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Stage II: Posterior Tibial Tendonitis

- Discussion:
    - inflammation causes tenosynovitis and elongation;
    - hindfoot remains supple and is reducible;
    - pt has flexible flat foot, & w/ removal of weight, foot resumes its normal arch;
    - it is essential to distinguish the supple type II lesion from the type III lesion (fixed deformity), since the later cannot be corrected
            w/ tendon transfers;

- Radiographs:
    - if there is medial and plantar subluxation of the talar head, then there must be failure/elongation of the spring ligament;

- Management:
    - generally deformity will progress during this stage, even with non operative treatment;
    - tendon transfer must be performed within weeks since fixed valgus deformity will occur w/ in several months;
    - furthermore, tendon transfers will not correct any flat foot deformity that has already taken place;
    - FDL tendon transfer:
           - if tendon is ruptured, joint is mobile, & no fixed deformity is present, a FDL tendon transfer to the navicular is performed 
                  (alternatively, the surgeon may use the FHL for transfer);
    - in the report by Johnson JE, et al (2000), the authors retrospectively reviewed the results of subtalar arthrodesis combined with spring 
           ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular;
           - there were 16 patients (17 feet) with an average follow-up of 27 months (9-52);
           - all deformities were passively correctable. The average age was 56 yrs (39-78).
           - 53% had lateral pain from subfibular impingement;
           - 2 patients were noted to have degenerative changes of the subtalar joint.
           - successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24).
           - standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees 
                  (24 degrees preoperative, 18 degrees postoperative);
           - talonavicular coverage angle improved an average of 17 degrees (34 deg preoperative, 17 deg postoperative).
           - lateral talo-1st metatarsal angle improved an average of 10 deg (18 deg preoperative, 8 degrees postoperative).
           - lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 deg postoperative);
           - distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively 
                  (avg. improvement 6mm).
           - this operative procedure allows correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the 
                  longitudinal arch;
    - in the report by Kitaoka HB, et al (2000),
           - 9 fresh-frozen foot specimens were studied to determine the mechanical behavior of the foot using calcaneocuboid distraction 
                  arthrodesis, an operation designed for treatment of posterior tibial tendon dysfunction with flatfoot deformity;
            - height arch increased after calcaneocuboid distraction arthrodesis an average of 3.2 ± 3.6 mm and was less than normal arch at 
                         an average of 2.1 ± 2.4 mm;
                  - calcaneotalar position improved after calcaneocuboid distraction arthrodesis in adduction and inversion;
                  - calcaneocuboid alignment compared with flatfoot improved after calcaneocuboid distraction arthrodesis in adduction,
                          plantar flexion, and eversion, but compared with an intact foot was overcorrected in all three planes of motion;
             - Calcaneocuboid Distraction Arthrodesis for Posterior Tibial Tendon Dysfunction and Flatfoot A Cadaveric Study


Three-D Morphometric Modeling Measurements of Calcaneus in Adults with Stage IIB PTT Dysfunction: A Pilot Study.

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency.
Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report.

Recovery of the posterior tibial muscle after late reconstruction following tendon rupture.

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