PTT Tears: Options for Full Thickness Tears with Collapse Matrona - PowerPoint PPT Presentation

PTT Tears: Options for Full Thickness Tears with Collapse Matrona Giakoumis, DPM Faculty, The New York College of Podiatric Medicine Faculty, The Podiatry Institute OSET ORTHOPAEDIC SUMMIT Evolving Techniques 2017

Conflicts of Interest No conflicts to disclose

Objectives Identify a certain subset of patients with PTT tears and collapse that would most benefit from arthrodesis. Review arch support and the function of dynamic and static stabilizers of the arch. Provide support for arthrodesis as surgical option by showing that the dreaded secondary OA from arthrodesis procedures is often asymptotic and merely a radiographic finding.

Arthrodesis Procedures Utilized to correct gross instability in order to maintain as much physiologic motion as possible

Myerson Modification of Johnson & Strom Classification of AAFD STAGE DESCRIPTION Mild medial pain + swelling - deformity; + double heel-rise + weakness on I repetition, tenosynovitis w/normal length Mod pain w/ or w/o lateral pain, flexible deformity, - heel rise, elongated II tendon w/longitudinal tears IIA < 30% talar head uncoverage IIB > 30% talar head uncoverage III Severe pain, fixed deformity, - heel rise tears, + tears IV Lateral talar tilt IVA Flexible ankle valgus w/o severe arthritis IVB Fixed ankle valgus w/ or w/o arthritis

Myerson Modification of Johnson & Strom Classification of AAFD STAGE DESCRIPTION Mild medial pain + swelling - deformity; + double heel-rise + weakness on I repetition, tenosynovitis w/normal length Mod pain w/ or w/o lateral pain, flexible deformity, - heel rise, elongated II tendon w/longitudinal tears IIA < 30% talar head uncoverage IIB > 30% talar head uncoverage III Severe pain, fixed deformity, - heel rise tears, + tears IV Lateral talar tilt IVA Flexible ankle valgus w/o severe arthritis IVB Fixed ankle valgus w/ or w/o arthritis

Arch Support Duchenne Keith R. L. Jones 15-20% tension stress from PT; > Muscles 1º supporter plantar ligaments, Ligaments after short plantar Faradization of PL muscles “fail” muscles 1868 1929 1941

Morton Harris & Beath Wood Jones Passive & Maintenance from supporting dual Only acute, heavy, structures & control, passive transient F’s (take muscles elasticity of ligaments off) require & active contractility responsible for muscles of muscles arch 1948 1949 1952

Besmajian & Basmajian Bentzon & Stecko Smith 100-200 lbs: passive Gen EMG w/ needle structures electrodes: TA, PL, Confirmed the same 400 lbs: muscles intrinsic’s no imp role come in play but with skin electrodes in static supp of arch inactive 1954 1954 1963

• Theoretical 3D finite element model of the foot and ankle • 1 º Objective: investigate internal load transfer, joint loading and strain of ligaments w/PTT, and the implications to pes planus and other deformities • Methods: • Geometry reconstruction and assembly • Mesh creation • Material properties • Boundary and loading conditions

FINDINGS: Load transfer of prox med column jnts weakened Compromised by increase along lat column & intercuneiforms during late stance Plantar TMT and cuboidnavicular ligament over-stretched INTERPRETATION: “ Posterior tibial tendinopathy altered load transfer of the medial column and unbalanced the load between the proximal and distal side of the medial longitudinal arch. Posterior tibial tendinopathy also stretched the midfoot plantar ligaments that jeopardized midst stability, and attenuated the transverse arch. All these factors potentially contributed to the progress of pes planus and other foot deformities.”

Indications Flexible (reducible) deformity • Increased BMI + unstable, gross deformity • DM • Increased age • Underlying inflammatory arthropathy • Underlying neurologic condition

• Level IV, Retrospective, multicentre study • n = 72 fusions (total: 22; partial: 50) • 1 º Objective : Evaluate long-term (avg f/u 15 +/- 5 yrs) outcomes in pts w/ partial or total AD of STJ or mid tarsal joints • Presence of OA not correlated w/ pain or lower Maryland Foot Score • 2 fusions were necessary due to secondary OA

• Level II, Retrospective review • n = 93 feet (81 pts) originally 87 ft (75 pts) 2003; 55 ft (48 pts) 2008 • 24 M pts; 24 F pts • age range between 22 and 82 yrs • mid-term study of single surgeon (7.5 yrs f/u post triple) • Short term results originally described in 2006 • Group 1: (Cavo)varus; Group 2 (Plano)valgus

• 1º Objective: Investigate development of 2º OA of AJ s/p triple • 2º Objective: Investigate the role of alignment on development of OA of AJ • Foot Function Index and Hindfoot AOFAS • Results • Group 1: trend towards OA aggravation w/highest medial angles post • Group 2: no relationship between OA aggravation and foot geometry • AOFAS and FFI remained unchanged btw 2 and 7.5 yrs f/u

CONCLUSION: “This study reports minor, not statistically significant changes of the ankle joint following triple arthrodesis after 7.5 years. Clinical outcome remained stable in time. Clinical relevance: It seems that triple arthrodesis as such does not lead to major osteoarthritis of the ankle given that adequate alignment of the hindfoot is achieved .”

• n = 54 pts • 48 pts (mean f/u 10 yrs) • 17 STJ AD (14 pts), 37 triple AD (28 pts) “ We found no statistically significant difference in the radiological score in unilateral fusions between feet with subtler and triple arthrodeses and the contralateral foot. In all four feet which showed an increase in degenerative changes of two or more grades, there was an abnormality of the tibiotalar joint before the fusion operation. Of the 14 feet which showed an increase of one grade, there was a similar increase on the contralateral side in nine.”

• Retrospective study • n = 67 feet (57 pts) • avg age 44 yrs (1st f/u); avg age 60 yrs (2nd f/u) • 1º Objective: Assess long-term outcomes of triple AD in young pts • Desired long-term data in order to advise pts as to whether the documented changes in symptoms, function and OA will continue or stabilize after some time. • Assessed level of symptoms, function, arthritis, and satisfaction

CONCLUSIONS: “ Despite progressive symptoms and radiographic degeneration in the joints of the ankle and midfoot, fifty-four patients (95 percent) were satisfied with the results of the operation…fifty-two patients (91 percent) stated they would recommend triple arthrodesis to patients who had the same foot problem… The triple arthrodesis was a satisfactory solution for imbalance of the handoff in this group of patients.”

• Retrospective cohort study • n = 42 cases • mean f/u 25 years • mean age 20 yrs “There was no case of delayed union or nonunion. We found degenerative joint changes in 12 ankles and in 9 feet; fourteen patients experienced pain. In spite of these-long term changes, which appear acceptable, triple arthrodesis is a useful procedure for many deformities of the foot and can solve patients problems for many years .”

Conclusions Full thickness tears of PTT likely cause underlying pathologic conditions to other dynamic and static stabilizers of the arch…HF AD necessary for true stabilization Secondary OA is generally well tolerated; though present, often not related to patient satisfaction Malalignment of HF fusion may be important contributing factor to development of OA Treat patients, not x-rays

References Aarts CAM, Heesterbeek PJC, et al. Does osteoarthritis of the ankle joint progress after triple arthrodesis? A midterm prospective outcome study. Foot and Ankle Surgery. 2016;22:265-69. Abousayed MM, Tartaglione JP, et al. Classifications in brief: Johnson and Strom classification of adult-acquired flatfoot deformity. cli Orthop Relat Res. 2016;474:588-93. Arvinius C, Manrique E, Urda A, Cardoso Z, Galeote JE & Marco F (2017) A mid-term follow-up of Koutsogiannis’ osteotomy in adult-acquired flatfoot stage II and “early stage III”. SICOT J, 3, 24 Basmajian JV, Stecko G. The roles of muscles in arch support of the foot. JBJS. 1963:45A(6) de Groot IB, Reijman M, et al. Long-term results after a triple arthrodesis of the hindfoot: function and satisfaction in 36 patients. Int Orthop (SICOT). 1008;32:237-241. de Heus JA, Marti RK, et al. The influence of subtler and triple arthrodesis on the tibiotalar joint. A long-term follow-up study. J Bone Jt Surg Br 1997;79:644-7. Ebalard M, Le Henaff G, et al. Risk of osteoarthritis secondary to partial or total arthrodesis of the subtler and mid tarsal joints after a minimum follow-up of 10 years. Orthop Traumatol Surg Res. 2014;100:S231-37. Haritidies JH, Kirkos JM, et al. Long-term results of triple arthrodesis: 42 cases followed for 25 years. Foot Ankle Int. 1994;10:548-551.