3 post-operatively (p = 0.000). There were three patients (20 %) with excellent outcomes, eight patients (53 %) with good outcomes, three patients (20 %) with fair outcomes, and one patient (7 %) with a poor outcome at follow-up.

CONCLUSIONS

A posterior arthroscopic approach can provide a safe, reliable technique for detecting and treating PTT lesions and a satisfactory surgical outcome. The technique is an alternative to PTT tendoscopy.

Posterior tibial tendoscopy

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.

Foot and ankle tendoscopy: evidence-based recommendations

PURPOSE

The purpose of this study was to provide a comprehensive review of the current literature on tendoscopy of the foot and ankle and assign an evidence-based grade of recommendation for or against intervention.

METHODS

A comprehensive review of the literature was performed on May 26, 2013, using the PubMed, Cochrane, and Scopus databases. Studies focusing on the use of foot and ankle tendoscopy were isolated, and these articles were then reviewed and assigned a Level of Evidence (I through V). The literature was then analyzed, and a grade of recommendation was assigned for tendoscopy of the tendons of the foot and ankle on which the procedure is generally performed.

RESULTS

There is weak evidence (grade Cf) to support the use of tendoscopy on the Achilles, flexor hallucis longus, and peroneal tendons. Insufficient evidence (grade I) exists to assign a grade of recommendation for tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus.

CONCLUSIONS

A comprehensive review of the literature on foot and ankle tendoscopy has shown predominantly Level IV and V studies, with just 1 Level II study. On the basis of the current literature available, there is poor evidence (grade Cf) in support of Achilles, flexor hallucis longus, and peroneal tendoscopy for the common indications. There is insufficient evidence to make a recommendation (grade I) for or against tendoscopy of the tibialis posterior, tibialis anterior, flexor digitorum longus, extensor hallucis longus, and extensor digitorum longus. Although current literature suggests that tendoscopy is a safe and effective procedure, original scientific articles of higher levels of evidence are needed before a stronger recommendation can be assigned.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, IV, and V studies.