Transferencia del flexor hallucis longus en un paciente con síndrome pospoliomielítico con déficit de la función del tendón tibial posterior. Reporte de un caso y técnica quirúrgica / Flexor hallucis longus transfer in a patient with post-polio syndrome with posterior tibial tendon dysfunction. Case report and surgical technique

El síndrome pospoliomielítico con déficit de la función del tendón tibial posterior puede presentarse con un pie equino flexible y marcha equina (steppage) en algunos pacientes. Se describe el caso de una paciente que solo conservaba la función muscular del tendón flexor hallucis longus y se decidió su transferencia al mediopié para obtener un pie plantígrado y restaurar la dorsiflexión. Nivel de Evidencia: IV

Post-polio syndrome with posterior tibial tendon dysfunction may present a flexible clubfoot and steppage gait in some patients. We describe the case of a patient who only preserved flexor hallucis longus tendon function; therefore, we decided to transfer it to the midfoot to obtain a plantigrade foot and restore dorsiflexion. Level of Evidence: IV

Tendoscopía en disfunción del tendón tibial posterior Estadío I: 8 años de seguimiento / Tendoscopy in stage I Posterior Tibial dysfunction: 8 years follow up

Cuando fracasa el tratamiento conservador en el Estadio I de Disfunción del Tendón Tibial posterior (DTTP), se debe indicar sinovectomía y debridamiento del tendón. En este estudio evaluamos la evolución con 8 años mínimo de seguimiento, de los pacientes con esta patología tratados vía tenoscópica. Este es un estudio retrospectivo de pacientes operados entre el año 2008 y el año 2011. En ese período de tiempo se intervinieron 11 pacientes con esta patología. Sólo 9 de los 11 pacientes operados pudieron ser evaluados. 7 pacientes mejoraron su sintomatología según el VAS y no progresaron a estadio II. En 3 pacientes se evidenció lesión tendinosa durante la tendoscopía y ameritaron reparación a cielo abierto. La sinovectomía tendoscópica del TTP es un procedimiento quirúrgico efectivo para tratar a los pacientes con DTTP Estadio I, rebeldes a tratamiento conservador(AU)

When conservative treatment fails for Stage I Posterior Tibial tendon dysfunction (PTTD), synovectomy and tendon debridement is indicated. In this study we evaluate tendoscopic treatment results for this pathology with a minimum of 8 years follow up. This is a retrospective study of patients after tendoscopic surgery performed between 2008 and 2011. 9 of the 11 patients were available for evaluation. 7 improved their symptoms according to VAS scale, and did not progress to stage II. In 3 patients tendon tear was visualized during tendoscopy and needed open repair. PTT tendoscopy is an effective surgical treatment to treat Stage I PTTD, failing to conservative treatment(AU)

Análisis biomecánico a través de simulación numérica de la ruptura del tendón del tibial posterior en el pie plano valgo: estudio en cadáver / Biomechanical analysis through numerical simulation of rupture of the tibial posterior tendon in valgus flat foot: a cadeveric study

Resumen: La insuficiencia del tendón del tibial posterior es la causa adquirida de dolor más común relacionada con la deformidad de pie plano valgo en adultos. El pie plano adquirido por el adulto es una deformidad sintomática muy dolorosa que resulta de un estiramiento gradual (atenuación) del tendón del tibial posterior, así como de los ligamentos que sostienen el arco de la planta del pie. El dolor progresivo en el pie plano adquirido por el adulto afecta cuatro veces más a las mujeres que a los hombres. Algunos factores que contribuyen a incrementar el riesgo del pie plano adquirido en el adulto son la diabetes, la hipertensión y la obesidad. Se piensa que la combinación de los eventos siguientes es la causa del pie plano adquirido por el adulto. La clasificación de Johnson Strom modificada por Mayerson lo evalúa en cuatro estadios. Este estudio se dividió en tres etapas: etapa 1: disección y análisis tridimensional del tendón, etapa 2: aplicación de herramientas de bioingeniería para determinar las causas de ruptura del tendón del tibial posterior y etapa 3: evaluación de 24 pacientes con enfermedad de pie plano valgo para describir la deformidad.

Abstract: The insufficiency of the posterior tibial tendon is the most common acquired cause of pain related to valgus flatfoot deformity in adults. The acquired flatfoot adult is a very painful symptomatic deformity resulting from a gradual stretching (attenuation) of the posterior tibial tendon and ligaments that support the arch of the foot. The progressive pain acquired flatfoot adult affects four times more women than men. Some factors that contribute to increased risk of acquired flatfoot in adults, are diabetes, hypertension and obesity. It is thought that the combination of the following events is the cause of acquired flatfoot adult. Johnson Strom classification modified by Mayerson evaluates in 4 stages. This study was divided into 3 stages: Stage 1: Dissection and three-dimensional analysis of the tendon, Step 2: Application of tools bioengineering to determine the causes of rupture of the tibial tendon: Stage 3: Evaluation of 24 patients with flatfoot disease valgus for describe the deformity.

Diagnosis of Flatfoot Deformity / 대한족부족관절학회지

Flatfoot is defined as loss of medial arch with hindfoot valgus, but normal condition is obscure due to wide individual variance. Loss or decreasing of medial longitudinal arch with radiographic image is clinically diagnosed as flatfoot. Flatfoot without symptoms is not an indication for treatment. The etiologies of flatfoot are congenital cause, hypermobility, tarsal coalition, neuromuscular disease, posttraumatic deformity, Charcot arthropathy, and posterior tibial tendon dysfuction. The flatfoot is classified as congenital and acquired, flexible, and rigid. The diagnosis is made by physical examination and radiographic findings. In particular, the posterior tibial tendon dysfunction is known as adult acquired flatfoot.

Treatment of Flatfoot Deformity / 대한족부족관절학회지

Flatfoot deformity, defined as loss of medial longitudinal arch, sometimes involves symptoms such as medial arch pain or Achilles tendon tightening, etc. Whether the etiology of deformity is congenital or acquired, i.e., posterior tibial tendon dysfunction, symptoms are largely resolved with conservative treatment including medication, orthoses, and activity modification. Surgery should be considered in cases of failure of conservative treatment and clinicians can select an appropriate technique among many surgical options including calcaneal osteotomy or flexor digitorum longus tendon transfer. Principles of corrective surgery include the recovery of alignment and the preservation of joint motion.

Tenodesis vs. tunelización del tendón flexor largo de los dedos en el tratamiento de la disfunción del tendón tibial posterior en estadio II / Tenodesis Vs. Tunneling of Flexor tendon length of the fingers in the treatment of Posterior Tibial Tendon Dysfunction Stage II

El tratamiento , en el estadio II de disfunción del tendón tibial posterior (DTTP) consiste en la transferencia del tendón Flexor Largo de los dedos (FLD) para suplir al tendón tibial posterior insuficiente y un procedimiento óseo para corregir la deformidad adquirida del retropié. En este estudio, evaluamos la función y eficacia de la transferencia del FLD tunelizado en el escafoide tarsiano vs la tenodesis del mismo al muñón distal del tendón tibial posterior. Material y método: Se realizó un estudio retrospectivo y comparativo de los pacientes intervenidos por esta patología en la Unidad de Pie y Tobillo del HCC, entre los años 2005 y 2012. En 27 pacientes se realizó tunelización del FLD en el escafoides tarsiano y en 49 pacientes se realizó tenodesis del FLD al muñón distal del tendón tibial posterior; en todos los pacientes se realizó un procedimiento óseo para corregir la deformidad adquirida del retropié. Se midió goniometricamente, inversión y flexión plantar del pie al año de postoperatorio en todos los pacientes y se comparó con el pie sano. Se evaluó pérdida de función ó dolor en zona de la transferencia. El análisis estadístico se realizó con t-student. Resultados: 6 pacientes presentaron DTTP bilateral y fueron descartados de este estudio. Los pacientes con tunelización del FLD en el escafoides tarsiano, presentaron una media de 62% de inversión y 86% de flexión plantar, los pacientes con tenodesis de FLD, presentaron una media de 86% de inversión y 89% de flexión plantar. Perdieron función del tendón, 1 paciente con tendón tunelizado, y 2 con tenodesis; presentaron dolor en la zona de la transferencia 2 pacientes con tenodesis del FLD. Conclusión: De nuestro estudio podemos concluir, que la tenodesis del FLD al muñón distal del tendón Tibial posterior, produce una mejor inversión del pie que la tunelización del FLD en el escafoides tarsiano(AU)

The surgical treatment of stage II posterior tibial tendon dysfunction (PTTD) is the transfer of the flexor digitorum longus tendon (FDL) to supply the posterior tibial tendon and a bone procedure to correct the acquired deformity of the hindfoot. In this study we evaluated the role and effectiveness of the FDL transfer to a tarsal scaphoid tunnel vs tenodesis of the distal stump of the posterior tibial tendon. Materials and methods: We performed a retrospective comparative study of patients with this disease in the Foot and Ankle Unit of HCC between 2005 and 2012, in 27 patients FDL tunnel was performed in the tarsal navicular and in 49 patients FDL tenodesis was performed to the distal posterior tibial tendon stump; in all patients a bone procedure was performed to correct acquired deformity of the hindfoot. Goniometrical measure was performed for forefoot inversion and plantar flexion at 12 months postop and compared with the healthy foot. Pain or loss of function in the transfer zone was evaluated. Statistical analysis was performed using T-student. Results: 6 patients had bilateral and PTTD and were excluded from this study. Patients with tarsal scaphoid FDL tunnel showed a mean of 62% forefoot inversion and 86% of plantar flexion, patients with FDL tenodesis, showed an average of 86% forefoot inversion and 89% of plantar flexion. One tendon tunnel patient lost tendon function and 2 tenodesis patient lost tendon function. 2 patients with FDL tenodesis had pain in the transfer area. Conclusion: From our study we can conclude that FDL tenodesis to the distal posterior tibial tendon stump produces a better forefoot inversion than the FDL tarsal navicular tunnel(AU)

Acquired Adult Flatfoot: Pathophysiology, Diagnosis, and Nonoperative Treatment / 대한족부족관절학회지

Acquired adult flatfoot is a deformity characterized by a decreased medial longitudinal arch and a hindfoot valgus with or without forefoot abduction. The etiologies of this deformity include posterior tibial tendon dysfunction, rheumatoid arthritis, trauma, Charcot's joint, neurologic deficit, and damage to the medial spring ligament complex or plantar fascia. Among these, posterior tibial tendon dysfunction is the most well-known cause. Although posterior tibial tendon dysfunction has been regarded as a synonym of acquired adult acquired flatfoot, failure of the ligaments supporting the arch can also result in progressive deformity even without a posterior tibial tendon problem. The authors describe the pathophysiology, diagnosis, and nonoperative treatment of acquired adult flatfoot, focusing on posterior tibial tendon dysfunction.

Adult flatfoot

Flatfoot deformity in adults is a type of postural deformity of the foot in which the arch collapses. This condition includes a wide spectrum of clinical situations, ranging from asymptomatic to progressive and disabling pathology. The common causes of adult-acquired flatfoot deformity are sustained flexible flatfoot from childhood, posterior tibial tendon insufficiency, tarsal coalition, generalized inflammatory diseases, neuropathic arthropathy, and posttraumatic deformities. The treatment of adult acquired flatfoot deformity should be individualized in each case, depending on the causes, symptoms, severity of deformity, and flexibility of the deformity. Therefore, it is mandatory for physicians to be acquainted with the basic pathomechanics of flatfoot deformity as well as the diagnostic procedures and treatments for each condition. The treatment usually begins with conservative methods and variable surgical procedures could be selectively performed. This article reviews the basic pathoanatomy, the diagnostic procedures for various causes and the treatment of flatfoot deformity in adult.

Estudio anatómico en cadáveres del portal de seguridad en la tendoscopia del tibial posterior / Cadaveric study for a safety portal of posterior tibial tendoscopy

Introducción: la cirugía mínimamente invasiva ha permitido mejoría en los resultados de los pacientes como es el caso de la tendoscopia del tibial posterior. Sin embargo, en ocasiones ciertos procedimientos se implementan sin suficientes estudios experimentales en animales o en cadáveres que den seguridad y trazabilidad en su realización y mejoren la curva de aprendizaje con impacto sobre los pacientes. Materiales y métodos: se diseñó un estudio descriptivo en un grupo de cadáveres a los que se les realizó la técnica convencional para el abordaje del portal de visión del tibial posterior. Se evaluaron las lesiones a las estructuras nobles involucradas. Resultados: se presentaron lesiones en el músculo, la arteria y la vena. Discusión: los resultados muestran la importancia de procesos de simulación en piezas anatómicas que permitan, en técnicas especiales como esta, realizar un entrenamiento previo que mejore las curvas de aprendizaje de los cirujanos.

Inclinação tibial posterior como fator de risco para lesões dos ligamentos cruzados anterior e posterior do joelho / Tibial slope as a risk factor for injury of anterior and posterior cruciate ligaments of the knee

Objetivo: O objetivo deste estudo é avaliar a influência da inclinação posterior da tíbia proximal na incidência de lesões dos ligamentos cruzados anterior e posterior do joelho. Métodos: Foram avaliadas, retrospectivamente, as radiografias pré-operatórias na incidência em perfil com filme longo de joelho de 30 pacientes consecutivos submetidos a reconstrução do ligamento cruzado anterior e 30 pacientes submetidos a reconstrução do ligamento cruzado posterior. Para comparação de variáveis categóricas entre os grupos foi utilizado o teste não paramétrico de Quiquadrado de Pearson. Foi assumido valor de a=5% como estatisticamente significante. Resultados: Dos indivíduos com inclinação tibial, £ 4,75% pertenciam ao grupo dos pacientes com lesão do LCP e 71,4% dos indivíduos com inclinação tibial ³ 10 pertenciam ao grupo de pacientes com lesão do LCA. Conclusão: Em indivíduos com valores intermediários de inclinação tibial posterior (5 a 9 graus) parece não haver a influência desta variável nas lesões ligamentares estudadas. Já nos extremos parece haver uma relação, no entanto estudos com maior número de pacientes seriam necessários para confirmar esta hipótese.

Papel do polimorfismo genético na expressão das metaloproteases na tendinopatia primária do tendão tibial posterior / Role of genetic polymorphism of the genes that express the metalloprotease in tendinopathy primary posterior tibial tendon

Este trabalho investiga a influência de polimorfismos na região promotora do gene das metaloproteases 1, 3 e 8 na fisiopatogenia da insuficiência primária do tendão tibial posterior. A amostra de 150 pacientes selecionados é dividida em grupo-teste: 50 pacientes com diagnóstico clínico e anatomopatológico de tendinopatia do tendão tibial posterior e grupo-controle: 100 pacientes com tendão tibial posterior íntegro. O DNA dos voluntários é obtido a partir de células epiteliais da mucosa bucal mediante a extração com acetato de amônia. As técnicas de PCR e RFLP são utilizadas para análise dos genótipos. A análise estatística dos resultados é realizada pelo teste do qui-quadrado com nível de significância de 5%. Os resultados mostram que os polimorfismos -1607 da MMP-1 e -799 da MMP-8 estão relacionados com risco maior para tendinopatia primária do tendão tibial posterior, enquanto o polimorfismo -1612 da MMP-3 parece não influenciar essa tendinopatia...

The aim of this study was to investigate the influence of polymorphisms in the promoter region of the gene of metalloproteinases 1, 3 and 8 in physiopatology of primary posterior tibial tendon insufficiency. The sample of 150 selected patients was divided into test group: 50 patients undergoing surgical procedures and pathological diagnosis of degenerative lesions of the posterior tibial tendon, and control group: 100 patients with posterior tibial tendon intact and no signs of degeneration. The DNA of the volunteers was obtained from oral mucosa epithelial cells, by extraction with ammonium acetate. PCR and RFLP were used for analysis of genotypes. Statistical analysis of results was performed by Chi-squared test with significance level of 5%. The results show that polymorphisms -1607 of MMP-1 and -799 of the MMP-8 are associated with increased risk for primary tendinopathy of the posterior tibial tendon, while the -1612 polymorphism of MMP-3 does not influence this tendinopathy...

Comparación entre resultados obtenidos en la corrección de valgo tibial proximal en pacientes pediátricos con sistema de grapas y sistema de placas en el Hospital Ortopédico Infantil Caracas Venezuela 2000-2007 / Comparison of results obtained in the proximal tibial valgus correction in pediatric patients with staple system and system of plaques in the Hospital Ortopédico Infantil 2000-2007 Caracas Venezuela

Las deformidades axiales de los miembros inferiores, motivo de consulta habitual, no corregen espontáneamente si son persitentes y sginificativas. La epifisiodesis produce la corrección grudual de la deformidad en un procedimiento mínimamente invasivo, en pacientes esqueléticamente inmaduros, en genu valgum y varum, con grapas o placas y tornillos. Según las observaciones clínicas, las placas permiten un mejor resultado en tiempo más corto, menor daño a la fisis y menos riesgo de complicaciones o falla de material en comparación con las grapas. La comparación de las técnicas en engrapado y placa en la resolución de deformidades en valgo de tibia proximal en los pacientes pediátricos en el Hospital Ortopédico Infantil, durante el periodo 2000 al 2007. Estudio retrospectivo simple y comparativo, se evaluaron 36 pacientes de ambos sexos con el diagnostico de Valgo Proximal Tibial, idiopáticos o asociados a otras patologías, que fueron tratados en el Hospital Ortopédico Infantil durante 2000 al 2007 con las técnicas de grapa y placa, mediante revisión de controles pre y postoperatorios de la historia clínica, y por medición radiológica de los ángulos FDLm, TPMm y MAD en radiogrfías panorámicas pre y postoperatorias. Se estudiaron 36 pacientes de ambos sexos, (16 varones y 20 niñas), promedio de edad de 10 años +/- 3,3 años. Existen similitudes en los primeros 12 meses en esta muestra, pero a partir de ese momento la Placa alcanza los valores de corrección antes que las grapas. Según la pendiente Y, la placa se proyecta para correcciones de 6,62 mm cada 6 meses, en cambio la grapa se proyecta para correciones de 5,72 mm cada 6 meses. Los valores del ángulo se estabilizan con la placa, y en cuanto a la grapa, se continúa la corrección en sentido contrario. La pendiente Y indica que la placa corrige -1,95º cada 6 meses, y la grapa corrige -2,95º cada 6 meses hacia el varo. Según la prueba ANOVA, combinando las variables Tiempo-Material, la placa alcanza....

The axial deformities of the lower limbs, common reason for consulation, will not correct spontaneously if they are persistent and significant. Epiphysiodesis produce gradual correction of deformity in a minimally invasive procedure in skeletally immature patients in valgum and genu varum with staples or plates and screws. According to clinical observations, the plates allow a better result in shorter time, less damage to the physis and less risk of complications or failure of material compared with the staples. Comparison of stapling techniques and plaque in the resolution of valgus deformity of proximal tibian in pediatric patients at Children's Orthopedic Hospital during the period 2000 to 2007. A retrospective and comparative simple, we evaluated 36 patients of both sexes with a diagnosis of Proximal Tibial Valgus, idiopathic or associated with other diseases, which were treated at the Children's Orthopedic Hospital during the period 2000 to 2007 with the techniques staple and plate by reviewing pre-and postoperative checks of medical record, and radiological measurements of the angeles FDLm, TPMm, and MAD in pre-and postoperative panoramic radiographs. We studied 36 patients of both sexes (16 boys and 20 girls), mean age 10 +/- 3,3 years. There are similarities in the first 12 months in this sample, but from that moment on the plate reaches the values of correction rather than staples. According to the slope and The plate is projected to corrections from 6,62 mm every 6 months, however the clip is projected to corrections of 5,72 mm every 6 months. The angle values are e¡stabilized with the plate, and as for the clip, continue the correction in the opposite direction. The slope indicates that the board and fixes -1,95º every six months, and the clip fixes -2,95º every six months into varus. According to the ANOVA test, combining the time-material variables, the plate reaches the expected correction before on the staple, the period aroun 12 months would.....

Body Mass Index in Patients with Early Posterior Tibial Tendon Dysfunction in Korea / 대한정형외과학회잡지

PURPOSE: Posterior tibial tendon dysfunction (PTTD) is known as the most common cause of adult acquired flatfoot syndrome and is common in middle-aged obese women. The purpose of this study was to describe the relationship between BMI (body mass index) and early stage PTTD in Korea. MATERIALS AND METHODS: Between May 2005 and June 2006 we evaluated 42 patients (58 feet) who were diagnosed and treated for early stage PTTD. We analyzed demographic data such as sex, age, BMI, physical findings, radiologic findings and clinical results. RESULTS: All 42 patients were women; their mean age was 52.6 years. Of the 42, 77% were middle aged (40-69). Increased BMI was detected in 75% of the 42 patients. There was no statistical significance in age-matched comparisons of BMI in Korea (p>0.05), or in the correlation between BMI and progression (p=0.293). Non-obese patients had superior clinical results (p=0.017). CONCLUSION: Overweight and obesity are commonly seen in patients with early stage PTTD in Korea but there do not appear to be any significant correlation between obesity and early stage PTTD and also no significant correlation between obesity and progression to later stages.

Eletroestimulação do nervo tibial posterior no tratamento da incontinência urinária de urgência e mista / Posterior tibial nerve electrical stimulation in the treatment of urge and mixed incontinence

Objetivo: Avaliar o efeito da eletroestimulação do nervo tibial posterior na freqüência miccional em mulheres com incontinência urinária de urgência ou com incontinência mista. Métodos: Seis pacientes do sexo feminino, com média de idade de 65,5 anos, com diagnóstico clínico de incontinência urinária de urgência ou mista, realizaram 12 sessões de eletroestimulação transcutânea no limiar sensitivo do nervo tibial posterior, utilizando eletrodos auto-adesivos. O efeito da eletroestimulação foi analisado por meio do diário miccional entregue às participantes antes da primeira e após a última sessão. Resultados: A análise estatística demonstrou uma redução significativa da freqüência miccional (p = 0,002). Em 50% das pacientes houve resposta completa ao tratamento e 33,3% resposta parcial. Todas as participantes optaram pela continuação do tratamento após o término do estudo. Conclusão: A eletroestimulação do nervo tibial posterior utilizando eletrodos auto-adesivos é uma técnica segura e de fácil aplicação, e foi capaz, neste estudo, de reduzir a freqüência miccional em pacientes com incontinência urinária de urgência ou com incontinência mista.

Objective: To evaluate the effect on posterior tibial nerve electrical stimulation on urinary frequency within women with urge or mixed urinary incontinence. Methods: Six female patients, 65.5 year-old average, with clinic diagnosis of urge or mixed urinary incontinence, performed 12 sessions of electrical stimulation on the sensitive edge of the posterior tibial nerve, using self-adhesive electrodes. Treatment effect was analyzed by voiding diary handed to the patients before and after the last session. Results: Statistics analyzes showed a significant reduction on urinary frequency (p = 0.002). In 50% of the patients there was a complete answer to the treatment and 33.3 % partial. All patients opted for continuing treatment after the studies ended. Conclusion: The posterior tibial nerve electrical stimulation using self-adhesive electrodes is a safe and easy handle technique, which was capable, within this study, to reduce urinary frequency in patients with urge or mixed urinary incontinence.

Changes in histoanatomical distribution of types I, III and V collagen promote adaptative remodeling in posterior tibial tendon rupture

INTRODUCTION: Posterior tibial tendon dysfunction is a common cause of adult flat foot deformity, and its etiology is unknown. PURPOSE: In this study, we characterized the morphologic pattern and distribution of types I, III and V collagen in posterior tibial tendon dysfunction. METHOD: Tendon samples from patients with and without posterior tibial tendon dysfunction were stained by immunofluorescence using antibodies against types I, III and V collagen. RESULTS: Control samples showed that type V deposited near the vessels only, while surgically obtained specimens displayed type V collagen surrounding other types of collagen fibers in thicker adventitial layers. Type III collagen levels were also increased in pathological specimens. On the other hand, amounts of collagen type I, which represents 95 percent of the total collagen amount in normal tendon, were decreased in pathological specimens. CONCLUSION: Fibrillogenesis in posterior tibial tendon dysfunction is altered due to higher expression of types III and V collagen and a decreased amount of collagen type I, which renders the originating fibrils structurally less resistant to mechanical forces.

The Effect of the Combined Stretching and Strengthening Exercise on the Clinical Symptoms in Posterior Tibial Tendon Dysfunction Patient / 대한족부족관절학회지

PURPOSE: The isolated exercise therapy and its effect for the treatment of posterior tibial tendon dysfunction (PTTD) is not well known. The purpose of this study was to identify the clinical effect of stretching and strengthening exercise program on the patients' muscle function and range of motion, pain and gait in the management of the early stage PTTD. MATERIALS AND METHODS: From October 2006 to March 2007, 14 patients with early stage PTTD (stage I or IIa) without surgical intervention were randomly assigned into two groups and we analyzed their clinical results. All patients were female and one who have sprained the same ankle during the program and one who withdrew from the program due to her private reason were excluded. At the last, the exercise group (EG) was seven and the control group (CG) was five. Mann-Whitney U test was used for the comparison of pain, ROM, muscle power, AOFAS score and 5 minute walking test of both groups. Wilcoxon-signed rank test was used for the comparison between the pre and post exercise program in EG. RESULTS: The pain was significantly reduced in EG compare to CG and only the dorsiflexion was significantly increased in EG in the analysis of ROM. The dorsi flexion and plantar flexion power were significantly increased in EG. CONCLUSION: Our 6 weeks stretching and strengthening exercise program showed noticeably improved clinical result, and therefore it is recommended as one of the useful treatment option in the management of early stage PTTD.

Split tibials posterior tendon transfer in the management of spastic talipes varus / Tratamento do pé varo espástico através da hemitransposicão do tendão do tibial posterior

Foram avaliados dez pacientes (12 pés) com paralisia cerebral espástica submetidos à hemitransposicão do tendão do tibial posterior para correcão da deformidade em varo do pé. Quatro pacientes eram do sexo feminino e 6 do sexo masculino. A idade média dos pacientes foi de 8 anos e 9 meses. Seis pacientes apresentavam paralisia cerebral espástica hemiplégica; 2,diplégica e 2 pacientes, paralisia cerebral tipo misto. O tempo médio de seguimento foi de 26 meses. Cirurgias associadas foram realizadas em 11 pés (92 por cento). Oito pés apresentaram bom resultado (67 por cento), três pés (25 por cento), resultado regular e um pé (8 por cento), mau resultado. Nenhum dos pés desenvolveu deformidade em calcâneo-valgo. Os resultados regulares e mau estiveram associados principalmente à insuficiência do músculo tibial anterior que levou à necessidade de manutencão do uso de órtese no pós-operatório, à influência de outras forcas deformantes no pé além do músculo tibial posterior e à presenca de deformidade óssea estruturada. Os autores concluem que a técnica de hemitransposicão do tendão do tibial posterior, associada a outras cirurgias quando necessário, tem bom resultado na correcão da deformidade em varo do pé na paralisia cerebral; desde que sejam determinadas corretamente as características dinâmicas da deformidade e eventuais deformidades associadas sejam tratadas de forma apropriada, concomitantemente.

MR Imaging Findings of Painful Type II Accessory Navicular Bone: Correlation with Surgical and Pathologic Studies

OBJECTIVE: To evaluate the MR imaging findings of painful type II accessory navicular bone and to correlate these with the surgical and pathologic findings. MATERIALS AND METHODS: The MR images of 17 patients with medial foot pain and surgically proven type II accessory navicular abnormalities were reviewed. The changes of signal intensity in the accessory navicular, synchondrosis and adjacent soft tissue, the presence of synchondrosis widening, and posterior tibial tendon (PTT) pathology on the T1-weighted and fat-suppressed T2-weighted images were analyzed. The MR imaging findings were compared with the surgical and pathologic findings. RESULTS: The fat-suppressed T2-weighted images showed high signal intensity in the accessory navicular bones and synchondroses in all patients, and in the soft tissue in 11 (64.7%) of the 17 patients, as well as synchondrosis widening in 3 (17.6%) of the 17 patients. The MR images showed tendon pathology in 12 (75%) of the 16 patients with PTT dysfunction at surgery. The pathologic findings of 16 surgical specimens included areas of osteonecrosis with granulomatous inflammation, fibrosis and destruction of the cartilage cap. CONCLUSION: The MR imaging findings of painful type II accessory navicular bone are a persistent edema pattern in the accessory navicular bone and within the synchondrosis, indicating osteonecrosis, inflammation and destruction of the cartilage cap. Posterior tibial tendon dysfunction was clinically evident in most patients.