Flexible Flatfoot Deformities: Tendon Transfer With Internal Suture Support

Flexible Flatfoot Deformities: Tendon Transfer With Internal Suture Support

This video will demonstrate a tendon transfer procedure with an internal support suture for additional treatment of a flexible flatfoot deformity. In review, flexible flatfoot deformities are initially the result of damage to the posterior tibial tendon over time. However, as time progresses, other soft tissue structures may be involved in the eventual collapse of the arch, including a structure called the spring ligament complex.

This complex connects the heel bone to a bone on the inside of the foot, called the navicular. Its role is to provide additional support to the arch of the foot. In this live surgical demonstration, a surgeon will be repairing the spring ligament complex. A nearby tendon will be transferred to provide additional support to this complex. This tendon is called the flexor digitorum longus, or F D L. An internal support suture will be used to provide additional reinforcement to the ligament repair and tendon transfer. The goal of the procedure is to provide needed support to the inside arch of the foot.

First, the surgeon makes an incision to the inside of the right foot and ankle. As the soft tissue layers are carefully opened, the posterior tibial tendon will be exposed. In this patient, the posterior tibial tendon is enlarged and inflamed. This portion of the tendon will be removed given it is no longer healthy. Deep to this tendon lies the flexor digitorum longus tendon, or FDL, which will be exposed and cut at one end. This cut portion of the FDL will eventually be transferred and used to support the arch.

The surgeon prepares the FDL tendon for transfer by suturing the recently cut end. The surgeon identifies the damaged spring ligament tendon complex. A temporary wire is placed in a small shelf on the heel bone. A drill bit will then be brought over the wire to drill a hole, which will support an incoming bone anchor and suture. The wire and drill will be removed. Then, an instrument called a tap will be placed into the hole to help clear additional bone and make room for the incoming anchor and suture.

The surgeon will then place the bone anchor and attached flat support suture into the recently drilled hole. Once the anchor and suture are in place, the spring ligament will be directly repaired with a new, smaller blue suture. The surgeon will use the suture to bring both ends of the tear together. Once the repair is complete, the surgeon will then place a temporary wire through the navicular bone in preparation for making a tunnel in the bone.

Before drilling a tunnel, the surgeon will measure the tendon graft to ensure the tunnel will be large enough to pass the tendon through. The surgeon will drill a hole over the wire that matches the size of the tendon graft. The flat support suture will then be attached to the top of the wire with a temporary passing suture. The wire and the 2 sutures will be pulled through the tunnel. A smaller, flexible wire will then be placed in the bottom of the tunnel using the previous passing suture.

The other end of the flat support suture and the FDL tendon will be shuttled with the passing suture through the end of the flexible wire from the bottom to the top of the tunnel. The surgeon will pull the sutures from the top of the tunnel and gently guide the tendon into the bone tunnel. The surgeon will then ensure the position of the foot is appropriate prior to securing the tendon and flat support suture. A screw implant is placed in the bottom hole of the bone tunnel to capture and secure the flat support sutures and the tendon. All excess suture is trimmed.

Here, the 2 ends of the support suture are shown in addition to the recently transferred tendon and the previously repaired ligament. A foot x-ray is shown with the implant securely in the navicular. The incision will be closed, and a surgical dressing will be applied. The surgery is now complete.