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Tibialis posterior tendon debridement

    Overview

    Learn the Tibialis posterior tendon debridement surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Tibialis posterior tendon debridement surgical procedure.
    In the appropriately selected patient a tibialis posterior tendon debridement and repair will provide a very effective (and rapid) means of both halting symptoms and also possibly progression of the tendon degeneration. It is used in the main for patients with symptomatic grade 1 tendinosis, according to the classification system of Johnson & Strom. In other words no functional lengthening of the tendon and with the ability to perform a single heel rise still preserved.
    A stripping of the paratenon, targeted, limited incisions into all areas of degenerative change and excision and repair of degenerative cysts and tears is followed by a variable period of non-weight-bearing in cast. This may be as short as two weeks, followed by three to four weeks in a post-operative boot and progressively loading the tendon.
    A return to full function is the norm in patients with non-inflammatory conditions as the cause.
    Late deterioration is in my experience an uncommon event after an initially successful surgical intervention.
    Most cases of grade 1 tendinosis however will settle with conservative management using a long post-operative boot and semi-rigid functional foot orthotic as long as presentation is early enough.
    The fuller reconstruction of the degenerate, lengthened and defunctioned tibialis posterior tendon is covered on OrthOracle with techniques including FDL transfer with Calcaneal osteotomy and arthroresis screw https://www.orthoracle.com/library/pes-planus-correction-fdl-transfer-calcaneal-osteotomy-wright-bioarch-arthroresis-screw/ as well as FDL transfer with Calcaneal osteotomy and spring ligament reconstruction https://www.orthoracle.com/library/tibialis-posterior-reconstruction/


    Indications

    INDICATIONS
    -Grade 1 Tibialis posterior tendinosis
    -Early and mild grade 2 Tibialis posterior tendinosis in the very occasional appropriate patient (for example an ability to heel rise but without subtalar inversion and with subtle reduction in arch profile only). A full reconstruction with FDL or FHL transfer and calacaneal osteotomy is however required in most cases of stage 2 deformity.
    -A post-traumatic acute partial tear in a healthy tendon
    SYMPTOMS & EXAMINATION
    Coming across patients with early Tibialis Posterior tendon pathology is uncommon. A diagnosis of inflammatory arthropathy should be part of the differential especially in younger adult patients with first presentation. They will have medial hindfoot pain in the line of the tendon (directly behind the medial malleolus) which is locally tender and associated most often with swelling. Palpation of the tendon at or above the level of the medial malleolus is by placing a finger just behind the posterior edge of the subcutaneous face of the Tibia and pressing forwards. The tendon is palpated below the Malleolus by placing the foot into supination , instructing it should be held rigidly in this position , and running a finger from the tip of the malleolus to the navicular.
    There will be no (or minimal) deformity of the weight-bearing profile of the foot. Given the lack of structural deformity lateral hindfoot and medial forefoot pain are not seen. The medial arch profile needs to be assessed with the patient weight-bearing and comparison made between both sides. The heel/hindfoot alignment is assessed from behind the weight-bearing patient and should appear normal.
    The classic description is that patients will be able to perform a single heel rise and this will still result in subtalar inversion (indicating that the tendon has not elongated secondary to degenerative change). Patients presenting with acute and active synovitis around the tendon however often struggle with this test due simply to pain and not secondary to tendon elongation so the single heel rise test needs to be regarded relatively.The single heel rise test is the only one worth doing. During a double heel rise a severely effected side will look fine due to preferential weight-bearing on the normal side.
    These are often younger patients ( 20s-40s) who are either doing a lot of sport or have an inflammatory joint problem .
    Occasionally there are patients with true grade 2 tendon pathology but at the mild end of the grade 2 spectrum in whom a simple debridement is justified. They will not have a complete loss of the medial arch but rather a unilateral reduction of the medial arch and lack of subtalar inversion. These patients will not have more diffuse mechanical /impingement pain and will be able to single heel rise well but without subtalar inversion. These are likely to be younger and lighter and fitter patients.
    The grading system of Johnson & Strom is most often used in describing the extent of the deformity and also is used in decision making on which intervention may be used most appropriately. Stage 1 is defined by tenosynovitis of the tendon with minimal deformity or weakness of the tendon and single heel raise is largely normal. This is likely to respond to conservative measures or a tendon sparing procedure .A stage 2 tendon produces the classic pes planus deformity due to elongation and reduction in power. A single heel rise will not be possible but the subtalar joint is mobile. This is the type of tendon requiring the reconstruction described if conservative management fails. In stage 3 arthritis has occurred and the valgus deformity is fixed .Surgical treatment now requires a triple fusion. In stage 4 the ankle is also in Valgus and if surgical treatment is required this is a true pantalar fusion.
    INVESTIGATION
    An MRI is less sensitive to lesser degrees of para-tenon inflammation or small areas of tendinosis than ultrasound in my experience. It will also reveal associated degenerative joint change (though in these early cases this is very unusual)
    Using ultrasound it is also possible to safely infiltrate steroid into the tendon sheath in cases with no or very minimal change to the body of the tendon if symptoms are especially acute or failing to resolve by conservative means.
    Structural deformity associated with more advanced stages of tendon disease will be best documented with weight-bearing X-ray or CT if the deformity has become fixed.
    NON-SURGICAL ALTERNATIVES
    The first line management of these patients is initially non-operative with activity modification and non steroidal anti-infammatory medications.
    An off the shelf semi-rigid functional foot orthotic or custom made rigid orthotic device and activity modification is a starting point. Physiotherapy modalities including theraputic ultrasound and a graded rehab program are appropriate. Occasionally a few weeks immobilisation and strict non-weight bearing in a cast
    A tall and appropriately designed post-operative boot is helpful for a number of weeks and beyond this the use of a more normal pair of boots that sit well above the ankle(for example hiking boots) help.
    In resistant cases an ultrasound assessment(to ensure no tears and that the pathology is within the paratenon only) and inter-current steroid injection may be considered.
    SURGICAL ALTERNATIVES
    Consider arthroscopic tendon debridement. It tendon tears are present however they most likely will require a degree of open operation to deal with adequately.
    Some would advocate a medialising Calcaneal osteotomy in conjunction with the debridement , but with little evidence behind this , and in patients who by definition will have no deformity.
    CONTRAINDICATIONS
    The usual conditions that compromise wound healing (vascular insufficiency, various medications and smoking).
    A classically presenting grade 2 Tibialis posterior tendinosis with loss of medial longitudinal arch and associated flatfoot deformity.

    Setup

    The operation is easiest carried out with the patient supine
    The incision used is postero-medial , directly over the tendon which sits positioned just behind the back of the medial malleolus and runs down to the navicular.
    One or two side supports should be placed on the operated side , at thigh and trunk level , whilst several sandbags are placed under the opposite buttock , thus turning the operated leg into external rotation
    The further addition of rolled up sterile towels allow an extra element of helpful rotation and access to the back and lateral aspects of the ankle.
    Thigh tourniquet to be used and Flowtron on non-operated calf.
    Prophylactic antibiotics and LMW-Heparin peri-operatively & post-operatively
    Bipolar diathermy

    Operation – 1

    In a grade 1 tendinosis the arch profile is well maintained in the loaded foot but discreet swelling is seen in the line of the tibialis posterior tendon, immediately behind the medial malleolus (1).

    In a grade 2 tendinosis the arch profile is compromised in the loaded foot but discreet swelling is still seen in the line of the tibialis posterior tendon (1).

    The landmarks to identify for the incision are the medial navicular and the distal posterior border of the tibia.The subcutaneous border of the tibia, just posterior to the tip of the medial malleolus (1) and the medial aspect of the navicular(2), the main insertion of the tibialis posterior tendon, are the two points between which the skin incision will run.

    Incise the skin between just proximal and posterior to the medial malleolus and the navicular.A medial skin incision is used. This is immediately behind the medial malleolus (1) and runs down to the navicular (2) and tibialis posterior insertion which are easily palpable.
    It is a useful excercise pre-operatively to identify the points of tenderness of the tendon , though the whole length of it should be inspected intra-operatively.

    Use a “swab dissection” initially through the fat layer.Once through the skin the fat layer (2) can be both blunt stripped ,using swabs, as well as scissors dissected off the investing layer of deep fascia (3).Distally this needs to be to the level of the navicular.
    In the fat beneath the level of the malleolus is usually a dense plexus of superficial veins(1) to be diathermised.
    There are no large cutaneous nerves in the line of the incision but the saphenous nerve and vein lie anterior to the medial malleolus.
    If the vein is cut inadvertently it will need to be tied off with 2.0 Vicryl ties.

    The deep fascia covers both the subcutaneous border of the tibia as well as the postero-medial structures and should be defined by blunt swab dissection of the fat off it.
    The tibialis posterior(1) will be easily palpable behind the bony posterior border of the tibia(2).
    The incision through the deep fascia should be planned to provide enough of a cuff of deep fascia to repair back onto and not be made immediately adjacent to the posterior border of the tibia.

    The fascia is opened above the medial malleolus (1), initially immediately behind the posterior border of the tibia, to expose the Tibialis posterior tendon (2).

    The tibialis posterior above the level of the medial malleolus should be retracted using a McDonalds to both inspect its deep surface as well as the posterior aspect of the tibia which may be the location of bony pathology which can abrade the tendon.There may well be inflamed synovial tissue that needs to be stripped from the tendon.

    The Flexor Digitorum longus (FDL) tendon lies immediately behind the tibialis posterior tendon at this level. It may share the sheath of the Tibialis posterior or as in this case lie in a separate sheath, as is the case here, which needs to be opened to access it.
    There is no need to access the FDL however unless in doubt about which tendon you have exposed.
    The FDL can be mistaken for the tib post at this level so if in doubt expose two tendons. Traction upon the tib Post will not produce the digital flexion that traction upon the FDL will. The FDL sits immediately behind the tib Post and anterior to tib post is just the posterior border of the Tibia.

    The deep fascia is more comprehensively opened by cutting carefully down onto a McDonalds The deep fascia is more comprehensively opened by cutting carefully down onto a McDonalds as shown here.
    Though one will have an idea from both imaging and examination about what part of the tendon is at fault the opportunity should be taken to inspect the whole length of it.

    The tendon is significantly thickened and degenerate.
    The pre-op examination has of course confirmed that its functional length has not been effected so one can be fairly confident that irrespective of appearance it should function appropriately following a successful debridement and repair.

    The deep aspect of the tendon must also be completely inspected. Access to this is much improved by placing the foot & ankle into supination, as shown here.

    With the hindfoot supinated there is immediately enough slack in the tendon to permit easy inspection along the whole of its deep aspect above the medial malleolus. Again the McDonlads is a useful tool to mobilise and control the tendon.

    The sheath of the tibialis posterior is entered with the McDonalds and the tendons’ path followed beneath the medial malleolus to expose it here for inspection.

    The sheath is opened by direct incision onto the McDonalds which ensures the correct point of incision. It is important to leave a sling of deep fascia undivided around the medial malleolus.This doesn’t limit the access to the tendon in any meaningful way. It makes closure easy and logically must reduce the risk of tendon subluxation occurring post-op which can occur if the whole of the deep fascia needs to be repaired at the end of the procedure.

    It should be confirmed that the tendon is the tibialis posterior by traction on it distally and observing its movement proximally.

    Distally the deep fascia is then opened as far at the tibialis posterior insertion.In the fat layer there are usually small leashes of vessels sitting superficial to the deep fascia that need to be secured as shown here. Once the fat layer is dissected open the distal extent of the deep fascia can be seen.

    Once the deep fascia has been opened distally the tendon needs to be inspected circumferentially. It often will have adhesions adherent which need to be sharp dissected away.Note the associated synovitis and thickening of the paratenon here.

    As adhesions and synovitis are removed it becomes evident that the tendon is also significantly degenerate at its insertion.
    All adherent tissue is dissected off. If the paratenon is present as a discreet and thickened layer (as part of the tendinopathy) then it is carefully dissected off the healthier underlying tendon.
    In this distal part of the tendon this can be seen and is marked 1.
    Inferior to the tendon insertion is an area of florid neo-vascularisation that needs to be dissected off the tendon and treated with bipolar diathermy.
    Though the tendon inserts predominantly into the Navicular a number of additional plantar attachments extend distally.
    There is no need to trace the tendon into the sole of the foot for this operation (unlike an FDL tendon transfer for Tibialis posterior reconstruction). The inferior aspect of the Tib Post tendon should always be adhered closely to avoid damage to the posterior Tibial neurovascular bundle if further plantar dissection is required.
    Beneath the medial malleolus at the level of the sustentaculum tali the local anatomy is that the tibialis posterior and flexor digitorum longus sit in separate sheaths , the tibialis posterior above the sustentaculum tali and the FDL immediately beneath it. Inferior again is the flexor hallucis longus and between the two flexors is the neurovascular bundle.

    With the foot supinated and traction upon the tibialis posterior it is evident that there is a tear on the deep tendon surface.
    This should be traced proximally and distally as far as it goes.
    Supination and inversion of the foot produces enough slack at the tendon insertion to also allow inspection of the spring ligament (talo-calcaneo-navicular) ligament. It is a key structure in the support of the medial longitudinal arch and a repair needs to be effected if there is evidence of injury.

    If a tendon tear is identified its surgical management involves its excision back to healthier tissue and placing some longitudinal cuts into the remaining tissue in the base of the tear, running in the line of the tendon fibres.

    The tear is repaired with a running 2.0 Vicryl suture.

    The tendon is described as being retubularised by the repair.
    It is important that the repair produces a good closure with smooth surface contours and that the Vicryl knots are not prominent within the sheath.
    The repair should not be left in any way bulky and the tendon should be seen to “run” well as the foot and ankle are moved through range.

    Attention is now turned back to the tendon above the malleolus.
    The paratenon is not generally a discreet layer to be dissected off here (unlike at the insertion). It is very obviously degenerate with loss of the normal fibrillar pattern seen with healthy tendons.

    Small longitudinal incisions are placed circumferentially around the tendon, in the line of the fibres, into any areas of degenerative change.The extent of degenerative change present in this tendon is not typical for a grade 1 tendinosis. Its extensive nature is more commonly encountered with a grade 2 tendon.
    Whether to close the incisions made into the tendon during debridement depends largely upon the extensiveness of these incisions. The only guide I can give is a few incisions have been used over a smaller section of the tendon then I do not close them. If long and more extensive cuts have been required then I tend to close number of these with running 2.0 Vicryl sutures.

    Operation – 2

    The deep fascia is closed with a combination of running and interrupted Vicryl sutures, followed by skin.
    A drain is not usually required unless a lot of bleeding has been encountered, which is not usual.

    The skin closure used is subcuticular.

    Post Operative

    The first two weeks are spent in a lightweight cast , limited weight bearing
    After two weeks into long post-operative boot and off the shelf semi-rigid orthotic and commence weight bearing using crutches.
    Usually by the end of 4 weeks post op it is comfortable to weight-bear just in the boot without the need for crutches.
    Beyond this an off the shelf semi-rigid orthotic is recommended , used in a tall hiking boot .
    Physiotherapy can commence from 6 weeks and should work on strengthening then proprioceptive rehabilitation.
    Static bike from as soon as the wound permits and cross-training from as soon as adequate balance and proprioceptive capacity has returned
    Light jog on treadmill and sport specific protocols thereafter.
    Of upmost importance through-out the post-operative period is that the wound is looked after . Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoewear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further excacerbate any skin breakdown . Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast

    Recommended Reading

    Treatment of stage I posterior tibial tendon dysfunction with medial soft tissue procedure
    Crates JM, Richardson EG
    Clin Orthop Relat Res. 1999 Aug;(365):46-9.
    11 month follow up of 7 patients , 6 asymptomatic and 1 had progressive deformity /pathology requiring FDL transfer and lateral column lengthening.
    Surgical treatment of stage I posterior tibial tendon dysfunction.
    Foot Ankle Int 1994 Dec;15(12):646-8.
    Teasdall RD, Johnson KA
    19 patients treated by synovectomy and tendon debridement.
    90% total relief of symptoms or minor pain only and in whom tendon function returned.
    1 patient with moderate and 1 with severe pain (with progressing flat foot deformity) proceeded to subtalar fusion .
    Tendoscopy in stage 1 posterior tibial tendon dysfunction
    Foot Ankle Clin. 2012 Sept;17(3):399-406.
    Khazen G, Khazen C
    The technique is described but also the need to revert to open operation if a tear is encountered

    Reference

    • orthoracle.com

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