Nonoperative Therapy

Nonoperative therapy (Table 68-1) is an appropriate initial intervention in almost all cases of PTTD. The goals of treatment are pain relief and the return of PTT function when possible. In a flexible deformity, the aim is to control the progressive valgus deformity of the hindfoot. In a rigid deformity, the goal is to support the position of the foot in situ with a brace that accommodates the bony deformities. In addition, symptomatic relief can be addressed with the use of nonsteroidal anti-inflammatory drugs, activity modification, and encouraging weight loss.

Few studies exist on the nonoperative treatment of PTT dysfunction, but it is believed that a well-fitted, custom-molded orthosis can be effective at relieving symptoms, and can delay and sometimes prevent surgical intervention⁶ (Level of Evidence V). Chao and colleagues⁷ performed a study of 49 patients with the diagnosis of PTTD treated with either a molded ankle-foot orthosis (AFO) or University of California Biomechanics Laboratory (UCBL) brace with medial posting (Level IV). Nonobese patients with flexible deformities and less than 10-degree residual forefoot varus with the heel in a neutral position received the UCBL brace. The remaining patients received the molded AFO. In total, 40 feet were treated with a molded AFO, and 13 were treated with a UCBL brace. Patients were divided into three groups based on a functional scoring system, and 67% of patients were found to have excellent to good results. Unfortunately, this study cannot be used to make a comparison between different disease stages because of the nonuniformity of treatment.

Augustin and coworkers⁶ studied the nonoperative treatment of various stages of PTTD with an Arizona AFO brace, a custom-molded leather and polypropylene orthosis (Level IV). Twenty-one patients with PTTD were evaluated just before brace use and after a minimum of 3 months of use using questionnaires and clinical examination. American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scores, Foot Function Index scores, and 36-Item Short Form Health Survey (SF-36) scores all increased significantly except for the change in health perception area of the SF-36. Six of six patients with stage I PTTD showed improvement attributable to the brace. The authors suggest that the Arizona AFO brace is effective at relieving symptoms and either obviating or delaying any surgical intervention, especially in earlier stages. Further studies are needed to determine whether an orthosis can prevent disease progression together with providing symptomatic relief.

Alvarez and coauthors⁸ studied the treatment of stage I and II PTTD in 47 patients with a nonoperative management protocol consisting of physical therapy, an aggressive home exercise program, and an orthosis (Level IV). Over a 4-month period, 39 (83%) patients had successful subjective and functional outcomes, and 42 (89%) patients were satisfied, with 5 (11%) patients requiring surgery.

Operative Treatment

A variety of surgical options exists for patients who do not respond to a trial of conservative treatment. The principal of operative treatment is to perform the least invasive procedure that will decrease pain and improve function.⁹ For stage I PTTD exploration and debridement of the PTT and soft tissue is often a recommended option. (Table 68-2). All tenosynovial tissue should be excised, with debridement of degenerated tendon areas and repair of any tears. Crates and Richardson¹⁰ report on a series of seven patients with stage I PTT dysfunction who were treated with debridement after failure of conservative treatment (Level IV). Six of the seven patients were pain free at 11-month follow-up examination. In Teasdall and Johnson’s study,¹¹ 14 of 19 patients had complete relief of pain after a synovectomy and debridement for stage I PTTD (Level IV). Sixteen patients had a return of function of the PTT as evidenced by the ability to perform a single-limb heel-rise test. Significant pathology within the substance of the tendon may require aggressive resection followed by flexor digitorum longus (FDL) transfer and Achilles lengthening to augment the PTT.

Nonoperative Treatment

Initially, stage II PTTD is treated similarly to stage I, but there are a few studies for nonoperative treatment of more advanced PTTD. Because the foot is flexible, corrective orthoses are utilized to prevent or correct deformity and control pain.¹² Alvarez and coauthors⁸ showed improvement in functional and subjective outcomes in patients with stage II PTTD with physical therapy, an aggressive home exercise program, and an orthosis (Level IV). If corrective orthoses are unable to correct the deformity, a medial posted UCBL device, as suggested by Chao and colleagues,⁷ may be used. Augustin and coworkers⁶ showed that all 12 patients using an Arizona brace showed pain relief referable to the brace and improvement in multiple clinical measurement instruments. If the deformity is severe, an AFO may be needed.⁷ As in stage I, stage II is given a 3- to 6-month trial before advocating surgical intervention.

Operative Treatment

A variety of options exists for the operative treatment of stage II PTT dysfunction. An FDL transfer is an accepted option,¹³ but isolated FDL transfer has failed to demonstrate long-term durability despite short-term success.¹⁴ A bony procedure will oftentimes be necessary to supplement the FDL transfer to improve its longevity. Bony procedures can be divided by position and include medial osteotomy, lateral column lengthening, or a combined procedure.

Medial Osteotomy with Flexor Digitorum Longus Transfer

A medial calcaneal slide osteotomy and FDL tendon transfer is one surgical option that has been shown to provide acceptable results for stage II disease (Table 68-3).¹⁵ Myerson and researchers¹⁶ performed a radiographic analysis of 18 patients 12 to 26 months after such a procedure (Level IV). They found improved radiographic values of the talar-first metatarsal angle and the distance from the medial cuneiform to the floor, concluding that the procedure may offset the weakness of isolated FDL transfer. Myerson and researchers¹⁶ also found high patient satisfaction and functional improvement in 32 patients treated with this procedure for stage II disease at a mean of 20 months after surgery (Level IV).⁵ Guyton and coworkers¹⁷ performed a review of 26 patients who underwent the procedure at a mean of 32 months follow-up (Level IV). All patients except three were able to perform a single-leg toe raise, which none could perform before surgery. Pain relief was rated as excellent by 75% of patients. Patients felt a prolonged period of steady improvement in symptoms and function over time. Radiographic improvement in the alignment of the foot was noted but did not correlate to self-reported improvement in appearance. These early clinical studies suggest that FDL transfer and medial displacement calcaneal osteotomy provide good functional outcome and symptomatic relief.

The decision to remove or retain the PTT when performing a FDL tendon transfer and medial displacement calcaneal osteotomy has been examined. Rosenfeld and investigators¹⁸