Limits...
Posterior tibialis tendon transfer via the circumtibial route: a cadaveric limb analysis.

Xu J, Geng X, Muhammad H, Ma X, Wang X, Huang J, Zhang C - J Orthop Surg Res (2014)

Bottom Line: The lengths of "ab," "ac," "ad," and "ae" were measured and compared at different height levels above the distal tip of the medial malleolus.The lengths of ac, ad, and ae were significantly less than the length of ab (p < 0.05).These angles were not significantly different from those at a height of 11 cm (p >0.05).

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedics, Huashan Hospital, Fudan University, No,12, Middle Wulumuqi Road, Shanghai 200040, China. maxinhuashan@yeah.net.

ABSTRACT

Background: Studies have yet to determine the optimal height at which the posterior tibial tendon (PTT) can be re-routed and the tendon length discrepancy at different height levels in terms of PTT transfer via the circumtibial route. This cadaveric study was conducted to determine the optimal height of PTT subcutaneous transfer and to compare tendon length discrepancies at different heights.

Materials and methods: Twenty-five fresh normal cadaveric lower legs were used for measurements. PTT was exposed and then isolated. An incision along the calf was made to re-route PTT outside the fascia. The upper edge of the incision was classified as point "a." The distal tip of the tendon was classified as point "b." The midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid were defined as points "c," "d," and "e," respectively. The lengths of "ab," "ac," "ad," and "ae" were measured and compared at different height levels above the distal tip of the medial malleolus. Angles α, β, and γ between the tendon outside the fascia connecting to different bones and the tendon inside the fascia were also measured as tendons were transferred at different bones and different height levels. Experimental data were collected and analyzed.

Results: At a height of ≥5 cm, all of the PTTs could reach the midpoints of the three bones. The lengths of ac, ad, and ae were significantly less than the length of ab (p < 0.05). At a height of 10 cm, angles α, β, and γ were 177° ± 2.1°, 170° ± 3.1°, and 164° ± 3.7°, respectively. These angles were not significantly different from those at a height of 11 cm (p >0.05).

Conclusions: PTT transfer via the subcutaneous route could achieve an adequate length to be transferred to the intermediate cuneiform, the lateral cuneiform, and the cuboid from a height of 5 cm above the distal tip of the medial malleolus. A height of 10 cm could be optimal for PTT transfer in the three bones via the subcutaneous route.

Show MeSH

Related in: MedlinePlus

Procedures used to expose and isolate the PTT. (A) With a 2-cm medial incision, the tendon was divided at its insertion to the navicular region, preserving as much length as possible. (B) The distal tip of the medial malleolus was confirmed with a small screw as a marker. (C) A second 2-cm long incision posterior to the medial region of the tibial crest was made along the fascia of the calf, where the upper edge was 3 cm proximal to the distal tip of the medial malleolus. (D) PTT was isolated and then re-routed.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4255935&req=5

Fig1: Procedures used to expose and isolate the PTT. (A) With a 2-cm medial incision, the tendon was divided at its insertion to the navicular region, preserving as much length as possible. (B) The distal tip of the medial malleolus was confirmed with a small screw as a marker. (C) A second 2-cm long incision posterior to the medial region of the tibial crest was made along the fascia of the calf, where the upper edge was 3 cm proximal to the distal tip of the medial malleolus. (D) PTT was isolated and then re-routed.

Mentions: The legs were placed in neutral positions by implanting a steinmann pin from the calcaneous through the talus to the tibia. The angle of ankle dorsiflexion is kept at 0° in the horizontal plane. Then the skin was removed meticulously to simulate subcutaneous PTT transfer. At a 2-cm medial incision on the skin of navicular tuberosity, the tendon was divided at its insertion to the navicular region, but the length was maintained as much as possible, although osseous materials were retained (Figure 1A). The distal tip of the medial malleolus was confirmed using a small screw as a marker (Figure 1B). A second incision with a length of 2 cm and posterior to the medial aspect of the tibial crest was made along the medial fascia of the calf, in which the upper edge was 3 cm proximal to the distal tip of the medial malleolus (Figure 1C). Underneath the medial fascia, the PTT was isolated and retrieved; no tendinosis was found in all of the specimens. The PTT was white, hard, and tough; no adhesion was observed. The PTT was re-routed (Figure 1D). The X-ray machine was then used to determine the midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid (Figure 2A, B, C), which were also marked using an X-ray. In this study, the point of the upper edge of the second incision was classified as point “a” to describe the length for comparison. This point can be changed according to different height levels for transfer. The distal end of the tendon was classified as point “b.” The midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid were defined as points “c,” “d,” and “e,” respectively (Figure 3A). PTT was then re-routed to reach the midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid by applying 10 N pre-tension; during this procedure, the limb was placed in a neutral position (Figure 3B, C). We fixed one end of a suture to the point of “a,” then pulled this suture to the points of “b,” “c,” “d” and made makers on the suture, respectively. The lengths of “ab,” “ac,” “ad,” “ae” were measured by determining the length of part of the suture which began from one end to the marker points, respectively. All the lengths of “ab,” “ac,” “ad,” and “ae” were individually measured. If the length of PTT was sufficient to reach the midpoints of the three bones, an angle was measured between the tendon outside the fascia connecting to the different bones and inner layers. To prevent the muscle-tendon force distribution, we placed the line of pull as close to the vertical line as possible. To measure the angle produced by tendon bifurcation at the tibial surface, we put a suture in the middle surface along the tendon. Then the angles produced by the suture bifurcation were measured by a protractor. The angle scan was used to determine the extent of the distributed force. Angles were denoted as α, β, and γ for the intermediate cuneiform, the lateral cuneiform, and the cuboid, respectively. After the angles at 3 cm to the distal tip of the medial malleolus were measured, the incision was extended upward in incrementing intervals of 1 cm.Figure 1


Posterior tibialis tendon transfer via the circumtibial route: a cadaveric limb analysis.

Xu J, Geng X, Muhammad H, Ma X, Wang X, Huang J, Zhang C - J Orthop Surg Res (2014)

Procedures used to expose and isolate the PTT. (A) With a 2-cm medial incision, the tendon was divided at its insertion to the navicular region, preserving as much length as possible. (B) The distal tip of the medial malleolus was confirmed with a small screw as a marker. (C) A second 2-cm long incision posterior to the medial region of the tibial crest was made along the fascia of the calf, where the upper edge was 3 cm proximal to the distal tip of the medial malleolus. (D) PTT was isolated and then re-routed.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4255935&req=5

Fig1: Procedures used to expose and isolate the PTT. (A) With a 2-cm medial incision, the tendon was divided at its insertion to the navicular region, preserving as much length as possible. (B) The distal tip of the medial malleolus was confirmed with a small screw as a marker. (C) A second 2-cm long incision posterior to the medial region of the tibial crest was made along the fascia of the calf, where the upper edge was 3 cm proximal to the distal tip of the medial malleolus. (D) PTT was isolated and then re-routed.
Mentions: The legs were placed in neutral positions by implanting a steinmann pin from the calcaneous through the talus to the tibia. The angle of ankle dorsiflexion is kept at 0° in the horizontal plane. Then the skin was removed meticulously to simulate subcutaneous PTT transfer. At a 2-cm medial incision on the skin of navicular tuberosity, the tendon was divided at its insertion to the navicular region, but the length was maintained as much as possible, although osseous materials were retained (Figure 1A). The distal tip of the medial malleolus was confirmed using a small screw as a marker (Figure 1B). A second incision with a length of 2 cm and posterior to the medial aspect of the tibial crest was made along the medial fascia of the calf, in which the upper edge was 3 cm proximal to the distal tip of the medial malleolus (Figure 1C). Underneath the medial fascia, the PTT was isolated and retrieved; no tendinosis was found in all of the specimens. The PTT was white, hard, and tough; no adhesion was observed. The PTT was re-routed (Figure 1D). The X-ray machine was then used to determine the midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid (Figure 2A, B, C), which were also marked using an X-ray. In this study, the point of the upper edge of the second incision was classified as point “a” to describe the length for comparison. This point can be changed according to different height levels for transfer. The distal end of the tendon was classified as point “b.” The midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid were defined as points “c,” “d,” and “e,” respectively (Figure 3A). PTT was then re-routed to reach the midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid by applying 10 N pre-tension; during this procedure, the limb was placed in a neutral position (Figure 3B, C). We fixed one end of a suture to the point of “a,” then pulled this suture to the points of “b,” “c,” “d” and made makers on the suture, respectively. The lengths of “ab,” “ac,” “ad,” “ae” were measured by determining the length of part of the suture which began from one end to the marker points, respectively. All the lengths of “ab,” “ac,” “ad,” and “ae” were individually measured. If the length of PTT was sufficient to reach the midpoints of the three bones, an angle was measured between the tendon outside the fascia connecting to the different bones and inner layers. To prevent the muscle-tendon force distribution, we placed the line of pull as close to the vertical line as possible. To measure the angle produced by tendon bifurcation at the tibial surface, we put a suture in the middle surface along the tendon. Then the angles produced by the suture bifurcation were measured by a protractor. The angle scan was used to determine the extent of the distributed force. Angles were denoted as α, β, and γ for the intermediate cuneiform, the lateral cuneiform, and the cuboid, respectively. After the angles at 3 cm to the distal tip of the medial malleolus were measured, the incision was extended upward in incrementing intervals of 1 cm.Figure 1

Bottom Line: The lengths of "ab," "ac," "ad," and "ae" were measured and compared at different height levels above the distal tip of the medial malleolus.The lengths of ac, ad, and ae were significantly less than the length of ab (p < 0.05).These angles were not significantly different from those at a height of 11 cm (p >0.05).

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedics, Huashan Hospital, Fudan University, No,12, Middle Wulumuqi Road, Shanghai 200040, China. maxinhuashan@yeah.net.

ABSTRACT

Background: Studies have yet to determine the optimal height at which the posterior tibial tendon (PTT) can be re-routed and the tendon length discrepancy at different height levels in terms of PTT transfer via the circumtibial route. This cadaveric study was conducted to determine the optimal height of PTT subcutaneous transfer and to compare tendon length discrepancies at different heights.

Materials and methods: Twenty-five fresh normal cadaveric lower legs were used for measurements. PTT was exposed and then isolated. An incision along the calf was made to re-route PTT outside the fascia. The upper edge of the incision was classified as point "a." The distal tip of the tendon was classified as point "b." The midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid were defined as points "c," "d," and "e," respectively. The lengths of "ab," "ac," "ad," and "ae" were measured and compared at different height levels above the distal tip of the medial malleolus. Angles α, β, and γ between the tendon outside the fascia connecting to different bones and the tendon inside the fascia were also measured as tendons were transferred at different bones and different height levels. Experimental data were collected and analyzed.

Results: At a height of ≥5 cm, all of the PTTs could reach the midpoints of the three bones. The lengths of ac, ad, and ae were significantly less than the length of ab (p < 0.05). At a height of 10 cm, angles α, β, and γ were 177° ± 2.1°, 170° ± 3.1°, and 164° ± 3.7°, respectively. These angles were not significantly different from those at a height of 11 cm (p >0.05).

Conclusions: PTT transfer via the subcutaneous route could achieve an adequate length to be transferred to the intermediate cuneiform, the lateral cuneiform, and the cuboid from a height of 5 cm above the distal tip of the medial malleolus. A height of 10 cm could be optimal for PTT transfer in the three bones via the subcutaneous route.

Show MeSH
Related in: MedlinePlus