Interesting Case #1

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Here are some intraoperative photos from an interesting case.

I thought it was going to be a usual accessory navicular with Posterior Tibial tendon work, but when I pulled on the tendon for examination it popped right out. Apparently it was attached by a very small margin and it didn't take much to detach it from the muscle belly.
I ended up suturing the FDL tendon to the stump and wrapping it in a Graft Jacket Graft.

Steve

 

Steve,

what was the history of this case?

cheers

Simon

 

58 y/o F with insidious onset pain / swelling left nav/post tib area X 2 years.
No Hx or trauma.
Had been treated by two podiatrist with orthotics, PT, cortisone, etc....... Got to me with weakness and obvious Post tib dysfunction. I normally get an MRI but didn't this time so I was quite surprised when the Posterior tibial tendon ruptured.
I cut the FDL tendon and rerouted it to the stump. I couldn't find the distal part of the Post Tibial muscle so I assumed it was atrophied.

Steve

 

Could the cortisone be the reason? We've stopped using it for other load-bearing tendons such as the Achilles and patella tendon due to the (small) risk of rupture.

Cheers,
Kent

 

Steve:

Nice photos. I would suggest, in addition to posting your excellent surgical photos, that you provide a brief narrative of the patient's case in your first posting with the photos. These will be very valuable cases for all of us to learn from (hundreds and possibly thousands of foot and ankle specialists and patients from around the world).

Also, would you mind if I, or anyone else, used your photos for our own lectures? Of course, we would give you photo credits if we used them.

Thanks in advance.

 

Very cool indeed :drinks.

And there i though it was all bunions

Robert

 

Hi Kevin:
Will do.
Feel free to use them.

Cortisone: This is well documented, however, from what I understand the two injections she received were at the point of attachment at the Nav Tuberosity.

As you might be able to see from the photo the tear was quite high, proximal to the med malleolus.
Photo #1 may be somewhat misleading. The tendon is actually free at both ends at this point. I placed it as best I could in an anatomic position for the photo.
I cleaned up both ends, attached the proximal to the FDL and the other with two Mitek anchors to the Navicular.

Thanks for the comments.

Steve

 

Neat, very interesting.
How is she doing now??
-John

 

Hell's Bells, why didn't you just use a Shannon 44?

Bill

 

Do you mean a Miltex Shannon burr #44?
As in, minimal incision-type surgery??
-John

 

Hi Gibby:
"how is she doing?"

This patient just amazed me.
The last I saw her she was around 7 weeks post op.

I discontinued her CAM walker at around 5 weeks. She was performing ROM and isolated Post Tib exercises at home since week 3.
I was planning on sending her to PT but she was doing so well I decided against it.

At the last visit her muscle strength was good and she had started wearing the support I had ordered (made locally) - minimal swelling, not even a limp. I was quite surprised by her rate of recovery. There was nothing more I could do so I discharged her.

Steve

 

That's great-
Neat case.
Nice job.
Apparently there are those who think a minimal incision burring-type procedure would have been an option. Hopefully, the excellent outcome will deter those who think blind grinding of bone and soft tissue would have been acceptable...

 

HAHA
Gibby:
I don't think there is an MIS alternative procedure for this case!
When you have 6 cm of Post tibial tendon sitting there free, not much
a Shannon #44 is going to do for you.

Steve

 

I agree.
But I'm sure someone would be willing to try.
I just saw a MIS "bunionectomy," done just after Hurricane Katrina (2005)-
Woman has a partial arthrodesis, in slight varus, very painful---

 

Sorry,

English irony a little too heavy here following a previous thread. My thoughts on 'blind grinding' are well known, the point being that this could not have been carried out by any manner of MIS.

All the best

Bill Liggins