Posterior tibial tendon tenosynovectomy for rheumatoid arthritis: a report of three cases.
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Adult↗
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Results for “Posterior Tibial Tendon Dysfunction”
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Sonography of posterior tibialis tendon dislocation.
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Adult↗
[Influence of the posterior tibial tendon on the medial arch of the foot: an in vitro kinetic and kinematic study].
INTRODUCTION: The respective contributions of the active and passive structures of the foot to the stability of the medical arch were investigated using an in vitro kinetic and kinematic model. The effect of the tibialis posterior tendon on foot and ankle movements, and plantar pressure distribution of the foot were tested in a cadaveric human foot. METHOD: The stance phase from heel-contact to toe-off of normal walking gait and after tibialis posterior tendon rupture was simulated in eight roentenographically normal human feet (age 66 +/- 19 years, males). Ground reaction force and tibial inclination was simulated by means of a tilting angle and force-controlled translation stage. Plantar pressure was measured using a pressure-measuring platform. The force developed by the flexors and extensor muscles of the foot were simulated via cables attached to 7 force-controlled hydraulic cylinders. Tibial rotation was produced by an electric servo-motor, and foot movements measured with an ultrasonic analysis system. RESULTS: The model was verified against the plantar distribution and kinematics of healthy subjects measured during normal gait. Tibialis posterior deficit did not result in any detectable changes in pressure or force-time integral in the medial regions of the foot--a common sign of flat foot (pressure: midfoot 0.2 < or = 0.9; medial forefoot 0.5 < or = p < or = 0.9; hallux 0.5 < or = p < or = 0.9; force-time integral: midfoot p = 0-871; medial forefoot p = 0.632; hallux p = 0.068). Only small tendential changes in the kinematics of the talus and calcaneus were observed in dorsiflexion (0-58 sec; talus 0.1 < or = p < or = 0.6; calcaneus 0.4 < or = p < or = 0.06) and eversion (talus: 0-60 sec. 0.1 < or = p < or = 0.6; calcaneus: 37-60 sec. 0.2 < or = p < or = 0.7). CONCLUSION: The results of this in vitro study show that defective tibialis posterior alone does not produce significant changes in the kinetics or kinematics of the stance phase of normal gait. This suggests that the development of flat foot observed in degeneration of the tibialis posterior tendon occurs only after fatigue of the passive structures of the foot.
Adult↗
Current concepts for treatment of the painful flatfoot in the elderly.
Flatfoot deformities are predominantly asymptomatic variants of normal, which do not adversely affect function. However, the acquired flatfoot deformity secondary to attrition of the posterior tibial tendon is a progressively painful condition, ultimately affecting the hindfoot, midfoot, and forefoot. It is most common during the sixth and seventh decades of life. Chronic micro-trauma to the tendon causes eventual rupture and the resulting deformity. Prior to tendon rupture, early symptoms are those of a unilateral localized inflammatory condition with tenderness and swelling behind the medial malleolus of the ankle. Early diagnosis is a key factor in limiting patient disability.
Aged↗
[High heels or tibialis posterior].
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Heel↗
[Posterior tibial insufficiency].
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Flatfoot↗
[Dysfunction of the posterior tibial muscle due to tendon insufficiency].
The mechanical integrity of the arch of the foot depends on static and dynamic factors. The posterior tibial tendon in particular is situated to provide dynamic support along the medioplantar aspect of the foot and arch. Tibialis posterior dysfunction is a progressive condition leading to a painful flatfoot deformity. To understand changes that occur in the pathological state, a clear analysis of the normal function of the tibialis posterior is necessary. Early diagnosis of posterior tibialis dysfunction is crucial for preventing a progressive deformity. For diagnosis, clinical findings are predominant. When passive correction of the foot deformity is still possible, a reconstruction of the tendon should be attempted. As retraction of the tendon ends or degeneration prevents primary repair, tendon transfer may substitute for the posterior tibial tendon. When a fixed flatfoot has developed, realignment by arthrodesis is advised. Triple arthrodesis may be appropriate to correct hindfoot valgus as well as forefoot abduction.
Adolescent↗
Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for stage-II dysfunction of tibialis posterior. Three- to five-year results.
The treatment of acquired flat foot secondary to dysfunction of the posterior tibial tendon (PTT) of stage II, as classified by Johnson and Strom, remains controversial. Joint sparing and soft-tissue reconstructive procedures give good early results, but few studies describe those in the medium-term. We studied prospectively the outcome of surgery in 51 patients with classical stage-II dysfunction of the PTT treated by a medial displacement calcaneal osteotomy and transfer of the tendon of flexor digitorum longus. We reviewed 44 patients with a mean follow-up of 51 months (38 to 62). The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot rating scale improved from 48.8 before operation to 88.5 at follow-up. The operation failed in two patients who later had a calcaneocuboid fusion. The outcome in 43 patients was rated as good to excellent for pain and function, and in 36 good to excellent for alignment. There were no poor results.
Adult↗
[The acquired buckling-flatfoot. A foot deformity due to obesity?].
Flatfoot deformity is characterized by a multiplanar hindfoot malalignment. Although the etiology remains unclear, the deformity is mainly attributed to ligamentous laxity and dysfunction of the posterior tibial tendon. Obesity is thought to be a risk factor that additionally impairs hindfoot stability. Performing a retrospective clinical and radiological study, we compared two groups, each with 75 patients. One group included patients with a flatfoot deformity stage 2, while the other group showed no hindfoot malalignment. Reviewing the weight and calculating the body mass index revealed significantly increased values for those patients with flatfoot deformity (P=0.034 and P>0.001, respectively). This correlation should be considered during the decision-making process on surgical strategies. In obese patients with flatfoot deformity, stage 2 soft tissue reconstruction and hindfoot osteotomies should be combined with hindfoot arthrodeses, i.e. subtalar fusion, to maintain sufficient and durable stability.
Adult↗
Spring ligament of the ankle: normal MR anatomy.
The plantar calcaneonavicular or spring ligament is visualized inconsistently and incompletely on routine MR images of the foot. This ligament is a vital stabilizer of the longitudinal arch of the foot, providing support for the head of the talus, which rests on the ligament's central portion. Laxity or rupture of the spring ligament permits plantar flexion of the talus. This motion results in valgus alignment of the calcaneus and a flatfoot deformity (pes planovalgus). Laxity or rupture of the spring ligament can develop in cases of chronic dysfunction of the posterior tibial tendon. In rupture of the posterior tibial tendon, surgical management may include plication of the spring ligament in addition to repair or reconstruction of the tendon to stabilize the medial column of the foot. Thus, the status of the spring ligament can be a significant consideration in preoperative planning. This pictorial essay illustrates the normal MR anatomy of the spring ligament, the planes of imaging required for optimal depiction of the ligament, and the neighboring structures with which the ligament can be confused.
Ankle↗
Evaluation of posterior tibial pathology: comparison of sonography and MR imaging.
OBJECTIVE: To compare the results of sonographic (US) and magnetic resonance (MR) imaging in detecting pathology of the posterior tibial tendon (PTT) in patients with PTT dysfunction. DESIGN: Twenty-two ankles that were clinically suspected by the orthopedic surgeon to have PTT dysfunction were evaluated with US (10 MHz linear-array transducer) and 1.5 T MR examinations within the same day. The US and MR studies were conducted and interpreted by two sonologists and two musculoskeletal radiologists who were masked to the results of the other study. Four patients had bilateral studies. Classic clinical findings were utilized as a standard reference in staging PTT dysfunction. PATIENTS: Eighteen women (mean age 61 years, age range 39-86 years). RESULTS: Based on a commonly accepted staging system for PTT dysfunction, 6 ankles were classified as stage I, 11 ankles as stage II, and 5 ankles as stage III. All stage I ankles were interpreted as having an intact PTT by both MR imaging and US. In the stage II and III tendons, MR imaging demonstrated PTT tears in 12 of 22 examinations, including 11 partial tears and 1 complete tear. US demonstrated PTT tears in 8 of 22 examinations, including 8 partial tears and no complete tears. The findings of US and MR imaging were consistent in 17 of 22 cases (77%). The five inconsistencies were as follows: in 4 cases, US reported tendinosis when MR imaging interpreted partial tears (no change in management); in one case, US diagnosed a partial tear when MR reported a complete tear of the PTT (no change in management because the clinical findings were more consistent with a partial tear). CONCLUSIONS: In this study, US and MR imaging of the PTT were concordant in the majority of cases. US was slightly less sensitive than MR imaging for PTT pathology, but these discrepancies did not affect clinical management.
Adult↗
Vascular density of the posterior tibial tendon: a cadaver study.
BACKGROUND: Degenerative pathology of the posterior tibial tendon, a common cause of foot and ankle dysfunction, frequently affects women over 40 years of age. Its etiology is still controversial. The literature reports decreased vascularization coinciding with the most common site of the lesion, near the medial malleolus. METHODS: Forty pairs of PTT obtained from human cadavers were transversally cut into six levels, from the musculotendon transition to its insertion point. In each segment, a histologic cut was made and stained with Masson's trichrome allowing viewing of the vascular structure of the tendon under a light microscope. By using an integrating eyepiece on the microscope, vascular density was calculated. This verified any variation of the vascular concentration in the normal tendon, a possible cause of its degeneration. RESULTS: When the results were compared by side, sex, and age, no statistically significant difference was observed. When the levels were compared, no area of decreased vascularization was seen in the midportion of the tendons, the most common site of degeneration of the posterior tibial tendon. CONCLUSION: These results indicate that an area of decreased vascularity is not a factor in degeneration of the posterior tibial tendon at the medial malleolus.
Adult↗
[Standardized ultrasound diagnosis (13 MHz) of the tendon of the posterior tibial muscle--normal findings in probands with healthy feet].
OBJECTIVES: Tibialis posterior dysfunction is often diagnosed at a very late stage. However, the early diagnosis of tibialis posterior dysfunction is crucial for therapeutic aspects and especially for the operative prognosis. The morphological correlate of the tibialis posterior dysfunction consists of degenerative changes and thickening of the posterior tibial tendon [2, 9, 11]. By means of a high frequency linear array transducer, a standardized technique of examination as well as reference values of cross-sections of posterior tibial tendon are introduced. MATERIAL AND METHODS: Investigating 51 healthy subjects (102 feet) without any foot deformities, standardized planes were defined by use of a 13 MHz linear array transducer in order to delineate the posterior tibial tendon. At exact anatomic landmarks, tendon diameters were measured using two longitudinal sections proximal and distal to the medial malleolus. Likewise, two diameters and the resulting roughly calculated cross-section of the tendon were determined, using two transverse sections at the level of the subtalar joint facet and the medial malleolus. The findings obtained by ultrasound in four female patients with the diagnosis of a tibialis posterior dysfunction confirmed during surgery are compared to the aforementioned 51 healthy subjects. RESULTS: A healthy tendon appears homogeneous and echo-rich in orthogonal ultrasound and displays average areas of 18.4 sq.mm. (SD 5.9 sq.mm.) at the subtalar joint facet level and 19.2 sq.mm (SD 4.8 sq.mm.) at medial malleolus level in transverse sections. The corresponding areas obtained in patients with tibialis posterior dysfunction were clearly enlarged than in healthy subjects. In 85% of all feet examined at the level of the medial malleolus, the tendon is surrounded by a hypoechoic halo which has a size smaller than two times the cross-section of the flexor digitorum longus tendon. CONCLUSION AND CLINICAL RELEVANCE: Reference values of tendon thickness and of intratendinous echo-structures at reproducible landmarks facilitate delimitations from pathological tendon alterations. The exact delineation of intratendineal echoes by high frequency array transducers and standardized examination techniques that measure tendons size is a prerequisite to enable an early assessment and registration of degenerative alterations and thickening of the posterior tibial tendon.
Adolescent↗
Tendoscopy of the posterior tibial tendon.
Posteromedial ankle complaints are most often caused by a disorder of the posterior tibial tendon. Two predominant groups of patients can be distinguished: the first involves younger patients who have some form of systemic inflammatory disease; the second involves older patients whose dysfunction is caused by chronic overuse. This article illustrates endoscopy of the posterior tibial tendon in a group of patients who had diverse pathology. None of the patients showed postoperative complications. All showed a quick recovery, early mobilization, none or mild postoperative pain, and nice wound healing. Although not all patients were free of complaints, all were satisfied with the intervention itself. Tendoscopy of the poterior tibial tendon offers the advantage of less morbidity, reduction of the postoperative pain, early mobilization, no wound healing problems and outpatient treatment.
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Outcomes for surgical correction for stages 2 and 3 tibialis posterior dysfunction.
Between the years 1991 and 1996, 13 patients with stage 2 or 3 tibialis posterior dysfunction were evaluated following surgical reconstruction. Those patients with posterior tibial tendon tendinitis with a progressive flatfoot were categorized as having a stage 2 deformity according to Mueller's developmental stages of tibialis posterior dysfunction. Those patients with increasing severity of symptoms including a forefoot abductus component were classified as stage 3. There were five patients in stage 2, ranging in age from 53 to 80 years old; and there were eight patients in stage 3, ranging in age from 41 to 73 years old. Standard conservative care was utilized prior to surgical intervention in all cases. Follow-up was 12 months to 63 months. Patients in stage 2 underwent a Cobb reconstruction utilizing a split tibialis anterior tenodesis, and patients in stage 3 underwent an Evans lateral column-lengthening procedure combined with a Cobb procedure. Utilizing retrospective radiographic evaluation and patient interviews, results indicated that patients in stage 2 had a better patient satisfaction than those patients in stage 3. Although both patient groups had a 6-point average decrease in pain according to the 0- to 10-point visual analog pain scale, 50% of the patients undergoing a Cobb-Evans procedure felt that the procedure did not meet their expectations. Only one out of the five Cobb procedure patients felt that the procedure did not meet his expectations. The results of this limited study of patients with stage 3 tibialis posterior dysfunction suggest that although the lateral column lengthening with tendon augmentation renders good radiographic correction, many patients develop protracted lateral column pain and felt that surgery did not meet their expectations. Additional calcaneal osteotomies and arthrodesing procedures of the hindfoot may render a more satisfactory outcome.
Adult↗
Ultrasonographic examination of the posterior tibial tendon.
The posterior tibial tendons (PTTs) of 16 patients with PTT dysfunction and 10 age-matched healthy subjects were examined ultrasonographically, using a 10-MHz linear-array transducer. Normal PTTs appeared hyperechoic (more echogenic) and oval, with an average diameter of 7.8 mm x 3.7 mm at the medial malleolar level. Degenerated PTTs appeared hypoechoic (less echogenic) and swollen (9.8 mm x 5.0 mm). Peritendinitis presented as a hypoechoic rim on the longitudinal sonogram (along the long axis of the tendon) and a "target sign" (hyperechoic central structure with a hypoechoic halo) on the transverse sonogram (at the right angle to the long axis of the tendon). Complete rupture of the PTT revealed an empty tibial groove at the level of the medial malleolus on the transverse sonogram and a wavy fibril pattern over the distal end on the longitudinal sonogram. Compared with the operative findings or the results of the magnetic resonance imaging, ultrasonography was sensitive and specific in diagnosing tenosynovitis and complete rupture of the PTT.
Ankle↗
Anatomy, function, and pathophysiology of the posterior tibial tendon.
The posterior tibial tendon is vital for the structure and function of the foot and ankle. Dysfunction of the tendon can be debilitating and devastating. In recent years, much attention had been directed toward the diagnosis and treatment of PTTD. To properly diagnose and devise an appropriate treatment regimen, the anatomy, function, and pathophysiology associated with PTTD need to be thoroughly understood.
Ankle↗