• Foot & Ankle Conditions
• Orthopaedics Clinical Trials
• Orthopaedic Procedures

• Foot & Ankle Conditions
• Orthopaedics Clinical Trials
• Orthopaedics
• Orthopaedic Procedures

Posterior tibial tendon dysfunction (PTTD) has a prevalence of 3% to 4% in the Western world. Selecting a management strategy for stage II PTTD is confusing because there are many recommended surgical procedures for this disorder. These surgical techniques can be broadly categorized into column-lengthening procedures and arthroereisis. The principles of surgical correction for PTTD include restoring the longitudinal and transverse arches of the foot, replacing the diseased tibialis posterior tendon with a tendon transfer, and balancing the mechanical forces of the foot.

Amila Silva, MBBS, MRCS, Singapore General Hospital, Singapore, presented the results of a study comparing the clinical and radiologic outcomes of column-lengthening procedures with arthroereisis procedures. According to Prof Silva, this is the only study that has compared the outcomes of the 2 types of surgical procedures for the management of grade IIB PTTD.

A prospective review was conducted from January 2007 to December 2012. Patients in the Singapore General Hospital prospective database with stage II-B PTTD diagnosed by the modified Johnson and Strom criteria were divided into group A and group B according to type of surgical procedure. Patients in group A underwent medializing calcaneal osteotomy, Evans distraction osteotomy, flexor digitorum longus transfer, or tendo-Achilles lengthening. Group B patients underwent subtalar arthroereisis, flexor digitorum longus transfer, or tendo-Achilles lengthening.

The following clinical outcomes were recorded and analyzed preoperatively and at 6 and 24 months after surgery: Short Form 36 (SF36) physical and mental health scores, American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot clinical score, midfoot Visual Analog Scale (VAS) pain score, and hindfoot VAS pain score. Radiologic measurements included hindfoot calcaneal pitch, talo-first metatarsal angle, medial cuneiform height, and talonavicular uncoverage.

Group A included 43 feet and group B included 34 feet. The mean patient age in group A was 46.3 years (18.9 to 73.5 years) and in group B was 46.88 years (18.9 to 68.1 years). There were 10 males in each group, along with 31 females in group A and 23 females in group B. Preoperative anthropometric measurements were as follows: weight, 72.5 kg (56.4 to 94 kg); height, 157 cm (150 to 180 cm); and body mass index (BMI), 29.1 (19.3 to 33.13). In comparison, postoperative anthropometric measurements were as follows: weight, 70.3 kg (51.8 to 91.6 kg); height, 161.6 cm (151 to 181.5 cm); and BMI, 27.2 (18.6 to 33.3; P = .02).

In group A, significant improvement was seen in the midfoot VAS score at 24 months (P = .002), and in the midfoot total score at 6 months (P = .04) and 24 months (P = .001; Table 1).

The radiologic measurements were improved in both surgical groups (Table 2).

Two patients in group A and 3 patients in group B required reoperation. In group A, 1 patient underwent surgical exploration because of sural nerve entrapment and 1 patient required surgical debridement and implant removal for surgical site infection. Three patients in group B underwent removal of the arthroereisis screw.

Patients with grade II-B PTTD experienced clinical and radiologic improvement in both the column procedures and arthroereisis groups. The long-term outcomes were better with medializing calcaneal osteotomy, Evans distraction osteotomy, flexor digitorum long transfer, and tendo-Achilles lengthening. Patients treated with these procedures had statistically significant improvement in midfoot AOFAS scores and midfoot VAS scores compared with those treated with arthroereisis.

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