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Total ankle arthroplasty and tibialis posterior tendon transfer for ankle osteoarthritis and drop foot deformity
Foot and Ankle Surgery 17 (2011) 203–206
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Total ankle arthroplasty and tibialis posterior tendon transfer for ankle osteoarthritis and drop foot deformity Hajo Thermann a, Iosif Gavriilidis a, Umile Giuseppe Longo b, Nicola Maffulli MD, MS, PhD, FRCS (Orth)c,* a
ATOS Clinic, Center for Knee and Foot Surgery, Sport Surgery, Heidelberg, Germany Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Longoni, 83, 00155 Rome, Italy c Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 June 2009 Received in revised form 15 September 2009 Accepted 8 October 2009
Total ankle arthroplasty is an alternative to arthrodesis in selected patients with end-stage arthritis of the ankle. We report on the clinical features, radiographic findings, management and results in a 58year-old man with associated ankle osteoarthritis and drop foot deformity. The patient was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Three years after the procedure, the patient was able to walk, had no pain, and had a stable joint with 58 dorsiflexion and 208 plantar flexion. ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Ankle Arthroplasty Tibialis posterior tendon Osteoarthritis Drop foot
1. Introduction Drop foot deformity is disabling, with marked weakness of ankle and toe dorsiflexion [1]. It can result from neurologic, muscular, and anatomic causes, alone or combined. Clinical examinations and electrophysiological investigations are required to formulate an appropriate diagnosis and plan accurate management [2]. A systematic diagnostic approach has a pivotal importance to avoid errors of diagnosis and management, as management of foot drop should address its aetiology. Ankle–foot orthoses or braces are often poorly tolerated [2]. Classically, several surgical procedures aim to correct the absence of active dorsiflexion and the concomitant cavo-varus foot [3]. Transfer of the tibialis posterior tendon, at times associated to transfer of the flexor hallucis longus or peroneus longus tendon to the dorsum of the foot, has been used [3,4]. Drop foot deformity associated to osteoarthritis of the ankle is very disabling [5]. In these patients, arthrodesis has traditionally been regarded as the ‘gold standard’ in the surgical management of end-stage arthritis of the ankle, even though new evidences suggest that at 2-year follow up total ankle replacement (TAR) is safe and effective [6].
* Corresponding author. Tel.: +44 20 8223 8839; fax: +44 20 8223 8930. E-mail address: [email protected] (N. Maffulli).
We report the clinical features, radiographic findings, management and medium term results of a patient with associated ankle osteoarthritis and drop foot deformity who was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Our patient was informed that data concerning his case would be submitted for publication. 2. Case report A 58-year-old man with severe pain in the left ankle and a severe limp was referred to our hospital from another orthopaedic centre. He had developed a drop foot deformity after an intramuscular injection in his left buttock 20 years before. The injection had produced a lesion of his sciatic nerve which had never recovered. Laboratory findings were unremarkable. The patient had no other pathologies which could be responsible for the droop foot deformity. Radiographs of the ankle showed end-stage ankle arthritis (Fig. 1A and B). The preoperative alignment was in varus. The patient underwent a total ankle arthroplasty (Mobility-De Puy, Inc., Warsaw, IN) with tibialis posterior tendon transfer at the same surgical time. After a standard TAR procedure (Fig. 2A and B), a small medial incision was performed over the navicular, and the distal portion of the tibialis posterior tendon over the tuberosity of the navicular was identified. This part of the tendon was detached from its insertion on the navicular with its periosteal flap, and its synovial attachments were separated. A second longitudinal incision was
1268-7731/$ – see front matter ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.10.004
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Fig. 1. Anteroposterior (A) and lateral (B) radiographs of the ankle: end-stage ankle arthritis is evident.
Fig. 2. (A) The window for the tibial stem in the distal part of the tibia and (B) the Trial prosthesis.
Fig. 3. (A) Detachment of tibialis posterior tendon from its navicular insertion. (B) The tibialis posterior tendon on the dorsum surface of the cuboid bone. (C) Fixation of the tibialis posterior tendon on the heel.
H. Thermann et al. / Foot and Ankle Surgery 17 (2011) 203–206
205
made at the level of the medial malleolus and continued proximally for 5 cm. The sheath of the tendon was split, the muscle was mobilized through the calf and the whole tendon was delivered into the proximal incision. A non-absorbable suture (fiberwire 2/0) was sewn into the distal part of the free tendon with the Krackow technique (Fig. 3A). The tibialis posterior tendon was then brought anteriorly in the leg, through the interosseous membrane, by piercing the membrane as close as possible to the posterior aspect, making sure that the hole produced allowed easy passage of the muscle. Another longitudinal incision of 3 cm long was made over the dorsum of the cuboid, and the tendon was passed subcutaneously to this incision (Fig. 3B). After identifying the peroneus brevis tendon, a side-to-side tenodesis of the two tendons with an absorbable suture (Vicryl 2/0) was performed for a distance of 2 cm. Finally, the two tendons were secured on the heel with a Kirschner wire and with the foot in neutral (Fig. 3C). The ankle was immobilized in a below-knee walking cast. A postoperative radiograph showed a medial malleolus fracture (Fig. 4A and B), despite the prophylactic intraoperative pinning with the Kirschner wire. The patient underwent a regime of belowknee cast with no weight bearing for the first three weeks, followed by partial weight bearing for the next three weeks. The fracture was completely healed after eight weeks, and at six months postoperatively the patient was able to walk, had a stable joint with 58 dorsiflexion (Fig. 5A) and 208 plantar flexion (Fig. 5B), and no pain at all. Three years after the procedure (Fig. 6A and B), the patient remains asymptomatic, with the same range of motion and function. 3. Discussion
Fig. 4. (A) Postoperative anteroposterior radiograph of the ankle, showing a fracture of the medial malleolus. (B) Postoperative lateral radiograph of the ankle.
TAR can be an alternative to arthrodesis in some patients. The advantage of TAR is preservation of movement and function. This may also result in improvements in gait including reduction of limp, and protection of other joints [5]. Ankle arthrodesis has often been associated with high complication and reoperation rates, with overloading of the adjacent joints [5]. Furthermore, loss of ankle joint motion leads to abnormal gait patterns and causes restriction on patients’ activities. A successful ankle replacement, on the other hand, provides a near-normal gait pattern in terms of kinematics of the knee, ankle and tarsal joints. Our patient had a challenging pathology, as it presented with simultaneous end-stage ankle arthritis and drop foot deformity. Droop foot can determine significant increase of risk of complications for both procedures (TAR and fusion). Preoperatively the patient was widely consented for postoperative complications.
Fig. 5. (A) 1-year postoperative anteroposterior radiograph of the ankle, showing the fracture was completely healed. (B) 1-year postoperative lateral radiograph of the ankle.
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H. Thermann et al. / Foot and Ankle Surgery 17 (2011) 203–206
Fig. 6. (A) Dorsiflexion and (B) plantar flexion of the foot 3 years after the index procedure.
For many years he had a droop foot, and he decided to undergo a procedure which could have restored some range of motion of the ankle, despite the risks of complication, before a definitive fusion procedure. The patient agreed that, had TAR failed, revision to arthrodesis would have been required. The transfer of the tibialis posterior tendon to the anterior aspect of the leg and successive anchoring to the foot has achieved good results in the management of droop foot deformity [1]. We use the subcutaneous route, even though technically more demanding, because it is more direct and produces less pronation and greater dorsiflexion [7]. The transferred tendon had sufficient passive tension to generate the maximum active tension in contraction. Had this not been the case, there would be a rapid fall off in total tension achieved, and the transfer would act more like a tenodesis than an active transfer. In conclusion, combination of end-stage ankle arthritis with drop foot deformity is challenging. The association of TAR and tibialis posterior tendon transfer can be an option in these patients.
Conflict of interest statement None declared. References [1] Williams PF. Restoration of muscle balance of the foot by transfer of the tibialis posterior. J Bone Joint Surg Br 1976;58(2):217–9. [2] Pritchett JW, Porembski MA. Foot drop. In: E-Medicine; 2006. Available from: http://www.emedicine.com/orthoped/topic389.htm [Online]. [3] Yeap JS, Birch R, Singh D. Long-term results of tibialis posterior tendon transfer for drop-foot. Int Orthop 2001;25(2):114–8. [4] Vigasio A, Marcoccio I, Patelli A, Mattiuzzo V, Prestini G. New tendon transfer for correction of drop-foot in common peroneal nerve palsy. Clin Orthop Relat Res 2008;466(6):1454–66. [5] Gougoulias NE, Khanna A, Maffulli N. History and evolution in total ankle arthroplasty. Br Med Bull 2009;89:111–51. [6] Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int 2009;30(7):579–96. [7] Goh JC, Lee PY, Lee EH, Bose K. Biomechanical study on tibialis posterior tendon transfers. Clin Orthop Relat Res 1995;(319):297–302.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Total ankle arthroplasty and tibialis posterior tendon transfer for ankle osteoarthritis and drop foot deformity Hajo Thermann a, Iosif Gavriilidis a, Umile Giuseppe Longo b, Nicola Maffulli MD, MS, PhD, FRCS (Orth)c,* a
ATOS Clinic, Center for Knee and Foot Surgery, Sport Surgery, Heidelberg, Germany Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Longoni, 83, 00155 Rome, Italy c Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 June 2009 Received in revised form 15 September 2009 Accepted 8 October 2009
Total ankle arthroplasty is an alternative to arthrodesis in selected patients with end-stage arthritis of the ankle. We report on the clinical features, radiographic findings, management and results in a 58year-old man with associated ankle osteoarthritis and drop foot deformity. The patient was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Three years after the procedure, the patient was able to walk, had no pain, and had a stable joint with 58 dorsiflexion and 208 plantar flexion. ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Ankle Arthroplasty Tibialis posterior tendon Osteoarthritis Drop foot
1. Introduction Drop foot deformity is disabling, with marked weakness of ankle and toe dorsiflexion [1]. It can result from neurologic, muscular, and anatomic causes, alone or combined. Clinical examinations and electrophysiological investigations are required to formulate an appropriate diagnosis and plan accurate management [2]. A systematic diagnostic approach has a pivotal importance to avoid errors of diagnosis and management, as management of foot drop should address its aetiology. Ankle–foot orthoses or braces are often poorly tolerated [2]. Classically, several surgical procedures aim to correct the absence of active dorsiflexion and the concomitant cavo-varus foot [3]. Transfer of the tibialis posterior tendon, at times associated to transfer of the flexor hallucis longus or peroneus longus tendon to the dorsum of the foot, has been used [3,4]. Drop foot deformity associated to osteoarthritis of the ankle is very disabling [5]. In these patients, arthrodesis has traditionally been regarded as the ‘gold standard’ in the surgical management of end-stage arthritis of the ankle, even though new evidences suggest that at 2-year follow up total ankle replacement (TAR) is safe and effective [6].
* Corresponding author. Tel.: +44 20 8223 8839; fax: +44 20 8223 8930. E-mail address: [email protected] (N. Maffulli).
We report the clinical features, radiographic findings, management and medium term results of a patient with associated ankle osteoarthritis and drop foot deformity who was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Our patient was informed that data concerning his case would be submitted for publication. 2. Case report A 58-year-old man with severe pain in the left ankle and a severe limp was referred to our hospital from another orthopaedic centre. He had developed a drop foot deformity after an intramuscular injection in his left buttock 20 years before. The injection had produced a lesion of his sciatic nerve which had never recovered. Laboratory findings were unremarkable. The patient had no other pathologies which could be responsible for the droop foot deformity. Radiographs of the ankle showed end-stage ankle arthritis (Fig. 1A and B). The preoperative alignment was in varus. The patient underwent a total ankle arthroplasty (Mobility-De Puy, Inc., Warsaw, IN) with tibialis posterior tendon transfer at the same surgical time. After a standard TAR procedure (Fig. 2A and B), a small medial incision was performed over the navicular, and the distal portion of the tibialis posterior tendon over the tuberosity of the navicular was identified. This part of the tendon was detached from its insertion on the navicular with its periosteal flap, and its synovial attachments were separated. A second longitudinal incision was
1268-7731/$ – see front matter ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.10.004
204
H. Thermann et al. / Foot and Ankle Surgery 17 (2011) 203–206
Fig. 1. Anteroposterior (A) and lateral (B) radiographs of the ankle: end-stage ankle arthritis is evident.
Fig. 2. (A) The window for the tibial stem in the distal part of the tibia and (B) the Trial prosthesis.
Fig. 3. (A) Detachment of tibialis posterior tendon from its navicular insertion. (B) The tibialis posterior tendon on the dorsum surface of the cuboid bone. (C) Fixation of the tibialis posterior tendon on the heel.
H. Thermann et al. / Foot and Ankle Surgery 17 (2011) 203–206
205
made at the level of the medial malleolus and continued proximally for 5 cm. The sheath of the tendon was split, the muscle was mobilized through the calf and the whole tendon was delivered into the proximal incision. A non-absorbable suture (fiberwire 2/0) was sewn into the distal part of the free tendon with the Krackow technique (Fig. 3A). The tibialis posterior tendon was then brought anteriorly in the leg, through the interosseous membrane, by piercing the membrane as close as possible to the posterior aspect, making sure that the hole produced allowed easy passage of the muscle. Another longitudinal incision of 3 cm long was made over the dorsum of the cuboid, and the tendon was passed subcutaneously to this incision (Fig. 3B). After identifying the peroneus brevis tendon, a side-to-side tenodesis of the two tendons with an absorbable suture (Vicryl 2/0) was performed for a distance of 2 cm. Finally, the two tendons were secured on the heel with a Kirschner wire and with the foot in neutral (Fig. 3C). The ankle was immobilized in a below-knee walking cast. A postoperative radiograph showed a medial malleolus fracture (Fig. 4A and B), despite the prophylactic intraoperative pinning with the Kirschner wire. The patient underwent a regime of belowknee cast with no weight bearing for the first three weeks, followed by partial weight bearing for the next three weeks. The fracture was completely healed after eight weeks, and at six months postoperatively the patient was able to walk, had a stable joint with 58 dorsiflexion (Fig. 5A) and 208 plantar flexion (Fig. 5B), and no pain at all. Three years after the procedure (Fig. 6A and B), the patient remains asymptomatic, with the same range of motion and function. 3. Discussion
Fig. 4. (A) Postoperative anteroposterior radiograph of the ankle, showing a fracture of the medial malleolus. (B) Postoperative lateral radiograph of the ankle.
TAR can be an alternative to arthrodesis in some patients. The advantage of TAR is preservation of movement and function. This may also result in improvements in gait including reduction of limp, and protection of other joints [5]. Ankle arthrodesis has often been associated with high complication and reoperation rates, with overloading of the adjacent joints [5]. Furthermore, loss of ankle joint motion leads to abnormal gait patterns and causes restriction on patients’ activities. A successful ankle replacement, on the other hand, provides a near-normal gait pattern in terms of kinematics of the knee, ankle and tarsal joints. Our patient had a challenging pathology, as it presented with simultaneous end-stage ankle arthritis and drop foot deformity. Droop foot can determine significant increase of risk of complications for both procedures (TAR and fusion). Preoperatively the patient was widely consented for postoperative complications.
Fig. 5. (A) 1-year postoperative anteroposterior radiograph of the ankle, showing the fracture was completely healed. (B) 1-year postoperative lateral radiograph of the ankle.
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H. Thermann et al. / Foot and Ankle Surgery 17 (2011) 203–206
Fig. 6. (A) Dorsiflexion and (B) plantar flexion of the foot 3 years after the index procedure.
For many years he had a droop foot, and he decided to undergo a procedure which could have restored some range of motion of the ankle, despite the risks of complication, before a definitive fusion procedure. The patient agreed that, had TAR failed, revision to arthrodesis would have been required. The transfer of the tibialis posterior tendon to the anterior aspect of the leg and successive anchoring to the foot has achieved good results in the management of droop foot deformity [1]. We use the subcutaneous route, even though technically more demanding, because it is more direct and produces less pronation and greater dorsiflexion [7]. The transferred tendon had sufficient passive tension to generate the maximum active tension in contraction. Had this not been the case, there would be a rapid fall off in total tension achieved, and the transfer would act more like a tenodesis than an active transfer. In conclusion, combination of end-stage ankle arthritis with drop foot deformity is challenging. The association of TAR and tibialis posterior tendon transfer can be an option in these patients.
Conflict of interest statement None declared. References [1] Williams PF. Restoration of muscle balance of the foot by transfer of the tibialis posterior. J Bone Joint Surg Br 1976;58(2):217–9. [2] Pritchett JW, Porembski MA. Foot drop. In: E-Medicine; 2006. Available from: http://www.emedicine.com/orthoped/topic389.htm [Online]. [3] Yeap JS, Birch R, Singh D. Long-term results of tibialis posterior tendon transfer for drop-foot. Int Orthop 2001;25(2):114–8. [4] Vigasio A, Marcoccio I, Patelli A, Mattiuzzo V, Prestini G. New tendon transfer for correction of drop-foot in common peroneal nerve palsy. Clin Orthop Relat Res 2008;466(6):1454–66. [5] Gougoulias NE, Khanna A, Maffulli N. History and evolution in total ankle arthroplasty. Br Med Bull 2009;89:111–51. [6] Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, et al. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int 2009;30(7):579–96. [7] Goh JC, Lee PY, Lee EH, Bose K. Biomechanical study on tibialis posterior tendon transfers. Clin Orthop Relat Res 1995;(319):297–302.