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Year |
2001 |
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Question Number |
10 |
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Category |
Select |
Question
A 55-year-old woman with chronic posterior tibial tendon deficiency has a painful planovalgus foot. Examination reveals that neither hindfoot valgus nor forefoot rotation is passively correctable. Management consisting of shoe wear modifications and use of an insert has failed to relieve her pain. Treatment should now consist of:
1 – reconstruction of the posterior tibial tendon and a medial
displacement calcaneal osteotomy.
2 – rotational osteotomy of the talar neck and reconstruction of
the spring ligament
3 – triple arthrodesis and lengthening of the Achilles tendon.
4 – arthrodesis of the ankle (tibiotalar) joint and a medial
displacement calcaneal osteotomy.
5 – subtalar fusion and transfer of the anterior tibialis tendon to the
medial navicular.
Figures
Answer (click for answer)
Correct Answer: 3- triple arthrodesis and lengthening of the Achilles tendon. PTT dysfunction may be classified from simple acute tenosynovitis to chronic dysfunction from tendon rupture. Myerson has described four stages involvinga ruptured PTT. In Stage I the hindfoot is flexible and the patient can do a heel-rise. In Stage IIvalgus angulation of the heel starts, the deformity is still flexible, but there is no heel-rise. In Stage III the hindfoot becomes rigid. In Stage IV valgus angulation of the talus occurs. This patient appears to be Stage III. Each stage may be treated conservatively; however, this patient has failed nonsurgical treatment. Surgical treatment for Stages I and II involves soft tissue surgery as well as possible calcaneal osteotomy. Stage III is treated with a triple arthrodesis. Stage IV is treated with a tibiotalocalcaneal arthrodesis. This patient would benefit from a triple arthrodesis. The Achilles tendon is lengthened because these patients tend to get a secondary Achilles contracture due to lateralization of the tendon from the progressive hindfoot valgus.
Reference: (Reference:Mizel, Miller, Scioli (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.American Academy of Orthopaedic Surgeons, 2000, pp 260-266)