Foot and Ankle cases 27

A 52-year-old male presents to your office reporting increased medial and lateral hindfoot pain for the past 8 months. He describes having “problems” with his left foot for many years and previously has worn orthotics and a custom brace to relieve symptoms. Physical examination reveals no ankle tenderness or pain with full ankle range of motion. The patient has tenderness to palpation at the lateral hindfoot and talonavicular region and limited hindfoot motion that is not correctable to a plantigrade position. Radiographs are obtained (Fig. 5–54A–C).

 

 

 

Figure 5–54 A–C: Weight-bearing radiographs of the foot and ankle.

 

What is the most likely cause of the patient’s pain?

1. Sinus tarsi and subfibular impingement

2. Talonavicular arthritis

3. Achilles tendinopathy

4. Extensor digitorum brevis contracture

5. Tarsal tunnel syndrome

 

Discussion

The correct answer is (A). The patient has stage 3 posterior tibial tendinopathy, which is characterized by a rigid noncorrectable deformity during attempted passive hindfoot joint manipulation. This deformity consists of a planovalgus subtalar joint and abduction deformity across Chopart’s joints with talonavicular uncoverage. Radiographs show loss of talo-first metatarsal alignment (Meary’s angle) on both the lateral and AP images. Hindfoot valgus leads to subfibular impingement as the calcaneus abuts the fibula. Sinus tarsi impingement occurs when the anterior process of the calcaneus abuts the lateral process of the talus due to abduction deformity with talotarsal subluxation. Medial-sided hindfoot pain, when present, is most commonly due to posterior tibial tendinopathy. There are no radiographic signs of talonavicular joint space narrowing or degeneration, which would suggest arthritis.

The patient works as an independent truck driver and is frustrated with persistent pain despite bracing and analgesics. He is currently in the off-season for his job and would like to consider surgical options.

Surgical treatment should consist of:

1. Posterior tibial tendon debridement, flexor hallucis longus tendon transfer, calcaneal osteotomy

2. Posterior tibial tendon debridement, flexor digitorum longus tendon transfer, calcaneal slide osteotomy

3. Posterior tibial tendon debridement, flexor digitorum longus tendon transfer, calcaneal slide osteotomy, and calcaneal lateral column lengthening

4. Posterior tibial tendon debridement, flexor digitorum longus tendon transfer, subtalar arthroereisis

5. Triple arthrodesis

 

Discussion

The correct answer is (E). Stage 3 posterior tibial tendon dysfunction is a rigid deformity and often will have some degree of arthritic change in the hindfoot joints. Therefore, joint sparing procedures including tendon transfers and osteotomies are not the treatment of choice. Triple arthrodesis of the talonavicular, subtalar, and calcaneocuboid joints (Fig. 5–55A and B) relieves hindfoot pain and allows for deformity correction. Patients with flexible posterior tibial tendon dysfunction (PTTD) should be treated with soft tissue and joint sparing procedures, traditionally including PTT debridement, FDL tendon transfer, and calcaneal osteotomy. All PTTD patients also should be examined for an associated Achilles or gastrocnemius contracture, which should be addressed if needed at the time of surgery.

 

 

Figure 5–55 A, B: Postoperative radiographs following triple arthrodesis.

 

Prior to surgery, the patient should be counseled about which associated risk in the future following triple arthrodesis?

1. Achilles tendinopathy

2. Ankle arthritis

3. Peroneal tendinopathy

4. Deep peroneal neuralgia

5. Fibular stress fracture

 

Discussion

The correct answer is (B). Following surgical reconstruction with triple arthrodesis, signs and symptoms of associated joint arthritis may be seen within 5 years. The most common location for arthritis following triple arthrodesis is at the ankle joint.

Tarsometatarsal arthritis has not been clinically correlated with hindfoot arthrodesis. Fibular stress fracture may be seen in PTTD, although a planovalgus foot deformity due to subfibular impingement would not be expected following a triple arthrodesis in a plantigrade position.

 

Objectives: Did you learn...?

 

 

Describe mechanisms for pain with PTTD? Treat rigid posterior tibial tendinopathy?

 

Describe long-term sequela of joint arthrodesis?