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

I Mild medial pain + swelling - deformity; + double heel-rise + weakness on repetition, tenosynovitis w/normal length II Mod pain w/ or w/o lateral pain, flexible deformity, - heel rise, elongated 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

I Mild medial pain + swelling - deformity; + double heel-rise + weakness on repetition, tenosynovitis w/normal length II Mod pain w/ or w/o lateral pain, flexible deformity, - heel rise, elongated 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

1868 1929 1941

Duchenne Keith

Arch Support

• R. L. Jones

Faradization of PL Muscles 1º supporter Ligaments after muscles “fail”

15-20% tension stress from PT; > plantar ligaments, short plantar muscles

1948 1949 1952

Harris & Beath Wood Jones Morton

Only acute, heavy, transient F’s (take

• ff) require

muscles

Passive & supporting structures & muscles responsible for arch

Maintenance from dual control, passive elasticity of ligaments & active contractility

• f muscles

1954 1954 1963

Besmajian & Bentzon Smith Basmajian & Stecko

Gen EMG w/ needle electrodes: TA, PL, intrinsic’s no imp role in static supp of arch

Confirmed the same with skin electrodes

100-200 lbs: passive structures 400 lbs: muscles come in play but inactive

• Theoretical 3D finite element model of the foot and

ankle

• 1º 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

• f 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)
• 1º Objective: Evaluate long-term (avg f/u 15 +/- 5 yrs)
• utcomes 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

• f 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

• peration…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.”

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

Conclusions

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’

• steotomy 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.

References

Holmes GB Jr, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle. 1002;12(2):70-9. Hutchinson ID, Baxter JR, et al. How do hindfoot fusions affect ankle biomechanics: A cadaver model. Clin Orthop Relat Res. 2016;474:1008-16. Ruffilli A, Traina F, et al. Surgical treatment of stage II posterior tibialis tendon dysfunction: ten-year clinical and radiographic results. Euro J Orthop Surg Traumatol. 2017 Saltzman CI, Fehrle MJ, et al. Triple arthrodesis: twenty-five and forty-four year average follow-up of the same

• patients. J Bone Jt Surg Am 1999;81:1391-402.

Shawen SB, Dworak TC. Severe Stage 2: Fuse or Reconstruct. Foot Ankle Clin N Am. 2017:22;637-642. Wong DW-C, Wang Y, et al. Finite element simulation on posterior tibial tendinopathy; Load transfer alteration and implications to the onset of pets planus. Clinical Biomechanics. 2018;51:10-16.