Outcome following addition of peroneus brevis tendon transfer to treatment of acquired posterior tibial tendon insufficiency

Clinical and variational evaluation of peroneus tertius muscle

This research was conducted to define the typology of the peroneus tertius, which is considered to be a part of the musculus extensor digitorum muscle and plays a role in dorsiflexion and eversion of the foot. In addition, another aim of the study was to examine the relationship of the peroneus tertius with the extensor digitorum longus and to investigate the possible effects of the tendon/insertio properties of the peroneus tertius on the fifth metatarsal. In this study; classical anatomical dissection was performed on 30 lower limbs. In this study, various parameters related to muscle origin, insertion, tendon and muscle dimensions were measured. It has been found that PTM was absent in 26.6% of the specimens and in 23.3% (n = 7) of the cases PTM was directly originated from the EDL. In 56.7% of the specimens (n = 17), the PTM tendon was mutually inserted into the dorsomedial surface of the 5th metatarsal and dorsolateral of the 4th metatarsal, while in 10.0% of the specimens it has thin medial bands (2 × 1 mm) towards the 5th digit. At the end of the study, the PTM origin was categorized into three different types and PTM insertion was categorized into five different types. Variation of PTM, muscle morphology and tendon diameter are extremely important in terms of minimally invasive surgical technique. Since the accessory tendon must have the properties close to the tendon that will be replaced, we believe that the results of our research provide unique useful information to clinicians. This study is the cadaver research.

Surgical Management of Musculotendinous Balance in the Progressive Collapsing Foot Deformity: The Role of Peroneal and Gastrocnemius Contracture

Surgical treatment of progressive collapsing foot deformity (PCFD) relies on understanding the dynamic and deforming musculotendinous structures that contribute to hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. Equinus commonly is seen in PCFD and consideration should be given to isolated gastrocnemius or Achilles lengthening. Although transfer of the flexor digitorum longus tendon is performed in PCFD attributed to dysfunction and pathology of the posterior tibialis tendon (PTT), retention of PTT is an area for further research. The peroneus brevis, which contributes to hindfoot imbalance in chronic cases, is a possible component of tendon rebalancing.

Fibular Tip Periostitis: New Radiographic Sign Predictive of Chronic Peroneal Tendon Subluxation-Dislocation in Pes Planovalgus

BACKGROUND. Tearing of the superior peroneal retinaculum is a known cause of peroneal tendon subluxation-dislocation. However, with the exception of cortical avulsions at the fibular attachment, superior peroneal retinaculum injury and subsequent peroneal tendon subluxation-dislocation are typically radiographically occult. OBJECTIVE. The purpose of this study was to evaluate the previously undescribed association between radiographic fibular tip periostitis and MRI evidence of peroneal tendon subluxation-dislocation in patients with hindfoot valgus. METHODS. Thirty-five patients with radiographic fibular tip periostitis and 35 ageand sex-matched individuals without periostitis were selected from among 220 consecutively registered patients with hindfoot valgus who had undergone both ankle radiography and MRI. Studies were retrospectively assessed by two musculoskeletal radiologists in consensus and by two additional blinded radiologists independently for the presence of peroneal tendon subluxation-dislocation, presence of subfibular impingement, and hindfoot valgus angle measurements. Interobserver agreement and accuracy, sensitivity, and specificity in the detection of fibular periostitis, peroneal tendon subluxation-dislocation, and subfibular impingement were calculated, and Fischer exact, Mann-Whitney, kappa coefficient, and intraclass correlation tests were performed. RESULTS. Both the consensus and the two independent interpretations showed that the frequency of peroneal tendon subluxation-dislocation was significantly greater in the group with periostitis (62.9%, 65.7%, and 85.7%) than in the group without periostitis (5.7%, 0%, and 14.3%) (p < .001). The finding of periostitis was specific and highly sensitive for predicting peroneal tendon subluxation-dislocation. The frequency of subfibular impingement was also statistically higher in the group with periostitis than in the group without it (p < .001). The hindfoot valgus angle was statistically larger in the group with periostitis than in the control group (p = .01-.002) and among patients with versus those without peroneal tendon subluxation-dislocation (p = .002 to p < .001). The blinded readers had substantial or almost perfect agreement on all imaging interpretations (concordance rate, 82.9-95.7%; κ = 0.66-0.91). CONCLUSION. The radiographic finding of fibular tip periostitis in patients with hindfoot valgus can be a predictor of peroneal tendon subluxation-dislocation and may also suggest advanced hindfoot valgus and subfibular impingement. These radiographic associations should be recognized by the radiologist, and MRI may be recommended as clinically indicated. CLINICAL IMPACT. Chronic undiagnosed peroneal tendon subluxation-dislocation can be a persistent cause of lateral ankle pain, leading to further degeneration and the possibility of complete peroneal tendon tears. Distal fibular periostitis in patients with hindfoot valgus can be a reliable radiographic indicator of this entity and may suggest the presence of subfibular impingement.

Dynamic correction for forefoot varus in stage II-A adult flatfoot: Technique tip

Posterior tibial tendon dysfunction (PTTD) is a progressive disorder and a common cause of adult acquired flatfoot deformity, and forefoot varus is a frequent component in advanced cases. The author proposes peroneus brevis-to-longus transfer as an additional step to correct the forefoot varus component of stage II-A posterior tibial tendon dysfunction. We have performed this dynamic correction of forefoot varus in 12 patients at our institution, and observed promising clinical and radiographic improvement. It is a soft tissue procedure that avoids additional incisions and represents a favorable alternative to more demanding techniques, such as osteotomy or arthrodesis.

Surgical Management of Stage 2 Adult and Pediatric Acquired Flatfoot Without Tendon Transfer or Arthrodesis: A Retrospective Study

Posterior tibial tendon dysfunction (PTTD) is a common pathology of the foot and ankle. Numerous techniques are available to reconstruct the flatfoot. Fusions and tendon transfers are popular methods; however, a wide range of complications have been associated with these procedures. The objective of the present study was to demonstrate the outcomes of reconstructive surgery for flatfoot correction without tendon transfer or arthrodesis. We performed a retrospective study of 43 patients and 56 feet who had undergone flatfoot reconstructive surgery from November 2011 to June 2016, with a mean follow-up period of 60 weeks (range 12 to 60 months). Each patient demonstrated a stage 2 flatfoot deformity classified using the Johnson and Strom classification. Depending on the patient's deformity, the procedures consisted of different variations of gastrocnemius recession, medial displacement calcaneal osteotomy, Evans osteotomy, and Cotton osteotomy. Six different preoperative and postoperative angles were radiographically measured on each foot studied. In all cases, the differences in the preoperative versus postoperative measurements were statistically significant (p < .003). We believe the foot and ankle surgeon can correct flatfoot deformity with the use of extraarticular procedures and create a plantigrade functional foot without fusion or tendon transfer.

Insertional Characteristics of the Peroneus Tertius Tendon: Revisiting the Anatomy of an Underestimated Muscle

The present study was performed to describe the morphologic characteristics of the peroneus tertius (PT) tendon, evaluate the variations in its insertion point, investigate the interconnections with the tendons of the extensor digitorum longus, and discuss whether these insertion differences of the muscle tension might have an effect on fracture formation. The length and width of the PT tendon and the width at its midpoint were measured in 44 lower extremities. The data obtained were compared statistically. The PT was found to occur in 2 types according to the number of tendons: type 1, a single tendon without a slip; and type 2, 2 tendons with a slip. It has been suggested that the PT tendon could contribute to avulsion fractures of the tuberosity of the fifth metatarsal bone. Therefore, to understand the mechanism of Jones fracture, knowledge of the PT tendon would be beneficial to determine the insertion points.

Tendon transfers in the treatment of the adult flatfoot

Tendon transfers are critical to successful surgical correction of adult flexible flatfoot deformity and may be beneficial in correcting rigid deformities as well. Patients with refractory stage I and II deformities often require selective osteotomies in addition to tendon transfer. Patients with stage III and IV deformities typically require hindfoot arthrodesis. One of several tendons can be used for transfer based on surgeon's preference. Flexor digitorum longus (FDL) and flexor hallucis longus (FHL) transfers have been shown to have good results. A peroneus brevis transfer is typically used to supplement small FDL or FHL transfer donors or in revision cases.

Tendon transfer options in managing the adult flexible flatfoot

Patients undergoing surgery for posterior tibial tendon dysfunction may require tendon transfer. The flexor digitorum longus is most commonly transferred, although the flexor hallucis longus and peroneus brevis have also been described in the literature. This article discusses the advantages and disadvantages of the different tendons, the surgical techniques used to perform them, and their results in the literature, concentrating principally on studies in which additional bone procedures were not performed. This article will also discuss the potential role for isolated soft tissue procedures in the treatment of stage 2 posterior tibial tendon dysfunction.

Tendon transfers and realignment osteotomies for treatment of stage II posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction (PTTD) has been approached with a multitude of surgical techniques. This article outlines the current understanding of the flexor digitorum longus transfer and flexor hallucis longus transfer in the context of various osteotomy techniques for the correction of stage II PTTD. Pertinent clinical literature and scientific evidence will also be compared and analyzed.

An in vitro study comparing the use of suture anchors and drill hole fixation for flexor digitorum longus transfer to the navicular

BACKGROUND

The surgical management of posterior tibial tendon dysfunction often includes transfer of the flexor digitorum longus (FDL) tendon through a tunnel in the navicular. Fixation often is obtained by sewing the tendon back onto itself. The purpose of this study was to compare this standard method of fixation with suture anchor fixation, a technique that may be associated with less surgical morbidity, because it requires the harvesting of less tendon length.

METHODS

FDL tendon transfer to the navicular was done in 13 fresh-frozen cadaver specimens. In six feet comprising the standard group, the FDL tendon was transected distal to the master knot of Henry, placed through a drill hole into the navicular, and sutured back onto itself. In seven feet the FDL tendon was transected proximal to the master knot of Henry, placed into a drill hole into the navicular, and fixed with a suture anchor. Load was applied to the proximal FDL muscle and tendon using a materials testing system (MTS) machine and peak load to failure was measured.

RESULTS

The mean load to failure was 142.48 N +/- 38.06 N for the standard group and 142.12 N +/- 59.26 N for the suture anchor group (p = 0.305 for the Student-t test and p = 0.945 for the Mann-Whitney test).

CONCLUSION

Transfer of the FDL tendon to the navicular using suture anchor fixation requires less tendon length yet provides similar fixation strength as compared to sewing the tendon back onto itself. However, suture anchors are considerably more expensive than sutures.

CLINICAL IMPLICATIONS

Suture anchors allow comparable fixation of FDL tendon transfer into a navicular without the need to disrupt the master knot of Henry. This technique may be associated with less morbidity including a shorter incision, decreased risk of medial plantar nerve injury, and decreased loss of lesser toe plantarflexion strength secondary to maintenance of the normal interconnections between the flexor hallucis longus (FHL) and FDL tendons.

Soft tissue procedures

Soft tissue procedures for PTT dysfunction and adult acquired flat foot improve function and preserve joint motion. These procedures can only be applied to patients who have correctable deformities. The durability of these procedures, without the addition of bone realignment procedures, has been questioned and needs to be investigated further. Reconstruction of the spring ligament complex corrects the flat foot in cadavers but has not been studied clinically. There is still much to be learned in this condition so we are able to provide optimal care for our patients.

Intermediate term follow-up of calcaneal osteotomy and flexor digitorum longus transfer for treatment of posterior tibial tendon dysfunction

Twenty-three patients with stage II posterior tibial tendon dysfunction who had failed non-surgical therapy were treated with flexor digitorum longus transfer and calcaneal osteotomy. At latest follow-up averaging 35 +/- 7 months (range, 24 to 51 months), 22 patients (96%) were subjectively "better" or "much better." No patient had difficulty with shoe wear; however, four patients (17%) required routine orthotic use consisting of a molded shoe insert. AOFAS scores were available on 21 patients and improved from a preoperative mean of 50 +/- 14 (range, 27 to 85) to a postoperative mean of 89 +/- 10 (range, 70 to 100). Our experience, at an intermediate date follow-up is that calcaneal osteotomy and flexor digitorum longus transfer is a safe and effective form of treatment for stage II posterior tibial tendon dysfunction.