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Tibialis posterior tear and surgery

Discussion in 'Foot Surgery' started by F. Fewster, Aug 10, 2007.

  1. F. Fewster

    F. Fewster Member


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    I have a patient with an US confirmed longitudinal tear to the TP tendon distal to the medial malleolus with sheath effusion. She is hypermobile and a moderate to severe overpronator. Age57.

    Her foot/ankle orthopod is rec. surgery. A previous episode 6 yrs ago, same foot, resolved with strapping,orthoses and boots + rest.

    What are the pro's and con's of surgery for this patient?
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. drsarbes

    drsarbes Well-Known Member

    FF: I would venture to say that if her previous "episode" resolved and now that she is scheduled for surgery, that this "episode" is not resolving.
    When I Dx a linear tear of the Post tib I normally assume this will not heal.
    In addition, chronic synovitis within the tendon sheath needs debridement.
    The problem with NOT repairing this is, of course, chronic Posterior Tibial Dysfunction and secondary rigid pes valgus.
    Repair is relatively simple and successful. I also frequently tenodese this to the FDL as well as removal of the Navicular Tubercle and reinsertion of the tendon slightly more dorsal.
    Good luck
    DrSArbes
     
  4. Dieter Fellner

    Dieter Fellner Well-Known Member

    drsarbes

    why do you prefer to insert TPT slightly more dorsal, and do you feel it is necessary to add a bone procedure (e.g. calcaneal osteotomy) ?
     
  5. drsarbes

    drsarbes Well-Known Member

    "why do you prefer to insert TPT slightly more dorsal"
    Most of these have accessory ossicles or an enlarged tubercle. I've always felt that one of the concommitant anatomic etiologies was that the Post tib is inserted (partially) more posterior and plantarly on the navicular thus the vector of force is more pronatory.
    Since I remove the attachement in order to get the bone resected it's easy enough, via two bone anchors, to reinsert the tendon in a more "normal" position.
    Whether this actually DOES anything is up for discussion, but I have had success with it.
    DrSArbes
     
  6. Dieter Fellner

    Dieter Fellner Well-Known Member

    Dr. S. Arbes

    Thank you for this insight. It is of interest how perceptions can vary - I always hypothesized that a more plantar insertion would create a better supinatory force - the Young procedure kind of does so by creating a sling effect in this way but could exert the effect through increased tension instead? Not sure what the right answer is?

    It could be the Young's achieves the effect because of a reduction in the obliquity of the tendon and increase vertical alignment of TA.
     
  7. drsarbes

    drsarbes Well-Known Member

    Hi Dieter:
    "Young procedure kind of does so.........." well, not really.
    The youngs takes the TA and redirects the force to PULL DORSALLY on the navicular only, thus (in theory) raising the arch. This always assumes that the talo-nav; nav-cuneiform joints are flexible and that the simple power of the TA can outperform both body weight and gravity! Good luck with the Youngs! It never worked for me.
    The Post tib, when functionally inserted more posteriorly and plantarly pulls the navicular in a pronatory direction. Also, as it weakens, the peroneals, of course, have less resistance.
    DrSArbes
     
  8. Stephen:

    I am trying to imagine how the posterior tibial tendon which is medial to the subtalar joint (STJ) axis and exerts its effects via tensile forces on its main insertion site onto the navicular tuberosity, will "pull the navicular in a pronatory direction." Please explain the biomechanics behind this and how repositioning the posterior tibial tendon more posteriorly and plantarly results in pulling the navicular "in a pronatory direction".

    In addition, I would tend to doubt that the peroneals are the main cause of posterior tibial dysfunction. Rather it is much more likely that the cause of PT dysfunction is the shortened supination moment arm for the posterior tibial tendon to the STJ axis and the lengthened pronation moment arm to the STJ axis for ground reaction force in a foot with a preexisting medially deviated STJ axis.

    I have treated many patients with slight "tears" in the posterior tibial tendon quite successfully with well-designed foot orthoses and shoe therapy. I would not agree that all posterior tibial tendon tears require surgical intervention. Unfortunately, in my opinion, many patients in the States are not given adequate trials of conservative care with well-designed foot orthoses due to the eagerness of many surgically trained podiatrists and orthopedic surgeons to cut on the patient as soon as possible. There is nothing wrong with treating the patient with aggressive conservative care with an MRI-confirmed PT tendon tear since many patients will opt for nonsurgical treatment when given the options for conservative care by a podiatrist or clinician that does not automatically "sell surgery" to the patient as the "only way to cure the problem".
     
  9. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    I enjoy this dialog.
    "I would tend to doubt that the peroneals are the main cause of posterior tibial dysfunction."
    I didn't say this. What I said was that once the Post tib has weakened (regardless of the cause) the Peroneals are unopposed (less resistance) and exert a deforming force. They often go into spasm which causes a rigid pes valgus. This can be reduced under anesthesia but often returns post-operatively (as I'm sure you are aware). Whenever I have PTD patients that respond to conservative treatment and are dicharged I always make a point to educate them as to early signs of Peroneal Spasms.

    A "slight" tear, not visualized primarily would be a non quantitative description. I have also treated many patients conservatively (as well as had them referred after prolonged conservative treatment) that did not respond. Once explored these tears can be documented, measured, (photographed) & repaired. I have had tears verified at the time of surgery that were not visualized via MRI. Perhaps those who do respond nonsurgically do not have tears afterall. Perhaps just tenosynovitis. How would you know for sure? Even with Tenoscopy it's very difficult to visualize the entire tendon.

    As far as the Post Tib and pronation.....perhaps I did not explain my thinking on this clearly. As the Talo-Nav pronates the navicular moves plantarly and medially relative to the long axis of the foot, the posterior tibial becomes a pronator. If you were to apply a posterior directed tractional force to the medial - posterior aspect of the navicular, allowing the talus to migrate medially and plantarly (which is has already started to do in these patients), you would, in effect, collapse the medial arch. The posterior Tibial Tendon has now become a pronator. As the navicular migrates does not the posterior tibial promotes the movement in the very direction it's going? Of course. And if you are repairing the tendon, why not reattach it more dorsally on the medial aspect? I do tighten the spring ligament and the tendon as well and frequently do a tenodesis to the FDL. This is not unlike the underlying theory behind the Young's tenosuspension.

    Well Kevin, it's late and I have a LOT of GOLF tomorrow.

    Thanks
    Steve
     
  10. Steve:

    What I meant was that many patients with MRI-confirmed defects (i.e. tears, splits) of the posterior tibial tendon can heal to become painfree with conservative care only. I have seen linear tears become asymptomatic and I have seen chronic synovitis become asymptomatic without surgery and with good conservative care. This was in response to your comment:

    Your statement above seemed to say that unless you surgically repair these linear tears, the patient will "of course" develop a chronic posterior tibial dysfunction and a rigid pes valgus. This is simply not the case in the hands of a clinician that understands how to perform effective conservative measures for PT dysfunction.

    You have lost me already, Steve. Are you speaking of midtarsal joint (MTJ) motion here? In the joints formerly known as the oblique and longitudinal axes of the MTJ, if the navicular were to pronate at either the longitudinal or oblique MTJ axes, it would dorsiflex-abduct and evert, not plantarflex and adduct as you state above. In addition, the posterior tibial never exerts a pronation moment about either the MTJ or STJ axes since its prime insertion on the navicular tuberosity is medial to both the MTJ and STJ axes.

    The posterior tibial tendon will always cause an adduction and plantarflexion moment of the navicular about the talo-navicular joint. The posterior tibial muscle-tendon unit, acting by itself, would not cause a STJ pronation moment since its tendon it always medial to the STJ axis (unless you have performed a tendon-transfer on it). The posterior tibial muscle-tendon will always cause some degree of STJ supination moment, even though it may be exceptionally small.

    The posterior tibial is not a "pronator" and the posterior tibial does not "promote the movement" of pronation even in severe flatfoot deformity since it always rests medial to the talus, no matter how flat the foot is. Steve, after you get off the golf course tomorrow, maybe you can provide me with a reference which states that the posterior tibial is sometimes a "pronator" of the subtalar joint since I don't believe I have ever read this anywhere in the medical literature before.

    Hope you have nice time on the golf course tomorrow.
     
  11. drsarbes

    drsarbes Well-Known Member

    "......posterior tibial is sometimes a "pronator" of the subtalar joint since I don't believe I have ever read this anywhere in the medical literature before.

    Hope you have nice time on the golf course tomorrow."
    Hi Kevin:
    Golf was great.........two days straight//And tomorrow too!
    Well, as far as this discussion goes, if the navicula'sr subluxing in a dorsal direction (relative to the head of the talus) I call that pronation. Perhaps we're comparing apples and oranges. I'm referencing pathological motion, not pronation in a normal foot.
    And BTW: in case the "conservative" tx was a slight dig on surgeons' reputation for being overly aggressive, I've performed many Post Tib repairs on someone elses conservative successes. In my opinion, these patients with tears (to get back to the original discussion) do not heal. If they are young enough and active enough they most likely will end up with a problems if gone unrepaired.
    Steve
     
  12. Steve:

    In an earlier note you wrote:
    You also stated later:
    Now you are saying that dorsiflexion of the navicular is pronation??? I thought your two notes above describe navicular pronation to be a plantarflexion motion not a dorsiflexion motion. Maybe you can explain yourself more clearly since I must not be the only one confused.

    In addition, pronation motion is the same direction of motion relative to the cardinal body planes whether this motion occurs in a "normal" and "pathological foot". Pronation, by definition, is a motion, not an indicator of pathology. By the way, Steve, how can you tell if pronation is "normal" or "pathological"?? :confused: Is this accomplished by nonweightbearing measurement, weightbearing measurement, gait examination or radiographic examination? I'm sure that many of our colleagues following along would like to know that when you see pronation, if it is normal or pathological pronation.

    This doesn't surprise me that you have performed surgeries on "someone elses conservative successes". I could tell a little bit about your attitude regarding conservative versus surgical care of patients from your opening statements on the subject when you said:

    Since I have worked in a group with orthopedic surgeons for the past 22+ years and am often referred the surgical failures of podiatrists and orthopedic surgeons, I am very familiar with the attitude of many surgeons who think that surgery is the "only way to permanently correct the problem". I just thought that I would highlight the difference between the attitude of surgically-oriented podiatrists versus conservative-oriented podiatrists in this discussion. You see, Steve, I often see surgical failures from other podiatrists. These patients are worse off after surgery than before surgery and, the funny thing is, their surgeon told them just what you told us: "Repair is relatively simple and successful". These patients, in retrospect, tell me that they wish they had seen me before they saw their surgeon who told them "the only way to permanently correct the problem is surgery".

    I think that we, as a profession, need to promote better conservative care for our patients in the hopes these patients won't need to undergo the expense, disability, pain and potential complications of surgery. Of course, surgery is often indicated and I do my fair share of surgery also. However, all it takes is a few surgical failures/infections/complications to make the prudent surgeon realize that exhausting conservative treatments before surgery is the right thing to do for our patients.
     
  13. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    Sounds like it's time to move on. We apparently are not going to agree on much as far as this topic is concerned.
    It's difficult to argue with success so I'll just keep doing what works.
    I am back in the office today after five glorious days of golf and fund raising, nice to be able to combine the two.
    Thanks again for the dialog.
    Steve
     
  14. Steve:

    Thanks for the reply. I enjoyed the discussion in which I feel we highlighted, for the many non-surgical podiatrists that frequent this site, the differences in opinion between podiatrists regarding when it is appropriate to perform surgery on patients and when it is not appropriate.

    I have wonderful success in what I do for my patients, as I'm sure you also do, Steve. However, being able to explain, in a concise mechanical fashion, why certain surgical and non-surgical treatments are either successful or are less successful, is a very difficult thing and is what I spend much of my time with academically at this point of my career. The best foot surgeons I know are also the ones that have gained the deepest knowledge regarding the biomechanics of the foot and lower extremity.

    Good luck.
     
  15. drsarbes

    drsarbes Well-Known Member

    "The best foot surgeons I know are also the ones that have gained the deepest knowledge regarding the biomechanics of the foot and lower extremity."
    I couldn't agree more.

    I do have a deep respect for those who can communicate complicated issues.

    I have a post tib repair this afternoon. 54 year old with chronic pain, swelling weakness and progressive pes valgoplanus. Her right foot is normal. Her ankle dorsiflexion with KE is 5 degrees. Since her STJ subluxation is reducible I plan on putting in an absorbable MBA along with the arch work. The hope is that with the repair and MBA her PT tendon will strengthen to the point where she won't need the STJ implant. I've done six of these absorbable implants but none more than a year out.
    Any experience with them?
    DrSArbes
     
  16. drsarbes

    drsarbes Well-Known Member

    The procedure went well. The navicular. BTW, was dorsally located in reference to her talar head (as commonly seen in these feet) although abviously plantarly located in reference to a normal navicular. This is what most of us would call patholgic pronation (as compared to the pronatory motion of a normal foot ). As per my previous observations, once the STJ was realigned a more dorsally located attachement of the PTT on the medial surface did infact help stablize the area, as it almost always does.
    I've found the main problem with the absorbable STJ implants are that they do not show up on radiographs.
    DrSArbes
     
  17. Steve:

    Your statement above makes absolutely no sense to me. Was the navicular more dorsally located relative to the talar head or more plantarly located relative to the talar head? It can't be both more dorsally located and more plantarly located than normal at the same time!!:confused:

    By the way, when you speak about the proper terminology for pathologic pronation, who is "us"?? Please provide at least one published medical reference which uses the same terminology that you use above to describe navicular position relative to the talus so we know who "us" is.
     
  18. drsarbes

    drsarbes Well-Known Member

    Hi Kevin:
    You need to stop speed reading.
    Where do I say plantarly located in reference to the head of the talus?
    ===========================
    I had a referral yesterday afternoon, a 47 year old male with chronic pain, swelling, weakness in the Post Tib area. His Primary Care had been treating him with orthotics (through P.T.) P.T., half days at work, NSAI, ice - for 12 months. His MRI shows a tear in the PTT.
    In these cases, which I categorize as common, I have no hesitation in scheduling him for surgery. I'll perform a repair PTT + a possible tenodesis to the FDL and an absorbable MBA implant. My only regret is that he wasn't sent to me 6 months ago. He can't even walk his dog. His quality of life has been decreased dramatically.
    Would you do anything different?
    How long do we carry out concervative Tx before we give up? (and please don't ask who "we" are!)
    When is surgery indicated if we think some tears will actually heal and allow a patient to carry out his or her normal activities?
    Do we wait until they have a unilateral pes valgoplanus? Peroneal spasms? When the patient does not show up for an appointment because they are tired of having no improvement?
    Do you have a time table for these patients?


    Steve

    "us" - hmmmmmm Well, I'm schizophrenic!
    (In case you don't realize it, that's a joke.)
     
  19. Steve, either you need to stop speed writing or reread what you wrote originally. You first say the the navicular was dorsally located relative to the talus, then you say it is plantar located relative to a "normal navicular" (whatever that means).

    I'll try to simplify it for you, was the navicular more dorsally located relative to the talus than normal or was the navicular more plantarly located relative to the talus than normal? I hope you can see the problem with your terminology..... ever find that reference yet as to who else "us" refers to?
     
  20. drsarbes

    drsarbes Well-Known Member

    NO need to "simplify" anything on my behalf.
    I've already answered this, twice. Please refer to my earlier posts.
     
  21. David Smith

    David Smith Well-Known Member

    Dear DrSarbes

    I just dropped in and read thru this thread as it is quite pertinent to a project I am working on at present. I find I am a little confused by your descriptions of the midtarsal joint and the TNJ in particular. I think it may be a case of terminological misinterpretation.

    So if I may, I suggest using a common reference frame of orthogonal axis system in the global and local axis orientation.

    Where globally
    Y = vertical axis, X = posterior anterior axis and Z = medio-lateral axis

    Positive translation Y axis is upward, X axis is forward and Z axis is from left to right, which is medial to lateral right foot and lateral to medial left foot.

    Positive rotations. When looking along the axis in a positive direction the positive rotation is clockwise. Commonly called the right hand rule.

    When moving to the local axis set they are rotated appropriately to the new orientation of the limb or limb segment.

    EG if, while standing, the Y axis of the shank (tibial) segment in global terms is vertical and then the knee is rotated (flexed) 90dgs, then the local Y axis is now horizontal and anterio-posteriorly positioned. The other axes are therefore relatively rotated so that X is vertical and Z remains horizontal left to right.

    It is necessary to identify also the segment axis set that is being referred to, EG -X rotation of the STJ in terms of the tibial axis set is pronation and -X in terms of the calcaneal axis set is supination.

    So, in a normal standing right foot the post tib tendon when active tends to have a -X rotation and a +Y rotation (r.) on the STJ in terms of the calcaneal axis set. Plus a +Y translation (t.) and a –Xt.

    If we assume the Talo-navicular joint is a segment of a ball and socket joint and the Navicular is free only to rotate thru 3dgs of freedom on the talar head and ignore tendency to translate. The PT tendon inserts into the inferior and posterior aspect of Nav - (Ref Kapanji V2 Lower Limb p214)- so then tension in the PT tends to rotate the Navicular -Zr, +Yr, +Xr in terms of the Nav axis set.

    If we return to our podiatry terminology for a moment, this action of the Navicular will tend to plantarflex, invert and adduct the 1st ray. If we now imagine the translation force of PT on Nav then this is –Xt and tends to compress the TN joint. These actions all tend to resist flattening or raise the medial longitudinal arch (MLA)

    If we look at the same foot with abnormal or maximal pronation and navicular drop (please don’t anyone pick me up on definition of abnormal, it’s boring – you know what I mean IE a completely plantargrade foot). OK then, If we look at a maximally plantargrade foot (a flat foot nav on the ground) ;) , then the original action is exaggerated by the fact that the PF is stretched and so increases tension potentially and because of the increased mechanical advantage due to positional change will tend to increase +Yr and –Xr IE increasing adduction and inversion and plantarflexion of the Nav, which = increased supination by classical definition. However the poor physiological position (max extension) of PT muscle may negate any mechanical advantage.

    According to some there is a tendency for the PT to adduct the whole midfoot IE translate it along the -Zt but It would seem to me that as the foot pronates and abducts the PT has more mechanical advantage to translate along the +Zt axis and again assist in supination.

    In the maximally plantargrade foot, by transferring the PT tendon to the dorsal posterior aspect of the Nav this will tend to translate along the +Yt and +Zt, rotate about +Zr, +Yr and –Xr. This appears to me to have a flattening effect on the MLA because it will tend to dorsiflex and abduct the 1st ray. It may however, also reduce tension in the PF and may perhaps allow the PT muscle to work in a more physiologically optimal position.
    PT also perhaps has a tendency to apply a net –Zr (this depends angle of PT and on the exact resultant of –Xt force * moment arm and +Yt force * moment arm applied by PT about TNJ in terms of Talus axis set.) about the TCJ. So by transferring from inferior to superior aspect of Nav there may be less tendency for PT to have a –Zr (P/flex) effect on talocrural joint in terms of the axis set of the talus or rearfoot.
    This may mean that post transfer the post tib now acts as a net dorsiflexor of the rearfoot. Just a guess!! But maybe these two considerations are the reason for improved outcome, especially where surgery is the preferred and perhaps only intervention.

    Do you agree with this or do you have an Alternative explanation? (Not Alternate like you Americans insist on saying :) :) )


    Respectfully Dave Smith
     
  22. Dave:

    Thanks for your reply. Certainly using standard biomechanical terminology to describe the kinematics and kinetics of the midfoot, midtarsal and subtalar joints makes much more sense to me. In this way, there is no ambiguity in the written description and a greater level of communication will occur. Unfortunately, most of the podiatry profession does not know how to speak or communicate using precise biomechanical terms so the subject is often misunderstood or unclear to many podiatrists. I'm glad to see I was not the only one confused by Dr. Steve's description of the navicular that existed in both the plantarflexed position and the dorsiflexed position at the same time! :eek:
     
  23. drsarbes

    drsarbes Well-Known Member

    Hi all:
    Well, as Dalton McGlamry once said in describing the effects of PTTD ....the terminology is variable and confusing. Apprently he was correct!
    I've always tried NOT to confuse these severly collapsed feet with common pes planus or maximally pronated feet.
    They are not descriptive in these cases.
    Perhaps the old Collapsing Pes Valgo Planus (CPVP) should have caught on.
    With any "pathological" sagittal plane motion of the STJ there is, obviously plantar fexion of the talus. If the TN joint is collapsing (in contrast to the nav-cuneiform) then - again- the naviclular is dorsiflexing in relation to the talar head. The position of the navicluar in these feet, as seen on weight bearing, is PLANTAR FLEXED IN RELATION TO THE NORMAL POSITION OF THE NAVICLULAR AND DORSIFLEXED IN RELATION TO THE TALAR HEAD. KEvin, please do not "remove" the word "relation".

    When I correct these, I do place the Post tib tendon in what is a more dorsally located position on the medial surface of the navicular. I realize this is not classic, but when the foot is repositioned, particularly after inserting a STJ implant, this position reinforces the medial arch/talar head. My theory as to why this works so well is that the repositioned ptt now somewhat reinforces the spring ligament. There is still an attachement on the plantar surface, of course. The insertion of the PTT is always quite expansive and rarely when these are reflected off the nav tubercle to resect the tuberosity is the entire attachement released. So basically what we end up with is a broadened attachement of the PTT along the entire medial surface of the navicular with fibers still running plantarly. For all of you who perform PTT work you can appreciate this anatomy.

    HAve a nice weekend

    DrSArbes

    Stephen Arbes, DPM, FACFAS
    Green Bay, WI
    Board Certified in Foot & Ankle Surgery
    ABPS
     
  24. Yes, both open kinetic chain (OKC) and closed kinetic chain (CKC) pronation of the subtalar joint (STJ) pronation causes plantarflexion of the talus relative to the calcaneus and in CKC, STJ pronation also causes plantarflexion of the talus relative to the ground.

    Steve, I never misquoted you. You simply did not make yourself clear enough for me to understand you. I have heard from others privately on Podiatry Arena that are also confused by your terminology. However, I finally understand what you are saying now that you have defined your reference landmarks for describing navicular position and motion.

    What I understand now is that you are saying that on a weightbearing lateral radiograph, in a foot with pathologic pes planovalgus deformity, the navicular is in a more plantarflexed position relative to the ground than would be present in a normal arched foot. In addition, it is also noted in a foot with a pathologic pes planovalgus deformity that the navicular is in a more dorsiflexed position relative to the talus on a weightbeairing lateral radiograph than would be present in a normal arched foot. By not clarifying your reference landmark for navicular position and motion in your earlier posts, Steve, you created great confusion for myself and I'm sure others trying to follow along. This is why it is so important, without the visual clues of seeing the foot or explaining by diagram, that a description of the complex three-dimensional positions and motions of foot is done with precision and clarity so that confusion is minimized and transfer of knowledge is maximized. You are not alone in this since it is probably harder to describe the surgery with words than it is to actually perform the surgery itself!

    Now that I understand what you are doing, due to your improved description, this makes total sense to me. In essence, by attaching a portion of the PT tendon more dorsally on the medial navicular during your surgery you are increasing the tensile force within the section of the PT tendon that is attached dorsally. This could very well help increase the STJ supination moment from the PT tendon if indeed the PT tendon was plastically elongated during the course of the progression of the pathological process of PT dysfunction.

    Moving the PT tendon dorsally may also increase the plantarflexion moment and adduction moment acting across the talo-navicular joint due to the increased tensile force within the fibers of the PT tendon that have been moved dorsally. Of course, this is pure conjecture but it makes biomechanical sense to me and I now understand your reasoning for making this surgical modification on your patients. :)
     
  25. drsarbes

    drsarbes Well-Known Member

    Sorry for any confusion.....it always made sense to me!
    I would like to move the discussion to a question I posted earlier; When is the decision made to “give up” on conservative treatment and schedule patients with PTTD for repair?
    Does anyone have a quantitative way of assessing this?

    DrSArbes
     
  26. F. Fewster

    F. Fewster Member

    Thank you all for your replies. The patient has decided to proceed with the surgery this week in addition of course to cons post op tx with orthoses, correct footwear etc. She has multiple health issues and the pain and disability of this foot is aggravating them. Her other foot is now flared up too.(tp)

    I'm awaiting details of the proposed procedure - I think it may be a little different to your descriptions. I'll let you know how she goes.

    I'd like to hear from some other surgeons on thier approach to this condition.

    F. Fewster
     
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