60 new STG Adult Flatfoot Student 2024.pdf

Pertinent Tendon/Muscle Anatomy 4 Pertinent Anatomy Posterior Tibial Tendon - Inverts the STJ - Forefoot Adduction - Forefoot Supination 5 Pertinent Tendon/Muscle Anatomy Flexor Digitorum Longus - Transfer Site - Master Knot of Henry Flexor Digitorum Longus - Transfer Site - Master Knot of Henry 6 P...

Pertinent Tendon/Muscle Anatomy 4 Pertinent Anatomy Posterior Tibial Tendon - Inverts the STJ - Forefoot Adduction - Forefoot Supination 5 Pertinent Tendon/Muscle Anatomy Flexor Digitorum Longus - Transfer Site - Master Knot of Henry Flexor Digitorum Longus - Transfer Site - Master Knot of Henry 6 Pertinent Ligament Anatomy ❖ Deltoid Ligament 7 Spring Ligament 8 Etiology Trauma Chronic Inflammation Vascular Insult Medications Repetitive Microtrauma Obesity Congenital Factors 9 10 Pathomechanics Equinus Valgus Rearfoot STJ Eversion Ground Reactive Force Dorsolateral Peritalar Subluxation Pronation Increased Stress PTT Spring Ligament Unlocking MTJ 11 Dysfunction of the PTT Overpull of the PB 12 Ground Reactive Forces Calcaneus is position lateral to the talus and leg STJ is forced into everted position Equinus Causes Eversion of the Calcaneus 13 Clinical Presentation Gradual Onset of Pain Starts Medial but can be Lateral Swelling Along the Posterior Tibial Tendon? One Foot Looks Different Walk like a duck 14 Weightbearing Exam Avoid External Rotation Swelling Along the Posterior Tibial Tendon Estimate Arch Collapse 15 Weightbearing Exam Lateral Skin Wrinkles Subfibular Impingement 16 Subfibular Impingement 17 Weightbearing Exam Hindfoot Valgus 18 Weightbearing Exam “Too-Many-Toes Sign” Forefoot Abduction 19 Double Heel Rise Test Key Components Legs Straight Two-finger Balance No Leaning Must start with heel on the ground 20 Double Heel-Rise Test 21 Single-Heel Rise Test Is the Posterior Tibial Tendon Functioning? 22 Single-Heel Rise Test Is the Posterior Tibial Tendon Functioning? 23 Non-Weigtbearing Exam Posterior Tibial Tendon - Strength of PT Tendon - Palpation of PT Tendon 24 Range of Motion Silversköldt - Gastrocnemius Equinus - Gastroc-Soleal Equinus - Osseous Equinus Cheats???? 25 Range of Motion Subtalar Joint - Flexible or Rigid - Prone or Supine 26 Range of Motion Midtarsal Joint Stability Medial Column 27 Non-Weightbearing Exam Rearfoot in Neutral Position Forefoot Varus Forefoot Supinatus Hammertoes 28 Radiographs 29 Normal Lateral Talocalcaneal Angle (Kite’s) 30 Abnormal Lateral Talocalcaneal Angle (Kite’s) 31 Normal Cyma Line 32 Abnormal Cyma Line 33 Normal Talo-1st Metatarsal Angle 34 Abnormal Talo-1st Metatarsal Angle 35 Normal Calcaneal Pitch 36 Abnormal Flatfoot Calcaneal Pitch 37 Normal AP Talocalcaneal Angle (Kite’s) 38 Abnormal Talocalcaneal Angle (Kite’s) 39 Normal AP Cyma Line 40 Abnormal AP Cyma Line 41 Normal Talo-1st Metatarsal Angle 42 Abnormal Talo-1st Metatarsal Angle 43 Dorsolateral Peritalar Subluxation Refers to the position of the navicular to the talus 44 Talo-Navicular Uncoverage 45 Weightbearing Ankle Imaging 46 Hindfoot Alignment Views 47 Tenosynovitis 48 Tendon Tear 49 Associated Pathology 50 Modified Johnson and Strom Classification Johnson, KA, Strom, DE ❖ Deland JT, Page A, Sung I-H, O’Malley MJ, et al ❖ Posterior tibial tendon insufficiency results at different stages. HSS Journal 2006;2:157-160. Vora AM, Tien TR, Parks BG, Schon LC ❖ Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989; 239:196–206 Correction of moderate and severe acquired flexible flatfoot with medializing calcaneal osteotomy and flexor digitorum longus transfer. J Bone Joint Surg Am 2006;88:1726- 1734. Myerson MS ❖ Adult acquired flatfoot deformity: Treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405. 51 Modified Johnson and Strom Stage 1 Examination ❖ PTT Swelling/Tenderness: Mild ❖ Single Heel-Rise: Mild Weakness ❖ Too-Many-Toes Sign: Absent ❖ Deformity: Absent Pathologic Features ❖ PTT: Normal Length, Paratendinitis Images ❖ Talo-1st Metatarsal Angle: Normal ❖ Talonavicular Uncoverage: Normal ❖ Arthritis: None ❖ Ankle Alignment: Normal 52 Modified Johnson and Strom Stage 2 Examination ❖ PTT Swelling/Tenderness: Moderate Swelling, Moderate Tenderness ❖ Single Heel-Rise: Marked Weakness ❖ Too-Many-Toes Sign: Present ❖ Deformity: Present (Flexible) Pathologic Features ❖ PTT: Elongation with Tearing Images ❖ Talo-1st Metatarsal Angle: Deformity ❖ Talonavicular Uncoverage: Deformity ❖ Arthritis: None ❖ Ankle Alignment: Normal 53 Modified Johnson and Strom Stage 3 Examination ❖ PTT Swelling/Tenderness: Minimal Swelling, Moderate Tenderness ❖ Single Heel-Rise: Marked Weakness ❖ Too-Many-Toes Sign: Present ❖ Deformity: Present (Rigid) Pathologic Features ❖ PTT: Elongation with Gross Disruption Images ❖ Talo-1st Metatarsal Angle: Deformity ❖ Talonavicular Uncoverage: Deformity ❖ Arthritis: Present ❖ Ankle Alignment: Normal 54 Modified Johnson and Strom Stage 4 Examination ❖ PTT Swelling/Tenderness: Minimal Swelling, Moderate Tenderness ❖ Single Heel-Rise: Marked Weakness ❖ Too-Many-Toes Sign: Present ❖ Deformity: Present (Rigid) Pathologic Features ❖ PTT: Elongation with Gross Disruption Images ❖ Talo-1st Metatarsal Angle: Deformity ❖ Talonavicular Uncoverage: Deformity ❖ Arthritis: Present ❖ Ankle Alignment: Valgus 55 Modified Johnson and Strom Classification 57 Stage 1 Conservative Treatment Goals - Minimize Pain - Improve Function - Slow Deformity Options - OTC Ankle Brace - Physical Therapy - Rest - Orthotics 58 Stage 1 Surgical Treatment Indications - Failure of Conservative Care - “Limitations” Goals - Remove Deforming Forces - Improve Function - Minimize Pain 59 Stage 1 Surgical Treatment Address Equinus Posterior Tibial Tenosynovecctomy Posterior Tibial Tendon Advancement FDL Tendon Transfer 60 Hoke Triple Hemisection 62 insert blade parallel to fibers 63 rotate blade 90º and cut up towards skin 64 Stage 1 Surgical Treatment Posterior Tibial Tenosynovectomy FDL Transfer?? 67 Stage 2 Conservative Treatment Goals - Minimize Pain - Improve Function - Slow Deformity Options - UCBL - OTC Ankle Brace - Arizona Brace 68 Stage 2 Surgical Treatment Indications - Failure of Conservative Care - “Limitations” Goals - Remove Deforming Forces - Realign the Foot - Improve Function - Minimize Pain - Essential Joint Sparing 69 Stage 2 Surgical Treatment Procedures - Gastrocnemius Recession - Tendo-Achilles Lengthening - Medializing Calcaneal Osteotomy - Evan’s Calcaneal Osteotomy - Naviculocuneiform Arthrodesis - 1st Tarsometatarsal Arthrodesis - Adult Miller - Cotton Osteotomy - FDL Tendon Transfer - Spring Ligament Repair - Young’s Tenosuspension - Posterior Tibial Tendon Advancement 70 Stage 2 Surgical Correction Equinus Gastrocnemius Recession (Gastroc) Tendo-Achilles Lengthening (TAL) 71 Modified Johnson and Strom Classification Johnson, KA, Strom, DE ❖ Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989; 239:196–206 Deland JT, Page A, Sung I-H, O’Malley MJ, et al ❖ Posterior tibial tendon insufficiency results at different stages. HSS Journal 2006;2:157-160. Vora AM, Tien TR, Parks BG, Schon LC ❖ Correction of moderate and severe acquired flexible flatfoot with medializing calcaneal osteotomy and flexor digitorum longus transfer. J Bone Joint Surg Am 2006;88:1726- 1734. Myerson MS ❖ Adult acquired flatfoot deformity: Treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46:393-405. 72 Talo-Navicular Uncoverage >30% Uncoverage Evan’s Osteotomy 73 Evan’s Osteotomy Mechanics Lateral Column Lengthening Triplane Correction Cuboid and navicular move as a unit The center of rotation of the cuboid is within the calcaneus 74 Medializing Calcaneal Osteotomy