SLR - April 2020 - Yu Ting Saw

Endoscopically Assisted Reconstruction of Posterior Tibial Tendon for Stage 2 Posterior Tibial Tendon Dysfunction 

Reference: Liang Z, Lui T. Endoscopically Assisted Reconstruction of Posterior Tibial Tendon for Stage 2 Posterior Tibial Tendon Dysfunction. Arthrosc Tech. 2019; Mar 8(3): e237-e243 

Scientific Literature Review 

Reviewed By: Yu Ting Saw, DPM 
Residency Program: Northwell Health Long Island Jewish Forest Hills Hospital – Queens, NY 

Podiatric Relevance: The posterior tibial tendon (PTT) is the main stabilizer of the medial longitudinal arch of the foot and thus PTT dysfunction causes 80 percent of adult-acquired flatfoot deformities. In stage two PTTD, a tendon transfer with a calcaneal osteotomy is often chosen to prevent worsening of the PTT. Recently, an endoscopic method of reconstructing PTT has been suggested by using the medial half of the anterior tibialis tendon (ATT) to augment the flexor digitorum longus (FDL) in addition to performing subtalar athroeresis. This technique would provide a less invasive alternative to the traditional procedure of choice. The article outlines the technical details of performing an endoscopically assisted reconstruction of the PT tendon for stage two PTTD.  

Methods: A 2.7 millimeter 30o arthroscope is used first for the posterior tibial tendoscopy and synovectomy, with the portal 1 centimeter proximal to the medial malleolar tip. Another incision is made at the level of the talonavicular joint, and the tendoscopy of the ATT is performed, visualizing the musculoteninous junction to begin separating the medial half. The split ATT is then passed and sutured to the proximal PTT. The FDL is then retrieved from the first incision and sutured to the ATT-PTT construct. Following this, a subtalar arthroereisis is performed.   

Results: This procedure may yield better cosmesis due to less soft tissue dissection and hence less post-operative pain all the while preserving the flexor hallucis longus and flexor digitorum longus tendons. While the ATT is disrupted, it does not completely lose its function. Some risks include medial plantar nerve injury, complete rupture of the ATT and possible dislodgement of the arthroeresis implant. 

Conclusions: The authors discuss a novel alternative to the traditional calcaneal osteotomy and a flexor tendon transfer. Overall, there are few disadvantages to performing this minimally invasive procedure compared to the more invasive traditional procedure. Furthermore, this procedure is not technically demanding and can easily be duplicated between surgeons. Patients are also more likely to be receptive to a less invasive procedure for treating a stage two PTT dysfunction.  

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