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Orthopaedic Surgery Foot
Table 1: Classification of Degenerative Pes Planus Valgus with Posterior Tibia Tendinopathy According to Johnson and Strom, and
Intra-operative Correspondence of Glenoid and Posterior Tibial Lesions
Patient Code Johnson Classification Glenoid Lesion Posterior Tibial Lesion
90F837PVA I Malacic Tenovaginitis
90F819CLF I Malacic Tenovaginitis
93F3576CGL III Fissuration throughout the entire thickness Tenovaginitis with thickening
96F7299GLT II Fissuration throughout the entire thickness Tenovaginitis
97F8207VLP III Malacic Tenovaginitis
97F7871SLM II Fissuration throughout the entire thickness Macroscopically normal PT
97F7721SVN II Fissuration not involving the entire thickness Fissurative tendonopathy
92F8617PNT III Malacic with cartilagineous exfoliation Tenovaginitis with thickening
01F11626DMR III Complete glenoid fracture with plantar dislocation Tenovaginitis
00F11102FGL I Malacic Tenovaginitis
01F11846ZCC II Fissuration throughout the entire thickness Tenovaginitis with thickening
00F11425MSL III Fissuration throughout the entire thickness Fissurative tenovaginitis
00F11425MSL III Fissuration throughout the entire thickness Tenovaginitis with thickening
Figure 1: Coxa Pedis
appearing for surgery with a clinical diagnosis of chronic posterior tibial
tendonopathy. One case was treated bilaterally (see Table 1). There was a
A
net female prevalence (10 of 12) and patients were aged between 26 and
79 years, with a mean of age 56 years. Only three cases reported a
traumatic sprain at onset; one of these cases was in eversion. No patients
suffered from either dysmetabolic or systemic inflammatory diseases. Two
patients were under drug treatment for hypertension. The symptoms had
set in over the past few months with a mean duration of 12 months
(ranging from one month to 10 years). All patients presented medial
tarsalgia; five had concomitant painful tarsal sinus and lateral posterior
subtalar symptoms. The 13 feet were classified pre-operatively according
to Johnson and Strom’s table
1
in the picture of posterior tibial tendon
dysfunction by focusing on various development stages: stage I – pain and
swelling along the distal tract of the posterior tibial tendon with neither
deformities nor radiographical signs of skeletal alterations and symmetrical
B
digitigrade inversion of the hindfoot; stage II – deformity with valgus
eversion, positivisation of the ‘too many toes sign’ and diminished or
absent digitigrade inversion of the foot; deformity can still be passively
reduced; stage III – degenerative and articular subtalar and Chopart
radiographical alterations with a deformity (see Figure 2) that cannot be
further reduced; tibiotarsal valgus deformity with radiographical
alterations during the transition to stage IV. Three feet were classified as
stage I, four as stage II and six as stage III (see Table 1).
Most patients had undergone medical and physical treatment before
surgery, and cortisone infiltrations were administered along the posterior
tibial tendon in one case of stage III deformity. Intra-operative findings
reported six cases of glenoid malacia, defining it as loss of the normal sheen
of fibrocartilaginous tissue, which appeared softened on palpation with
either fissurative lesions that did not involve the entire thickness or a groove
on the accessory navicular bone. One case associated an exfoliative lesion
of the glenoid surface coated with hyaline cartilage that articulates with the
A: skeletal components; B: fresh specimen, evident acetabulum and epiphysis components.
talar head. In cases of lesions involving the entire thickness, intra-operative
the gastrocnemius–soleus complex partly loses its action on the metatarsal findings reported fissuration of the medial surface corresponding to the
region and, by inducing talonavicular hyperextension, maintains calcaneal superomedial calcaneonavicular ligament (see Figure 3) and even massive
valgism due to its lateral action and progressive retraction. The evolution tearing in stage III. In cases of clinical deformity resulting from valgus
leads to deformity with valgus eversion of the foot typical of degenerative eversion, intra-operative findings reported glenoid interruption, except for
pes planus in the adult. one case in which the glenoid was only malacic. In all cases, posterior tibial
tendon continuity was preserved with signs of tendovaginitis and exudative
Materials and Methods build-up in the sheath. The tendon had thickened in four stage III cases,
Between 1990 and 2001, 12 patients with a glenoid lesion (with no and one stage II case presented fissurative tendinopathy. The accessory
tendon injuries) of the coxa pedis were identified among patients navicular bone was found in eight of 13 cases (61%).
72 EUROPEAN MUSCULOSKELETAL REVIEW
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