Posterior Tibial Tendon Repair: Kidner, FDL Transfer, and Medial Displacement Calcaneal Osteotomy

Abstract

Pes planus deformity, whether associated with an accessory navicular syndrome or an adult-acquired flatfoot deformity, is a major source of disability across a broad spectrum of patients. Posterior tibial tendon dysfunction (PTTD) is the most common etiology for a progressive flatfoot in the adult population. Patients frequently present with a complaint of “ankle pain” demonstrating variable hindfoot alignment issues. In the acute onset, mild to moderate tenosynovitis without major deformity may be the typical finding. Without treatment, continued inflammatory changes lead to progressive degenerative changes, tendinosis, tearing, and elongation which result in structural changes. Johnson and Strom classified three stages of PTTD which can serve as a guide to treatment based on structural integrity and function of the tendon. Most frequently patients present with long-standing symptoms, and often the tendon has lost structural integrity, and surgical intervention is frequently necessary. Multiple options for joint preservation via tendon transfers and osteotomies exist which allow reduction of symptoms and enhanced function despite the fact that many of these procedures are not considered to be “arch restoring.” The postoperative recovery after surgical management of both the recalcitrant symptomatic PTTD and accessory navicular syndrome is a significant undertaking. It is crucial to assess the ability of each patient individually to successfully navigate the process and withstand several months of rehabilitation. While the initial recovery is approximately 12 weeks, time to maximal medical improvement may be as long as 12–18 months. The surgical outcomes are very good with appropriate patient selection, planning, and execution.