Foot and Ankle Clinics Volume A Refined Classification System
Foot and Ankle Clinics Volume A Refined Classification System
Foot and Ankle Clinics Volume A Refined Classification System
12 (2007) 233249
* Corresponding author.
E-mail address: [email protected] (E.M. Bluman).
1083-7515/07/$ - see front matter 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.fcl.2007.03.003
foot.theclinics.com
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Table 1
Classication of posterior tibial tendon rupture
Normal anatomy
Tenderness along PTT
Normal
Normal anatomy
Tenderness along PTT
Slight HF valgus
Tenderness along PTT
Normal
C
II
Slight HF valgus
A1
Supple HF valgus
Flexible forefoot varus
Possible pain along PTT
HF valgus
Mearys line disruption
Loss of calcaneal pitch
A2
Supple HF valgus
Fixed forefoot varus
Possible pain along PTT
Supple HF valgus
Forefoot abduction
HF valgus
Mearys line disruption
Loss of calcaneal pitch
HF valgus
Talonavicular uncovering
Forefoot abduction
Treatment
Immobilization NSAIDs Cryotherapy Orthoses
Tenosynovectomy
Systemic disease-specic pharmacotherapy
Immobilization NSAIDs Cryotherapy Orthoses
Tenosynovectomy
Immobilization NSAIDs Cryotherapy Orthoses
Tenosynovectomy
Orthoses
Med. displ. calc. osteot.
TAL or Strayer and FDL transf. if deformity
corrects only with ankle plantarexion
Orthoses
Med. displ. calc. osteot. and FDL transf.
Cotton osteoectomy
Orthoses
Med. displ. calc. osteot. and FDL transf.
Lateral column lengthening
et al
Most characteristic
radiographic ndings
Substage
BLUMAN
Most characteristic
clinical ndings
Stage
III
Supple HF valgus
Fixed forefoot varus
Medial column instability
First ray dorsiexion with
HF correction
Sinus tarsi pain
HF valgus
First TMT plantar gapping
Rigid HF valgus
Pain in sinus tarsi
Rigid HF valgus
Forefoot abduction
Pain in sinus tarsi
Tibiotalar valgus
HF valgus
Tibiotalar valgus
HF valgus
Abbreviations: HF, hind foot; FDL transf., exor digitorum longus transfer; med. displ. calc. osteot., medial displacement calcaneal osteotomy; NSAID,
nonsteroidal anti-inammatory drugs; PTT, posterior tibial tendon; TAL, tendo Achilles lengthening; TMT, tarsometatarsal joint; TTC, tibiotalocalcaneal.
IV
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a fourth stage that involves valgus tilting of the ankle joint within the mortise and associated deltoid ligament insuciency with or without lateral
tibiotalar arthritis. Treatment for stage IV disease is determined by the
presence of ankle arthritis and the ability to reduce the deformity. Treatment of stage IV generally consists of arthrodesis [1,6,7] or a foot realignment with deltoid reconstruction [810].
Since Johnson and Stroms initial 1989 classication, an increasingly
complex array of deformities of the foot has been recognized in association
with PTTR. This wide spectrum of deformity is not completely addressed
by the current classication system. Further, the existing system does not
leave sucient room for variation within a given treatment stage. For example, there are a myriad of treatment options for stage II disease. This reects the wide variation in medial ray hypermobility, forefoot abduction,
and forefoot varus seen in patients grouped together as having a exible
atfoot.
We believe that a more comprehensive classication system that
addresses the diversity of the adult acquired atfoot deformity is necessary.
This scheme should take into account ankle and hindfoot valgus, forefoot
supination, forefoot abduction, and medial column instability. Accordingly,
we now present and discuss a new classication for PTTR based on the clinical experiences of the senior author (MSM). It is not the authors intention
to propose the ideal surgical correction for each deformity encountered. It is
our hope, however, that this revised classication assists the foot and ankle
surgeon in planning treatment for the varied, complex problem of adult acquired atfoot deformity. Although we suggest treatment alternatives based
on these stages and its subcategories, a range of surgical alternatives given
the exact stage of deformity is available, many of which we have limited
experience with and we therefore do not discuss. We maintain the existing
Myerson modication to the Johnston and Strom scheme and use it as a general outline into which we have subdivided a more descriptive and comprehensive system. Table 1 summarizes the rened classication, including
pertinent ndings and suggestions for treatment for each of the described
stages.
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foot inversion strength with the foot plantarexed. Stage I is subdivided into
three categories:
A. Inammatory disease. PTT inammation or rupture secondary to systemic disease, such as rheumatoid arthritis and the other inammatory
arthritides, is recognized as a separate entity [12]. In stage I-A, hindfoot
anatomy is maintained and the foot alignment is normal. Treatment
consists of conservative nonoperative care [13] or tenosynovectomy [14].
B. Partial PTT tear with normal hindfoot anatomy. Although the etiology is
separate from stage I-A, similar treatment with conservative nonoperative care or tenosynovectomy is recommended.
C. Partial PTT tear with minor hindfoot valgus. There is slight (5 or less)
hindfoot valgus deformity to distinguish this from stage II disease.
Although the authors still begin with conservative treatment of antiinammatory medications and immobilization in a cast, walking boot,
or custom brace, stage I-C may represent incipient rupture and should
be monitored closely. If surgery is performed, in addition to a tenosynovectomy a medial translational osteotomy of the calcaneus should be
considered [15].
Stage II: ruptured posterior tibial tendon, exible atfoot
The presence of stage II disease implies signicant PTT attenuation or
frank rupture as evidenced on physical examination by a clinically apparent
atfoot deformity, inversion weakness of the plantarexed foot, and inability to perform a single or repetitive heel rise. Stage II disease is subdivided
into three categories (with the rst further subdivided into two subcategories), depending on the most salient feature present. Because some patients exhibit several of the following features, some degree of overlap
may exist.
A. Hindfoot valgus. In stage II-A, the salient feature is valgus deformity of the
hindfoot (Fig. 1A, B). Once the heel is reduced from valgus to neutral,
there are varying degrees of residual forefoot supination. This supination
is caused by accommodative changes that allow the medial and lateral columns of the forefoot to remain in contact with the ground in the setting of
hindfoot valgus. The forefoot supination may be minimal or reducible
(stage II-A-1) or xed (stage II-A-2). Nonoperative treatment typically involves an inverted, medially posted foot orthosis or a custom brace [13,16].
The authors preferred operative treatment for stage II-A consists of a medial displacement calcaneal osteotomy and FDL tendon transfer to the navicular (Fig. 1C, D) [17,18]. As an alternative to calcaneus osteotomy an
arthroereisis may be considered. Treatment does not end here, however;
the deformity may have pulled the forefoot into varus, and this needs to
be assessed and dealt with as follows:
1. Flexible forefoot varus. In stage II-A-1, reducing the hindfoot from
valgus to neutral results in forefoot varus (Fig. 2). The forefoot
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Fig. 1. Radiographic stage II-A, or exible atfoot with hindfoot valgus. Preoperative lateral
(A) and AP (B) views. Lateral (C) and AP (D) views of the same patient after medial displacement calcaneal osteotomy and exor digitorum longus to navicular transfer.
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Fig. 2. Forefoot varus associated with acquired atfoot deformity. (A) Appearance of forefoot
with uncorrected hindfoot deformity. (B) Manual correction of the hindfoot valgus reveals residual forefoot varus. This forefoot deformity may be exible or rigid.
supination deformity. Typically this is performed with corticocancellous allograft, and internal xation for this stable osteotomy is rarely
used.
B. Forefoot abduction. Abduction of the forefoot (stage II-B) is commonly
observed in conjunction with the hindfoot valgus that characterizes stage
II-A deformity (Fig. 3A, B). The forefoot abduction may occur at the
transverse tarsal joint (most commonly) or at the rst tarsometatarsal
(TMT) joint, and occasionally at both complexes. First TMT joint instability can be a primary deformity or secondary to TMT joint arthritis.
The simplest way to determine this distinction is examination of the lateral foot radiograph for the presence of a gap at the plantar joint surface;
this gap may be associated with primary deformity of the rst TMT
joint, which may then result in secondary hindfoot deformity, including
rupture of the PTT. Forefoot abduction occurring through the transverse tarsal joint is easily evaluated by way of an anteroposterior (AP)
foot radiograph. Abduction through this joint manifests as talar head
uncovering (Fig. 3B) and can be quantied with the anteroposterior talar
head uncoverage angle or by percent of the talar head uncovered [20].
Talar head uncovering of greater than 40% warrants consideration for
performance of a lateral column lengthening procedure.
Surgical treatment of stage II-B deformity consists of an FDL transfer
plus the addition of a lateral column lengthening to correct the forefoot abduction (Fig. 3C, D). It is recommended that the lateral column lengthening
be incorporated into the surgical plan if talar head uncovering is greater
than 40%. Uncoverage of lesser magnitude is corrected adequately with
a medializing calcaneal osteotomy and tendon transfer. A lateral opening
wedge osteotomy in the calcaneus is created 1.5 cm posterior to the calcaneocuboid joint, held open with corticocancellous allograft, and stabilized
with a single 5.0-mm screw from anterior to posterior. A medializing
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Fig. 3. Pre- and postoperative roentgenogram views of stage II-B disease corrected with a lateral
column lengthening and an opening wedge medial cuneiform osteotomy. (A) Preoperative lateral view demonstrating loss of medial arch height. Note the minimal hindfoot valgus. (B) Preoperative AP view of the same patient shows talar head uncovering of approximately 40%. (C)
Postoperative lateral view shows restoration of the medial column height. Bone blocks are used
to hold the lateral column and medial cuneiform osteotomies open. A fully threaded position
screw gives xation and aids in the maintenance of the lateral column lengthening. Fixation
of the medial cuneiform osteotomy is usually not needed. (D) Correction of the talonavicular
uncovering is evident in the postoperative anteroposterior view of the foot. In (C) and (D)
the arrowhead demonstrates the medial cuneiform opening wedge osteotomy bone block, and
the arrow points to the bone block in the anterior process of the calcaneus.
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C. Medial ray instability. The most salient component in stage II-C disease
is medial ray instability. As with the stage II-A-2 foot (xed forefoot
supination), the stage II-C foot tends to retain forefoot varus even
with reduction of the heel from valgus to neutral, and even then with ankle plantarexion. This is caused by medial column instability (Fig. 4A,
B). It may arise from any component: the talonavicular, naviculocuneiform, medial cuneiform-rst metatarsal joint (rst TMT), or any combination thereof. After correcting the heel to neutral, the unstable medial
ray tends to dorsiex, causing the foot to pronate with weight bearing,
and leads to painful subtalar impingement. Additional treatment consisting of arthrodesis of the pathologic component of the medial column
may be warranted (Fig. 4C, D) provided that the rst TMT joint is
unstable. A medial cuneiform opening wedge osteotomy (as described
under stage II-A-2) also corrects medial column instability. The decision
Fig. 4. Stage II-C, or exible atfoot with medial column instability. (A) Preoperative lateral
view. Gap at plantar aspect of rst tarsometatarsal joint is shown by arrowhead. (B) Preoperative AP roentgenogram demonstrating forefoot abduction with talar head uncovering. (C)
Postoperative lateral view showing restoration of arch height and TMT fusion to correct gapping and instability of joint. (D) Postoperative anteroposterior view showing correction of talar
rst metatarsal angle, rst TMT fusion, and lateral column lengthening.
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Fig. 5. Pre- and postoperative roentgenograms of severe stage III PTTR. (A) Lateral view
shows severe hindfoot valgus, talonavicular subluxation, and loss of medial arch. (B) AP
view of the same patient demonstrating greater than 50% uncovering of talar head. (C) AP
weightbearing view of the ankle demonstrates that despite severe hindfoot valgus there is no
tibiotalar joint deformity. (D) Lateral view after triple arthrodesis shows correction of talar declination angle and restoration of medial arch height. (E) Postoperative AP view of the foot
shows correction of talonavicular coverage angle.
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Fig. 6. Stage IV-A hindfoot valgus secondary to under-corrected triple arthrodesis with exible
tibiotalar valgus tilting. Preoperative lateral foot Roentgenogram of the foot (A) demonstrates
under-corrected medial longitudinal arch from a prior triple arthrodesis. An AP view of the
ankle (B) shows severe tibiotalar valgus tilting without substantial erosive changes of the joint.
A revision triple arthrodesis was performed with reconstruction of the ruptured deltoid
ligament. Postoperative lateral (C) Roentgenogram of the foot demonstrates restoration of
the arch. Tibiotalar joint correction is shown in (D). Although the use of soft tissue anchors
to aid in reconstruction of the deltoid is shown the authors have found the use of allograft
for such reconstructions to be more durable.
This article has taken the original Johnson and Strom [2] classication for
PTT rupture and revised it into a more comprehensive and discriminating
system encompassing the various presentations seen within each stage.
The purpose is ultimately to make treatment decisions more rational and individualized to each patients particular anatomic pathology. The clinical
applicability of any classication system depends to a large extent on its usefulness in planning treatment, and it is with this goal in mind that the authors have proposed this system.
The most obvious expansion is with stage II disease. From the standpoint
of foot morphology seen, this has typically been the most heterogeneous
group of patients, with surgical decision making being made more dicult.
It has been the authors experience that a exible atfoot (stage II) typically
has a combination of one or more of the following features: hindfoot valgus,
forefoot abduction, forefoot varus, or medial column instability. Depending
on which is the most salient feature, there may be some variability in the
optimal treatment choice.
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Fig. 7. Stage IV-A rigid hindfoot valgus with exible tibiotalar valgus tilting. (A) Preoperative
lateral. (B) Preoperative AP. (C) Preoperative AP ankle. (D) Preoperative uoroscopy showing
passive correction of valgus tibiotalar tilt. (E) Postoperative lateral foot. (F) Postoperative AP
foot. (G) Postoperative AP ankle. Allograft tendon with soft tissue interference screws was used
for deltoid reconstruction in this patient.
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Fig. 8. Stage IV-B rigid hindfoot valgus with rigid tibiotalar valgus tilting. Preoperative lateral
(A) and AP (B) roentgenograms show severe hindfoot valgus and loss of arch height. Preoperative AP ankle view (C) shows severe rigid tibiotalar valgus deformity with substantial arthritis.
Postoperative lateral (D) and AP ankle view (E) shows correction obtained with tibiocalcaneal
fusion with retrograde intramedullary xation.
Stage IV in particular is an interesting problem in its etiology. Some patients who have stage IV disease have had a previous triple arthrodesis. Fitzgibbons addressed the question of whether the ankle deformity is secondary
to increased valgus moment produced by the triple arthrodesis or to natural
progression of disease [30]. At least two groups have performed experiments
demonstrating increased strain in the deltoid ligament complex of posterior
tibial tendon decient cadavers that had undergone triple arthrodesis [5,31].
Although some investigators have reported that the rigid tibiotalar valgus
of stage IV is more frequently encountered than the correctable form, the
incidences of these two substages may depend on the timing of patient
presentation and referral patterns to the foot and ankle surgeon. Tibiotalar
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Summary
With time we have become aware of a greater variety of presentations of
PTT pathology and thus have recognized the deciencies associated with the
initial generic three-stage PTTR classication. This newly proposed
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classication system should not only improve the clinicians awareness and
discrimination of the spectrum of disorders associated with PTT rupture,
but also help in planning the proper treatment.
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