Chapter 27: Muscle and Tendon PathologyMuscle PhysiologyPrinciples of Tendon RepairTendon Lengthening and TenotomyTendon TransfersTendon GraftsPosterior Tibial Tendon RupturePosterior Tibial Tendon Dysfunction (Acquired Adult Flatfoot Syndrome)Peroneal Tendon PathologyAchilles Tendon RuptureLateral Ankle Stabilization Procedures Postoperative Care and Training Following Tendon TransferTenosynovitis

MUSCLE AND TENDON PATHOLOGYTendon repair and tenoplasty are integral parts of many podiatric procedures, thus it is imperative that the podiatric surgeon be familiar with the principles of tendon healing and repair. Knowledge about tendon healing will allow the surgeon to make appropriate decisions concerning the procedure performed, materials used, postoperative care, and potential complications

Muscle Physiology1. Anatomy:a. Connective tissue surrounding the musclei. Intact muscle enclosed by the epimysiumii. Muscle fascicles enclosed by perimysiumiii. Individual muscle fiber enclosed by endomysium b. Muscle's structural and functional subunits:i. Fasciculusii. Muscle fiberiii. Myofibril: The myofibrils complex protein structure is the basic contractile unit: Actin: Thin protein filament containing contractile proteins tropomysin and

troponin Myosin: Thick protein filamentiv. Sarcomere: the smallest functional unit of the muscle fiber extending from one "Z" line to the next The myofibril is composed of alternating "A" bands corresponding to the

thick myosin filaments and "I" bands corresponding to the thin actin units The "A" band encloses the "H" band (where cross bridges are absent) and

in the middle of the "I" band is the "Z" line T-tubules are invaginations of the sarcolemma which form an

interconnected network The sarcoplasmic reticulum extends from one T-tubule to the next forming

the terminal cisternaev. Myoneural junction: The axon gives rise to several terminal twigs, the end of each is dilated

and unmyelinatedvi. Organelles: Mitrochondria are found between the myofibrils and appear in varying

amounts depending upon the type of muscle fiber Cytochromes for oxidation, and glycogen appear in varying amounts c. Tendons:i. Dense connective tissue between connective tissue in muscle, and insertion areaii. Golgi tendon organs transmit information concerning tendon tension

2. Physiology of muscle fiber:a. Muscles function according to the Sliding Filament Theory of Muscular contraction: rest, excitation coupling), contraction, recharging, and relaxationb. Initiation of contraction:

i. The axons released acetylcholine which initiates an action potentialalong the sarcolemmaii. The action potential is propagated into the depths of the myofibril viathe T-tubule systemiii. This in turn mediates a release of calcium from the sarcoplasmicreticulum (the sarcoplasmic reticulum has an active pump to recovercalcium once it is released)iv. In the presence of repeated neural stimulation calcium will remain inthe sarcoplasmv. Following the action potential is an absolute refractory period, duringwhich no action potential may be initiatedvi. Next follows a relative refractory period during which a greater thannormal neural stimulus may initiate another action potential in thesarcolemma

c. Myofibril contraction (the ratchet mechanism):i. In the absence of calcium, tropomycin blocks the myosin-binding sites on the F-actinii. When calcium is released by the sarcoplasmic reticulum into the sarcoplasm, it bonds to the Tn-C portion of the troponin, which mediates a conformational change in tropomyosin which uncovers the myosin binding sitesiii. ATP binds to heavy meromycin (form of myosin), which releases it from the actin. The ATP-ase activity of the heavy meromysin then cleaves the phosphate, and the myosin can once again bind to actiniv. Upon binding with actin, the heavy meromysin changes conformation, thereby pulling the actin alongv. As calcium is reabsorbed by the sarcoplasmic reticulum, the myofibrils again relax

d. Fast twitch vs. slow twitch muscle

Feature Fast Twitch Slow Twitch# of type 1 fibers + +++# of type 2 fibers +++ +Speed of response +++ +Strength + +++Stamina + +++Major energy source anaerobic aerobic

e. Type 1 vs. Type 2 muscle

Feature Type 1 Type 2Color RED WHITE

NOTE* Motor unit response is an all or nothing

Myoglobin content +++ +Mitochondrial content +++ +Glycolytic enzymes + +++Glycogen content + +++Complexity of T-tubules + +++Speed to respond to stimulus + +++

f. Energy system function:i. Phosphagen system (anaerobic) ATP and phosphocreatine Availability of energy is rapid Small amounts of energy available for a few seconds (30 seconds) Utilized in sprinting, jumping, swimming etc. Primary source of energy muscle storageii. Glycolytic system (anaerobic) For activities 30 seconds to 1.5 minutes No oxygen required Formation of lactate takes place Lactate accumulation results in oxygen debt and muscle fatigueiii. Aerobic phosphorylation For activities greater than 1.5 minutes Carbohydrates, proteins and fats utilized through the Krebs cycle and

electron transport system (oxidative phosphorylation) Site of energy formation is the mitochondria -No lactate formation

3. Training programs:a. Most training programs are an adaptation of sprinting and endurance trainingi. Endurance training results in hypertrophy of type 1 fibers ii. Sprint training results in hypertrophy of type 2 fibers

iii. Training results in cardiac hypertrophy, increase in cardiac stroke volume, and decrease in heart rate

4. Types of training:a. Isometric excercises:i. Contraction in which a muscle maintains a constant lengthii. Contraction against stationary objectsiii. Maximal isotonic contraction increases strength to a greater extent than

NOTE* Sport activities require all 3 sources of energy but in different proportions depending on the sport characteristicsNOTE* Rigor mortis occurs due to exhaustion of A TP in the presence of

calcium (in the absence of ATP, myosin becomes tightly bound to actin)

NOTE* Fiber type can change in response to training programs, but there is no proof that one fiber can transform to another fiber type

submaximal contractionsiv. Isotonic training does not require a long time of excercisingv. Maximal strength gained is very specific for the joint angle at which the training is performedvi. Motor performance is not increased by isotonic exercise vii. Isometrics are static excerciseviii. Strength gained by isometrics decrease the maximal speed of a limb

b. Isotonic excercises (concentric): Implies constant tensioni. During isotonic excercise the amount of force exerted on a weight being lifted depends on the acceleration of that weight (Newton's 2nd law: F+W+MA)ii. In case of isotonic training, voluntary maximal contraction (VMC) takes place somewhere during trainingiii. The maximal lift is really the weakest point in the ROM of the joint. If the weight could be lifted quickly on each repetition, the VMC would be possible to perform through the entire ROMiv. Motor performance is increasedv. There is an increase in lean body mass and a decrease in body fats c. Eccentric excercises: Negative weight trainingi. A contraction in which the muscle lengthens upon contractionii. Strength gained is not different than in concentric or isotonic contractioniii. Less effort is required to gain the same strength as in concentric trainingiv. Tension developed in the muscle during eccentric contractions (as compared to concentric contraction) utilizing equal weights indicates that more tension is developed during concentric contractionv. To cause equal tension as that during concentric training, more weight has to be used during eccentric trainingvi. Eccentric training has the following disadvantages: Muscular soreness Trainer is necessary to use heavier weights Weight handled can be hazardous Training time is longer than with other training methods

d. Isokinetic excercises: Constant velocity excercisei. The machine is set at a constant velocity but the resistance is not set; whatever force the trainee applies to the machine set at a certain velocity, is offered as a resistance to the trainee by the machineii. The above allows the VMC throughout the entire ROMiii. To be strong at fast speed of movement, the athlete should be training at fast speed of movementiv. Isokinetics increases motor performancev. Motor performance is increased to a greater extent at fast speed than at slow speedvi. Muscular soreness is minimalvii. No weight is liftedvii. Length of the workout is decreased

e. Variable resistance exercises:i. Percentage of increase in resistance that an individual can tolerate and complete a particular movement depends upon the following variables: Limb length Muscle length Point of attachment of the tendons on the bone Bony positionii. Motor performance increases with variable resistance machinery (high cost)

f. Comparisonsi. Isotonic vs. isokinetics: Strength increase is greater in isokinetic as compared to isotonics Isokinetic contractions are preferred over isotonics Isokinetic training increases isokinetic and isotonic strength more than

isotonics Isokinetic training (at fast speeds) increases motor performance more

than isotonics Isokinetics is as effective as isotonics in decreasing fat and increasing lean

body mass Less muscle soreness with isokinetics over isotonics ii. Isokinetics vs. isometrics: Isokinetics causes a greater increase in isometric and isokinetic strength

than does isometricsiii. Isotonics vs. Isometrics: Motor performance is Improved to a greater extent with isotonics than

isometricsiv. Variable resistance vs. isometrics: Probably better motor performance with variable resistance

Principles of Tendon Repair1. Histology:a. Tropocollagen: The most basic molecular unit of tendon

b. Tendons are composed of 3 anatomical coverings:i. Endotenon: Surrounds groups of collagen fibers and forms units called fasciclesii. Epitenon: This covers groups of fascicles. It is also the visceral layer and is responsible for the intrinsic repair response

NOTE* The strength training choice will depend upon the cost of the equipment, amount of strength gains, and motor performance increase

NOTE* Successive molecules of tropocollagen are assembled and eventually form collagen fibers. These longitudinally anastomosed fibers constitute a tendon

iii. Paratenon: A loose filmy structure that covers the entire tendon and has a rich vascular supply that communicates with the, tendon itself. The paratenon allows the tendon to glide

2. Tendon healing:a. 4 stages each taking approx. one weeki. Stage 1: The severed ends being joined by a fibroblastic splint. At the end of this stage the repair site is in its weakest state consisting of serous material and granulation tissue (termed zone of degeneration)ii. Stage 2: Shows an increase in paratenon vascularity and collagen proliferation. Immobilization is still necessary.iii. Stage 3: Collagen fibers begin to form longitudinally and give the tendon a moderate degree of strength. At this time controlled passive motion is beneficial to decrease the formation of fibrous adhesions (CPM)iv. Stage 4: Exhibits fiber alignment which imparts increased strength to the tendon. At this point active mobilization can be initiated

b. Tendon lengthenings will often result is a loss of muscle strength roughly equal to one grade of manual examination once healed

3. Suture selection: Plays a vital role in uneventful tendon surgerya. Surgilon®: This non-absorbable non inflammatory suture allows for increased strength during the end of stage 1 when the tendon is the weakestb. Stainless steel: Excellent to anchor tendon to bone and then removed when healing occurs. It is the strongest and least reactive, and best in contaminated wounds. Its drawbacks are it can "kink" up and "saw" through a tendon.c. Silk: Was used for years but has been replaced with less reactive nonabsorbable and absorbable sutures.d. Tevdek®/Ticron®: Nonabsorbable braided polyester that retains greater ability to resist gap-producing forces at 3 weeks than either nylon or polypropylenee. Vicryl®/Dexon®: Absorbable polygalactic acid and polyglycolic acid usually provide strength long enough for the repair

4. Methods of tendon repair: tendon to tendon suture techniques (see following diagrams)a. Bunnell end-to-end: Excellent technique but can cause tissue restriction b. Double right angle: Good for quick repair of small tendons c. Lateral trap: Firmly grips the outside of the tendon without constricting the microcirculation in the center. The central mattress suture acts as a temporary anchor.d. Chicago: A simple x-stitch described by Mason and Allene. Robertson: An excellent method of anastamosing tendons of unequal diameter

NOTE* Without the paratenon, the tendon would stick to the surrounding tissue, so care must be made during surgery not to damage this structure

f. Interlace: Another method for attaching smaller to larger tendons as in tendon graftingg. Herringbone stitch and insertion: A method of grafting one tendon into the center of anotherh. Bunnell pull-out suture: A pull-out stitch is a non-absorbable suture that anchors a deep stitch to the outside of the skin so it can be removed once healing it complete. Anchored to the outside with a button.

NOTE* Side-to-Side anastamosis of a transferred tendon provides the most physiological pull, the greatest danger is that of slippage, so the adjoining surfaces should be roughened and the epitenon scraped free (encourages fibrous union) and then sutured

NOTE* When suturing a tendon it is important to preserve the microcirculation and therefore not encircle or strangle large amounts of tendon tissue. Close apposition is important but the tendon ends must not bunch or overlap excessively. Tendon-to-tendon approximation must be equal otherwise fibrous tissue extrusions will bind to the surrounding tissues. Necrotic ends must be debrided

5. Securing tendon to bone: Most secure form of fixationa. Trephine plug: Using a Michele vertebral trephine a hole is drilled into the bone with the tendon pressed inside and the resultant plug is later tapped into place securing the tendonb. Three hole suture (see diagram prior page): Anchoring the transposed tendon with a double armed suture and placing it in a drill hole. The sutures (a nonabsorbable polyester suture is recommended) are then tied into 2 adjacent small drill holes.c. Buttress and button anchor: For tenodesis using a nonabsorbable suture (stainless steel) that is removed once the healing is complete d. Tunnel with sling: Can only be used with a tendon with sufficient length. Made via a tunnel in a bone with the tendon passed through and sutured on itself. Used with a Jones suspension of the EHL e. Screw and washer (cleated polyacetyl): Useful where there is little soft tissue for the transferred tendon can be sutured. f. STATAC Device (Zimmer® Inc.): Titanium implant that is drilled into the bone with non-absorbable sutures attached that can be threaded to Keith needles and sewn through a tendon.

6. Objectives of tendon transfer:a. To improve motor function where weakness and imbalance exist andthereby prevent contractures and further deformity b. To eliminate deforming forces c. To provide active motor power d. To provide better stability e. To eliminate the need for bracing f. To improve cosmesis

7. Principles of tendon transfers:a. Select suitable cases, do not create a new imbalance b. Understand the anatomy and physiology c. Correct the fixed or structural deformities first d. Select the proper timing (age of patient)e. Select a suitable tendon for the transfer (adequate length and strength) f. Provide a direct or mechanically efficient line of pull g. Perform stabilizing procedures first (if needed) h. Preserve the gliding mechanismi. Use atraumatic techniquej. Preserve blood supply and innervationk. Provide adequate muscle-tendon tension on fixation l. Use secure fixation techniquesm. Provide detailed postoperative management

8. Grading system of manual muscle testing:5 Normal Full resistance at end range of motion4 Good Some resistance at end ROM4+ Moderate resistance at end ROM4- Mild resistance at end ROM3 Fair Able to move against gravity alone

2 Poor Able to move with gravity eliminated1 Trace Can palpate or visualize muscle contraction0 Zero No evidence of muscle contraction

Tendon Lengthening and TenotomyTendon lengthening and tenotomy have limited indications when abnormal contracture of a musculotendinous unit compromises normal function. Absolute tenotomy has few applications in reconstructive foot surgery (severing the adductor tendon in HAV surgery, the FDL for mallet toe, and tenotomy for lengthening of the Achilles tendon) 1. Common procedures:a. Strayer technique (distal recession): Modification of the Volpius-Stoffel procedure. Lengthening the gastrocnemius ms., requiring the complete severence of the aponeurosis, suturing the retracted proximal aponeurosis to the underlying soleus, and casting the foot in neutral to allow for healing at the new lengthb. Silverskiold procedure (proximal recession): Release of the muscular heads of the spastic gastrocnemius from the femoral condyles and reinsertion to the proximal tibial area (a 3 joint muscle is converted to a 2 joint muscle)c. Fulp and McGlamry tongue-in-groove procedure (distal recession): Modified Baker procedure. The tongue-in-groove cuts are inverted in the gastrocnemius

NOTE* These procedures are utilized for the correction of non-spastic ankle equinus secondary to gastroc. shortening. If a spastic gastroc. equinus is present then you must also perform a concomitant excision of the central soleus aponeurosis

d. White tenotomy: Tenotomy of the anterior 2/3 of the distal end of the Achilles tendon and the medial 2/3 of the tendon, performed 5-7.5 cm proximal to the insertion (presumption of torque) e. Hoke's tenotomy: A triple tenotomy of the Achilles tendon starting 2.5 cm from the insertion and the others at 2.5 cm intervals extending proximallyf. Hibbs procedure: Tendo Achilles lengthening via a lateral skin incision, with the medial 2/3 of the tendon divided proximally and then split longitudinally in the distal direction at the lateral end of the incision. The lateral 2/3 of the tendon is then divided near the point insertion and it is split longitudinally in the proximal direction at the medial end of the incisiong. Sliding Z-plasty: Can be used for the Achilles (Hauser or White procedures) or extensor tendonsh. Abductor hallucis tenotomy: Tenotomy of the abductor hallucis in the treatment of congenital hallux varus and metatarsus adductus.

Tendon Transfers1. Common procedures:a. Murphy modification (for advancement of the tendo Achilles): Is utilized in young patients with CP where the spasticity of the triceps is causing ankle equinus. This procedure is performed by transecting and rerouting the achilles tendon into the calcaneus distally just proximal to the subtalar jointb. Peroneus brevis tendon transfer: This muscle is transferred to aid in dorsiflexion via rerouting the tendon medially into the 3rd cunieform.c. Peroneus longus tendon transfer: This muscle is transferred when additional dorsiflexory power is needed via rerouting the tendon medially into

NOTE* Tendon lengthenings (once healed) will often result in a loss of muscle strength roughly equal to one grade of manual examination

the 3rd cuneiform. It can also be rerouted into the posterior calcaneus when paralytic calcaneal deformities are present

d. Tibialis posterior tendon transfer: Has the potential to be a good dorsiflexor when replacement is needed via rerouting the tendon laterally, and inserting it into the 3rd cuneiform

e. Tibialis anterior tendon transfer: To reduce the supinatory forces in the foot via detaching the tibialis anterior over the navicular and rerouting it laterally into the 3rd cuneiform.

f. Split tibialis anterior tendon transfer (STATT): Its goal is to increase true dorsiflexion of the foot by balancing its power laterally via splitting the tibialis anterior and suturing the lateral portion to the peroneus tertius (see chapter 21, Surgery of the Congenital Foot)

h. Hibbs tenosuspension: Is performed to release the retrograde bucking at the MPJ's causing the flexible forefoot equinus, is done via detaching all 4 tendons of the EDL distally enough and fused at the base of the 3rd metatarsal to the. corresponding EDB

i. Jones suspension: Used for treatment of a cocked-up hallux by transecting the EHL at the IPJ of the hallux and rerouting it through a medial to lateral drill hole in the head of the 1st metatarsal

NOTE* The peroneus longus tendon transfer to the cuneiform is utilized with a drop foot deformity and weakness or paralysis of the anterior muscle group

NOTE* The tibialis posterior tendon transfer is indicated when a weak or paralyzed anterior muscle group is present, equinovarus deformity, drop foot, Charcot-Marie-Tooth deformity, and permanent peroneal nerve palsy

NOTE* Tibialis anterior tendon transfer can be used for recurrent clubfoot, flexible forefoot equinus, drop foot, and Charcot-Marie-Tooth deformity

NOTE* The STATT is recommended for spastic rearfoot varus, fixed equinovarus, excessive invertor power, forefoot equinus with swing phase extensor substitution and claw toes, flexible cavovarus deformity, and dorsiflexory, weakness

NOTE* EDL slips 4 and 5 must be attached to EDB tendon 4

j. Young procedure: A tendon transposition (rerouted through a "keyhole" in the navicular) for flatfoot (see chapter 21, Surgery of the Congenital Foot)k. Kidner procedure: Advancement of the tibialis posterior either inferior to the navicular bone or modified by attachment to the medial cuneiform to increase its adductory influence on the forefoot (see chapter 21, Surgery of the Congenital Foot)l. Lowman procedure: For flatfoot, a rerouting of the a medial band of the tibialis anterior tendon under. the navicular and sutured to the spring ligament and transfer of a section of tendo Achilles (see chapter 21) m. Heyman procedure: A panmetatarsal suspension for equinus foot via suturing the EDL to their respective metatarsal heads (see chapter 21, Surgery of the Congenital Foot)n. Flexor digitorum longus transfer: Transferring the FDL to the proximal phalanx of the involved digit will convert it into a strong plantarflexor of the MPJo. Peroneal anastomosis: Involves securing the peroneus longus to the peroneus brevis at the level of the midcalf (for pes cavus deformity to decrease the plantarflexory force on the 1st ray and to increase the eversion force to the foot)p. Joplin sling procedure: To narrow the forefoot (used with children where you do not want to do an osseous procedure). It is done via cutting the EDL tendon 5 and passing it through and underneath the 5th MPJ joint capsule to the abductor hallucis and back around and over the EHL suturing it to the 1st MPJ joint capsule. The EDL tendon 4 is sutured to stump of the EDL 5. The adductor is transected.2. Healing for tendon transfers:a. Casting for 4 weeks (foot in neutral position and at right angles to the leg)b. Early passive ROM at about 3 weeks by bivalving the cast c. Later, progressive weight-bearing excercise (isometrics)

Tendon Grafts1. Donor tendons: Are usually from the plantaris, peroneus tertius, strips of the Achilles, and slips of the EDL or EDB

2. Carbon Implants: The carbon acts as a scaffold on which new tendon can develop, which makes it appropriate for filling large gaps as can be present in the Achilles tendon (experimental as of now)

3. Silastic sheets: Used to protect a tendon anastomosis in one study

4. Silicone rod Implant: Used in staged gliding tendon transplant in patients where the gliding bed has been damaged. This creates a pseudosheath for delayed tendon grafting5. Tendon xenografts: Bovine grafts are experimental at this point

NOTE* The Jones suspension has been utilized for flexible cavus foot flexible plantarflexed 1st ray (with or without hammered hallux), and prophylaxis when both hallucal sesamoids are removed

6. Dacron mesh (Dacron Cooley graft): The dacron vascular graft is split to provide a band of material of the desired length that can be woven through or around a ruptured Achilles tendon as a lattice for further healing, In the same manner as the plantaris tendon is used

Posterior Tibial Tendon Rupture1. Anatomic considerations:a. Deep posterior compartment muscleb. Originates from the tibia, fibula and interosseous membranec. Extrinsic insertions into all bones of the midfoot except the talus, 1st and 5th metatarsald. Passes retromalleolarly with the flexor retinaculum and functions as a two pulley system (medial malleolus and navicular) providing a mechanical advantage to the tendon

2. Functional considerations:a. Open kinetic chain:i. Supination (plantarflexion-,adduction-inversion) b. Closed kinetic chain:i. Deceleration of STJ pronationii. Acceleration of STJ and oblique MTJ supination in midstance phase of gaitiii. Rigid lever for gastro-soleus function

3. Etiology:a. Traumatic forces and injuriesb. Progressive degeneration due to excessive demand (severe forefoot varus, equinus, obesity)c. Severe degeneration secondary to systemic disease (RA, mixed connective disease, DM, etc.)d. Neoplasms

4. Subjective findings:a. Medial arch and/or ankle painb. Diffuse swelling and tenderness along the course of the TP tendonc. Symptoms aggravated by proloned weightbearing and ambulationd. May be more painful on initial arising in the AM (post-static dyskinesia) e. Progressive flatfoot deformityf. Sedentary/decreased activity

5. Clinical findings:a. Edema and increased warmth of the medial aspect of the foot and ankleb. Palpable tenderness along the course of the tibialis posterior tendon c. Tenosynovitis may be presentd. Collapse of the medial arche. Palpable defect with complete rupturesf. Increased heel valgus and midfoot abduction g. Decreased muscle strength with guarding

h. Positive single heel rise testi. Apropulsive/antalgic gait without resupination j. Flexible to rigid depending upon the duration

6. Radiographic findings: a. DP view:i. Increased T-C angle (angle of Kite)ii. Increased calcaneocuboid angle (cuboid abduction angle) iii. Degenerative arthritic changesb. Lateral view:i. Decreased calcaneal inclination angle (can be normal) ii. Increased T-C angleiii. Increased talar declination angle iv. Significant medial column faulting v. Forefoot supinatus vi. Degenerative arthritic changesc. Special studies:i. MRI: T1-weighted images provide images about the tendon itself, T2weighted images are useful to highlight fluid within the tendon sheath oradjacent edema

ii. CTiii. Tenogram

7. Conservative treatment: Not usually helpful a. NWB cast 4-6 weeksb. Shoe modifications/orthotic devices c. NSAIDS

8. Surgical treatment: Depends upon the time since the rupture, degenerative changes taken place, rigidity of the deformity, and expected functional demandsa. Soft tissue procedures:i. Early tendon repair: Excision of all scar tissue Excision of inflamed synovium Z-plasty shortening repair technique or transfer of tibialis anterior Primary reattachment to the navicular tuberosityii. Delayed primary repair with tendon free graft and desmoplasty

NOTE* MRI is most revealing. Three patterns of rupture have been reported:a. Type 1: Intrasubstance tears noted on MRI with longitudinal splits and hypertrophy of the tendon (increased signal on T1)b. Type 2: Progression of intrasubstance tears noted on MRI as decreased girth and attenuation of the tendonc. Type 3: Complete rupture (noted as discontinuity of the tendon on MRI)

iii. Delayed primary repair with tendon transfer and desmoplastyiv. Evans type procedure

b. Osseous procedures:i. Isolated STJ arthrodesisii. Evans calcaneal osteotomy iii. Talonavicular arthrodesis iv. Combinations of above v. Triple arthrodesis vi. Ankle arthrodesis vii. Pantalar arthrodesisviii. Talonavicular arthrodesis with lateral column lengtheningc. Ancillary procedures: i. TALii. Gastrocnemius recessioniii. Medial column suspension procedures iv. Bone graftingv. Subtalar joint arthroereisis

Posterior Tibial Tendon Dysfunction (acquired adult flatfoot syndrome)1. Etiology:a. Tenosynovitis of tendonb. Shallow or absence of malleolar groove c. Attenuation of tendon d. Rupture

2. Differential diagnosis:a. Residual calcaneal valgus b. Torsional abnormalities c. Limb length discrepancy d. Post-traumatic arthritis e. Charcot arthropathy f. Lisfranc dislocation

3. Signs and symptoms:a. Painb. Edemac. Abducted forefootd. Apropulsive gaite. Loss of inversion power f. Progressive flatfootg. Antalgic gaith. Difficulty on toe raisingi. Heel not inverting with standing on toes

NOTE* The indications for primary soft tissue repair alone are limited

4. Diagnostic studies:a. Tenogram b. CTc. MRI

5. Treatment (conservative)a. BK cast immobilization in equinovarus x 4 weeks b. Orthosesc. NSAIDS

6. Treatment (Surgery):a. Tendon repairb. FHL tendon transposition c. Secondary stabilization:i. Medial column fusionii. Modified Young procedureiii. STJ arthroereisisiv. Evans calcaneal osteotomyv. Triple arthrodesis

Peroneal Tendon Pathology1. Types of pathology: a. Dislocation:i. Etiology: Eversion/dorsiflexion trauma Congenital absence of groove in the lateral malleolus Direct blow to the lateral ankle with the ankle invertedii. Signs and symptoms: Ankle edema Tendonitis Pain “Clicking” sound Avulsion flake from the fibula noted on x-rayi. Treatment: Strapping (acute and chronic cases) Cast immobilization 3--6 weeks (acute)

NOTE* Posterior tibial inflammation can be divided into peritendonitis, chronic tenosynovitis, and stenosing tenosynovitis.a. Peritendonitis: elicits pain at the musculotendinous junction, and is consistant with an overuse syndrome. Treatment is physical therapy and orthoses b. Chronic tenosynovitis: elicits pain around the tendon between the tip of the malleoli and the navicular (seen with rheumatic disease patients), requiring orthoses and steroid injectionsc. Stenosing tenosynovitis: elicits pain around the malleoli, and requires surgical intervention

Surgical repair (acute and chronic) followed by BK cast x 4 weeks and physical therapy

b. Stenosing Tenosynovitis:i. Etiology: Direct trauma Lowgrade/chronic trauma Enlarged peroneal tubercle Calcaneal fracture Arthritisii. Signs and symptoms: Pain Trigger point pain Thickened tendon sheath Pain with ankle inversion Chronic edemaiii.Diagnostic studies: X-ray (calcaneal axial view) CT MRI Peroneal tenogram

iv. Treatment: Surgical repair of osseous pathology Surgical repair of the tendon sheath Iontophoresis Physical therapy

c. Tendon rupture:i. Etiology: LacerationChronic degenerationii. Signs and symptoms Pain Edema Loss of eversion strength Inability to plantarflex the 1st ray Increased soft tissue massiii. Diagnostic studies: Peroneal tenogram MRI CTiv. Treatment: Cast x 6 weeks Surgical repair (either primary repair or secondary with a graft)

Achilles Tendon RuptureIn most cases rupture results in longitudinal tearing of the tendon tissue into irregular strips either at the musculotendonous junction (younger patient) or at the point of insertion into the calcaneus (middle-aged people), the 2 most common sites of rupture. The areas most susceptible to rupture are areas of decreased circulation, myotendonous junctions, and the area 4-6 cm proximal to the tendo Achilles insertion

1. Etiology:a. Direct blow b. Lacerationc. Abnormal muscle pull

2. Clinical diagnosis:a. Pain at the siteb. Palpable tendon gapc. Increased soft tissue massd. Loss of plantarflexory strengthe. Inability to walk on toesf. Doherty-Thompson Test (+) (or just Thompson Test): The patient attempts to plantarflex the foot while the calf is being squeezed. The inability to perform this plantarflexion is a strong indication of Achilles tendon rupture

3. Radiographic findings:a. Obliteration of Kager's triangle b. Increased soft tissue density c. Toyger's angle (130-150°) d. CT scane. MRI

4. Treatment: Partial rupturea. BK cast x 3-4 weeks in plantarflexionb. Followed by another BK cast with less plantarflexion x 4 weeks

5. Treatment : Complete rupture (24 hours-5 days) a. Full equinus BK cast x 3 weeks, followed by b. Gravity equinus BK cast x 3 weeks, followed by c. Heel lifts

6. Treatment: Complete rupture (5 days or longer) a. Surgical repairb. BK NWB cast x 3 weeks, followed byc. BK weight-bearing cast x 3 weeks, followed by d. Heel lifts (19 mm to 13 mm to 6 mm)

NOTE* Plantaris rupture often mimics tendo Achilles rupture but with this the Thompson test is normal, and the pain is usually located along the course of the ruptured plantaris tendon

NOTE* If a diagnosis of a distal rupture is made within 10 days, the Lynn procedure is ideal.

Lynn procedure: A 7 inch medial/longitudinal incision parallel to the medial border of the TA. The paratenon is opened in the midline and with the foot held in 20° plantarflexion, and without excising the irregular ends, the TA is sutured using an absorbable suture. If the plantaris is intact, its insertion at the calcaneus is divided and the tendon is fanned out to form a membrane, which is then placed over the TA repair and sutured into place (covering the TA 1 inch above and below the repair). The TA paratenon and skin are closed. Cast applied

NOTE* If a diagnosis of a proximal rupture is made within 10 days, a McLaughlin procedure is preferred.

McLaughlin's procedure: A midline incision curving laterally is made. The frayed tendon edges are trimmed back to healthy tissue. A drill hole is made medially to laterally through the calcaneus, and a stab wound is made at its point of emergence. A long screw is passed through the drill hole in the calcaneus. A wire suture is inserted into the proximal tendon fragment, which is then pulled into position by the 2 ends of the wire suture which are fastened to the projecting ends of the screw. With retraction thus counteracted, the trimmed tendon ends are sutured together. The superfluous portion of the screw is cut free and removed. A twisted wire with a split lead shot (for palpable localization of the mattress suture) is attached to the proximal portion of the wire suture. Cast applied.

NOTE* The Bosworth procedure or the Lindholm procedure is used for late repair of a rupture.

Bosworth procedure: Ruptured tendon exposed through a posterior longitudinal midline incision from the calcaneus to the proximal 1/3 of the calf. Excision of scar tissue at the ruptured ends. Free up from the medial raphe of the gastrocnemius a strip of tendon 1/2 inch wide and 7 inches long, leaving this strip attached just proximal to the rupture site. The strip is turned down and passed transversely through the proximal tendon and then passed transversely through the distal tendon, and then passing the tendon through the distal end from anterior to posterior, while holding the knee at 90° and the ankle in plantarflexion. Once again the strip is brought proximally and passed through transversely and sutured onto itself. Cast appliedLindholm procedure: A posterior curvilinear incision is made from the midcalf to the calcaneus. The rupture is exposed, the ragged ends are debrided and apposed with a box-type mattress of heavy silk or other non-absorbable suture. From the proximal tendon and gastrocnemius aponeurosis, 2 flaps are fashioned, each approx. 1 cm wide and 7-8 cm long. These flaps are left attached at a point 3 cm proximal to the site of rupture,- and each flap is twisted 1800 on itself so that its smooth external surface lies next to the subcutaneous tissues as it is turned distally over the rupture. Each flap is sutured to the distal stump of the tendon and to the other flap, completely covering the site of the rupture. Wound closed. Cast applied.

5. General surgical principles:

a. Functional length restorationb. Approximation of clean ends c. Avoid the sural nerve d. Preserve the tendon sheath e. Evacuate the hematomaf. Use proper anchoring sutures for the tendon g. Tendon graft as necessary

6. Complications:a. Nonoperativei. Occurs from long term cast immobilization in equinus (needs aggressive isokinetic rehabilitation). At the 10-15 week mark atrophy of the triceps occursb. Operative:i. Intratendinous hemorrhage and irreparable damage to the paratenonii. Every attempt must be made to cover the newly repaired tendon with the paratenon complex, because if not, this will become immobile and nonglidingiii. Reruptureiv. Infection, wound dehiscence, sinus tarsitis, and STJ damage

Lateral Ankle Stabilization Procedures (tendontransfers)

Single ligament rupture:Watson-Jones*: This uses the peroneus brevis, which passes through the fibula from posterior to anterior, through the neck of the talus from plantar to dorsal, back through the fibula, from anterior to posterior, and sutured back onto itself.Lee Procedure (modified Watson-Jones)*: This uses the peroneus brevis tendon, which is then passed through the fibula, from posterior to anterior, and then sutured back onto itself.Evans*: This utilizes the peroneus brevis through an oblique hole through the fibula sutured back onto the belly of the peroneus brevis. StorrenNilsonnePouzetHaigCastaing and MeunierDockery and Suppan

Double ligament rupture:Elmslie*: Originally described as using the fascia lata and passed through a drill hole in the lower aspect of the fibula, through the calcaneus, back through the same drill hole, and tied onto itself, after passing through the neck of the talus.Chrisman and Snook*: This uses the split peroneus brevis, which is passed through the fibula from anterior to posterior through a flap in the calcaneus, and is then sutured back to the peroneus brevis tendon.

Stroren HamblyWinfieldGschwend-Francillon

Triple ligament rupture:SpotoffRosendahl and Jansen

NOTE* In the case of lateral instability, both the Watson-Jones and the Evans procedures are utilized.a. The Watson-Jones restores the function of the calcaneofibular and talofibular ligaments by rerouting the peroneus brevis tendon. The chief drawback of this procedure is that it involves drilling a hole through the neck of the talus (difficult to accurately accomplish). A second problem can arise with this technique if the peroneus brevis is too short to be threaded through the tunnels fashioned to receive it.b. The Evans technique, which was designed to obviate the potential difficulties of the Watson-Jones, has the disadvantage of involving reconstruction of only the calcaneofibular ligament.

Postoperative Care and Training FollowingTendon Transfer1. Age of the patient at the time of the transfer:a. Should be old enough to cooperate in training (>4 years old) b. Earlier transfer is indicated when delay would result in structural deformity

2. Support In overcorrected position:a. Until full function is restored and no tendency for reccurrenceb. Bivalved cast will help hold tendon in relaxed position during this period

3. Preoperative training to localize contracture In muscle to be transferred

4. Instruct patient to contract transferred muscle:a. Voluntary contracture through the original arc while guiding the part in the direction provided by the transferb. Initially palpate the belly of the ms. and tendon to ensure proper contractionc. Initially excercises are performed in the bivalved castd. Mild gentle tension on the transferred tendon may be used to assist patient in "finding" the transfere. Electrical stimulation may also be used to assist patient in "finding" transfer

5. Establish motion in the new function provided

6. Development of motor strength:a. Once motor strength becomes fair, the bivalve cast is gradually discontinued during the dayb. Controlled activities are permitted to develop functionc. Resistance excercises are begun to develop strength when a normal ROM and fair strength are establishedd. Important to excercise antagonistic muscles also

7. Incorporation of the transfer into the new functional pattern:a. Action of the transfer may be good through full range and moderate resistance and yet during walking, voluntary control is lost b. Use of crutches during this period is helpfulc. Careful supervision is requiredd. Walking periods are gradually increased until gait pattern becomes a conditioned reflex

c. The Chrisman and Snook procedure was designed to repair the anterior talofibular and inferior calcaneofibular ligaments, with preservation of the peroneus brevis tendon

8. Use of bracing:a. Should be judicious and for specific reasonsb. Standing and walking excercises must also be performed without a brace to stimulate function in the transfer

9. Bivalved casts:a. Prolonged use is very importantb. Continue until the muscle has developed full strength and balanced function with no tendency for reccurrence of the original deformity

10. Triple arthrodesis:a. If dynamic balance can be established prior to the development of structural deformity, arthrodesis can be avoidedb. Perform the osseous correction/stabilization and then perform tendon transfer and muscle reeducation after bone union has taken place

TenosynovitisAn inflammation of the synovial lining of the tendon sheath 1. Etiology:a. Acute infectious tenosynovitis: Caused by a pyogenic organism. The bacterial invasion and the resultant purulent exudate can involve the entire length of the tendon sheath. Treatment with antibiotics must be prompt, I and D may be necessary when the purulent material organizesb. Chronic infectious tenosynovitis: Caused by diseases such as syphilis and TB. The synovial wall becomes thickened and there is a fibrinous exudate which affects the peroneal and extensor tendons most frequently. c. Acute simple synovitis: Results from overuse most commonly affecting the EHL, TA, and tendo Achillesd. Chronic simple tenosynovitis: Caused by continuous shoe friction on the extensors or Achilles tendone. Stenosing tenosynovitis: Usually affects the anterior and posterior tibial, EDL, and the peroneals below the lateral malleolus and in the inferior retinaculum. Caused by friction with-in the "pulley system" of the ankle within the fibrous sheath. In digits, "trigger toe" occurs. f. Hemorrhagic tenosynovitis: Caused by trauma in which the epithelial lining of the sheath is ruptured followed by hemorrhage and clot formation (excision of the hematoma is recommended) g. Paratendonitis: Results from excessive friction between the tendon and the paratenon caused by overuse, crepitation can occur h. Acute tenosynovitis caused by rheumatoid arthritis: Nodular masses can form within the tendon sheath, which may be rheumatoid nodules.