ajkim1's version from 2015-05-08 11:43


Question Answer
PTTDMost common cause of acquired unilateral adult flatfoot deformity
Structure that must be cut to access TP tendonFlexor retinaculum, must repair after surgery with 2.0 vikril absorbable suture
Biomechanical function of TPStrongest supinator of foot, stance phase muscle, works 2-42% gait cycle, locks MTJ
TP watershedBegins 40mm from medial tubercle of navicular and extends 14mm proximally usually behind medial malleolus
Checking for TP tearGo under TP tendon with instrument or finger and flip it around
Etiology of TP tearHypovascular zone rubs against bone with other factors leads to loss of TP function and collapsing of foot
Transfer commonly used to treat PTTDFDL transfer
Ligament essential for surgerySpring ligament
Position of talus when foot is flatPlantarflexed and adducted
Pathological anatomy of PTTDParatenonitis, paratenonitis with tendinosis, tendinosis
ParatenonitisInflammed, treat by bracing, surgically treat by synovectomy along TP tendon, some debridement
Paratenonitis with tendinosisNodular thickening of tendon, which can rupture, foot is still mobile, flexible deformity becoming more rigid, heel inverts to try to get back to neutral, try bracing, NSAIDs, physical therapy, surgery (FDL transfer or medial calcaneal osteotomy)
TendinosisFoot fixed in RF valgus, sinus tarsi pain, treat by bracing, arthrodesis surgery
Pathological anatomy progressionEdema synovitis-->fusiform swelling-->longitudinal rents/tears with yellow mucoid discoloration-->attenuation/rupture, adhesions-->tendon end atrophy and cell death
Etiology of PTTDMiddle-aged obese ladies, intrinsic abnormality of tendon
First presentation of patientTalus is sticking out and plantar flexing, MTJ unlocked causing abduction, very unstable foot
History of PTTDUnilateral flat foot, present for a long time
Condition in which PTTD would present bilaterallyRA
Classic presentation of PTTDFixed heel valgus, talar plantarflexion, flattened medial arch, abduction at Chopart's articulation, sinus tarsi pain
Clinical exam for PTTDSwelling/fullness of medial ankle, "too many toes" sign, single/double heel raise, manual muscle testing
Single heel raise testStand and hold table, raise unaffected foot off floor and try to raise toes on affected side (indicates integrity of TP)
Double heel raise testGo on both toes at the same time, check if both heels evert (indicates flexibility of RF)
Various symptoms of PTTDTenosynovitis, partial rupture, complete rupture
How long might it take for symptoms to show up?Months to a year
Gold standard for PTTD diagnosisMRI
If MRI doesn't show healed rupture, what does?Healed tendon will elongate, increase in resting tendon length
How much does TP need to be elongated to lose stability?1cm
Non-surgical managementControl pain with analgesics, decrease inflammation with NSAIDs, stabilize joints and prevent progression with bracing
Richie braceGood for Stage I, built-in orthotic, hinged
Arizona braceGood for stage I and II, decreases RF valgus and prevents lateral calcaneal displacement and prevents medial collapse of ankle and arch
AFOControls plantarflexion, stabilizes arch and medial-lateral motion, unloads ankle and RF, loads proximal calf to relieve pressure off RF, last alternative before surgery
Shoe modifications for PTTDWiden medial base, stiffen medial counter, rocker bottoms
Surgical management factorsAmount of pain, deformity, dysfunction, x-ray/MRI changes
Surgical mangementDirect repair, FDL tenodesis with spring ligament repair, osteotomies, arthrodesis, medial/lateral column procedures, stage IV (tilted ankle)
Common surgical proceduresFDL transfer, Koutsigiannis
Post op care PTTDPosterior mold 7 days, foot in equinus and adduction, transition to NWB SLC 8-12 weeks, patient improves up to 2 years