Endoscopically Assisted Reconstruction of Posterior Tibial Tendon for Stage 2 Posterior Tibial Tendon Dysfunction Zhuohao Chow Liang, B.B.C., Tun Hing Lui, M.B.B.S. (H.K.), F.R.C.S. (Edin.), F.H.K.A.M., F.H.K.C.O.S. Arthroscopy Techniques Volume 8, Issue 3, Pages e237-e243 (March 2019) DOI: 10.1016/j.eats.2018.10.019 Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 1 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. The patient is in the supine position with the legs spread. (A) Posterior tibial tendoscopy is performed with the proximal portal as the viewing portal and the distal portal as the working portal. (B) Endoscopic synovectomy is performed. (DPp, distal portal for posterior tibial tendoscopy; IS, inflamed synovium; PPp, proximal portal for posterior tibial tendoscopy; PTT, posterior tibial tendon.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 2 Endoscopically assisted reconstruction of PTT for stage 2 PTT dysfunction of left foot. The patient is in the supine position with the legs spread. Posterior tibial tendoscopy is performed with an arthroscope: the distal portal is the viewing portal, and the proximal portal is the working portal. The Sm between the PTT and FDL tendon is released by an arthroscopic shaver. (FDL, flexor digitorum longus; PTT, posterior tibial tendon; Sm, septum.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 3 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. The patient is in the supine position with the legs spread. (A) Anterior tibial tendoscopy is performed via the distal portal. The ATT is traced proximally to its musculotendinous junction, marked by the arthroscopic light spot (arrowhead). (B) Endoscopic view shows the ATT under the ER. (C) A 1-cm incision is made at this point. The ATT is split, the medial half is cut, and a stay stitch is applied with a No. 1 Vicryl suture. (D) The ATTg is stripped distally to the DPa with a TS. (E) The ATT is sutured with a No. 2 Ultrabraid suture (arrowhead) at the DPa to prevent further splitting of the tendon. The ATTg is retrieved to the DPa. (ATT, anterior tibial tendon; ATTg, split ATT graft; DPa, distal portal for anterior tibial tendoscopy; ER, extensor retinaculum; TS, tendon stripper.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 4 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. The patient is in the supine position with the legs spread. (A) The PTT is pierced by a pointed TP at the DPp. (B) The TP is advanced to the DPa, and the stay stitch of the ATTg is grasped. (C) The graft is then transferred to the DPp and passed through the PTT. The ATTg is tensioned, and the intersection between the PTT and the graft is sutured with a No. 2 Ultrabraid suture (arrowhead). (ATTg, split anterior tibial tendon graft; DPp, distal portal for posterior tibial tendoscopy; PPp, proximal portal for posterior tibial tendoscopy; PTT, posterior tibial tendon; TP, tendon passer.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 5 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. The patient is in the supine position with the legs spread. (A) Posterior tibial tendoscopy is performed with the proximal portal as the viewing portal and the distal portal as the working portal. (B) The PTT is cut proximal to the sutured site of ATTg to the PTT with Supercut scissors. (ATTg, split anterior tibial tendon graft; DPp, distal portal for posterior tibial tendoscopy; PPp, proximal portal for posterior tibial tendoscopy; PTT, posterior tibial tendon; S, Supercut scissors.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 6 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. The patient is in the supine position with the legs spread. (A) The PTT stump is retrieved to the PPp. (B) The ATTg is transferred to the PPp and weaved to the PTT proximal to the diseased tendon segment in the Pulvertaft manner with a No. 2 Ultrabraid suture. The tendons are tensioned, and the foot is plantarflexed and inverted during the repair. (ATTg, split anterior tibial tendon graft; DPp, distal portal for posterior tibial tendoscopy; PPp, proximal portal for posterior tibial tendoscopy; PTT, proximal posterior tibial tendon.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 7 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 PTT dysfunction of left foot. The patient is in the supine position with the legs spread. The FDL tendon is retrieved to the proximal portal for posterior tibial tendoscopy by using a hemostat. The tendon is side-by-side sutured to the ATTg-PTT construct with a No. 2 Ultrabraid suture. The foot is plantarflexed and inverted, and the lesser toes are dorsiflexed during the repair. (ATTg, split anterior tibial tendon graft; FDL, flexor digitorum longus; PTT, posterior tibial tendon.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 8 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. The patient is in the supine position with the legs spread. (A) A GW is inserted into the ST and tarsal canal. (B) The ST is dilated with a cannulated D. (C) A Prostop AI is inserted into the sinus tarsi. (AI, arthroereisis implant; C, calcaneus; D, dilator; GW, guidewire; ST, sinus tarsi; T, talus.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions
Fig 9 Endoscopically assisted reconstruction of posterior tibial tendon for stage 2 posterior tibial tendon dysfunction of left foot. (A) Preoperative standing lateral radiograph of the illustrated case shows flatfoot deformity with talonavicular sag. (B) Postoperative standing lateral radiograph shows correction of the deformity. (AI, Prostop arthroereisis implant; C, calcaneus; N, navicular bone; T, talus.) Arthroscopy Techniques 2019 8, e237-e243DOI: (10.1016/j.eats.2018.10.019) Copyright © 2018 Arthroscopy Association of North America Terms and Conditions