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At least 19 recordsLinked to original sources

PubMed2004

[Posterior tibial tendon dysfunction].

Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot in adults. The posterior tibial tendon is the primary dynamic stabilizer of the medial longitudinal arch of the foot. Various histological alterations in the tendon substance disrupt the normal linear structure of the collagen fibers. As a result the tendon weakens, elongates, tears and its function is compromised. This in turn places the static stabilizers of the arch under excessive stress, which eventually leads to their collapse and formation of pes planovalgus deformity. Many etiologies have been proposed as an underlying cause of posterior tibial tendon dysfunction. The average age at the time of presentation is forty years and many of the patients are women, white, obese and suffer from hypertension. The diagnosis is mainly based on clinical findings and supported by radiographic findings. Posterior tibial tendon dysfunction was classified by Johnson and Strom according to the appearance of pes planovalgus deformity, its flexibility and the development of arthritic changes in the subtalar and ankle joints. In Stage I there is no deformity, in Stage II there is a flexible deformity, in stage III there is a rigid deformity and in stage IV there is an involvement of the ankle joint secondary to long standing rigid deformity of the hindfoot. The initial treatment for any stage should be non-operative and includes immobilization and anti-inflammatory drugs for the acute phase and different kinds of orthotics for the chronic phase. Failure of the non-operative treatment is an indication for surgery. The surgical procedures for the first stage include soft tissue debridement with or without tendon transfer. The surgical procedures for second stage include tendon transfer combined with various osteotomies or joint fusions. The surgical procedures for the third and fourth stages are triple arthrodesis and pantalar arthrodesis respectively.

Flatfoot↗

PubMed1999

Pathoanatomy and etiology of posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction is a cause of painful acquired flatfoot in adults. It is associated with progressive collapse of the medial longitudinal arch, hindfoot valgus, and forefoot abduction deformities. The clinical manifestations and surgical treatment have been well documented in the literature. Epidemiologic studies have not shown any clear predisposing factors to the disease. Numerous etiologies have been proposed to explain the clinical evidence of tendon degeneration found at the time of surgery including trauma, anatomic, mechanical inflammatory, and ischemic factors. Although previously thought to be secondary to an inflammatory process resulting in acute and chronic tendinitis, more recent histopathologic evidence has revealed a degenerative tendinosis with a nonspecific reparative response to tissue injury characterized by mucinous degeneration, fibroblast hypercellularity, chondroid metaplasia, and neovascularization. These pathologic changes result in marked disruption in collagen bundle structure and orientation. This may compromise the tendon and predispose it to rupture under physiologic loads. However, it cannot be determined whether these changes precede or postdate posterior tibial tendon dysfunction. It seems that there are many contributing factors to the etiology of posterior tibial tendon dysfunction all culminating in a common disease process with resulting tendon degeneration and an insufficient repair response.

Adult↗

PubMed2000

Posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot deformity in adults. Although this term suggests pathology involving only the posterior tibial tendon, the disorder includes a spectrum of pathologic changes involving associated tendon, ligament, and joint structures of the ankle, hindfoot, and midfoot. Early recognition and treatment is the key to prevention of the debilitating, long-term consequences of this disorder. Conservative care is possible in the earliest stages, whereas surgical reconstruction and eventually arthrodeses become necessary in the latter stages. The purpose of this article is to review the symptoms, physical examination, radiological examination, classification, and treatment of posterior tibial tendon dysfunction.

Arthrodesis↗

PubMed1992

Posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction, a common entity, frequently is unrecognized and inappropriately managed. Acutely, pain and swelling are present over the medial ankle and longitudinal arch. Long-standing inflammation can lead to tendon rupture, resulting in a progressive planovalgus or "flat foot" deformity. Plain radiographs illustrate the changes in bony anatomy associated with chronic posterior tibial deficiency, while magnetic resonance imaging scans can identify the three stages of posterior tibial tendon pathology. Most cases are amenable to conservative therapy, including rest and administration of nonsteroidal antiflammatory agents. Often a short period of immobilization in a cast or the use of an orthosis is beneficial. In cases with persistent tenosynovitis, complete tendon rupture, or progressive deformity, surgical intervention is indicated.

Biomechanical Phenomena↗

PubMedDate not supplied

Tendon reconstruction in posterior tibial tendon dysfunction.

Successful treatment of posterior tibial tendon dysfunction depends on accurate staging and the appropriate selection of surgical procedures. Magnetic resonance imaging is the most sensitive diagnostic modality for evaluating the tendon and is also the best predictor of clinical outcome following surgery. Procedural selection for patients with posterior tibial tendon dysfunction depends on many factors, including the underlying cause, age, weight, apex of the deformity, and relative integrity of the posterior tibial tendon.

Contraindications↗

PubMed1996

Nonoperative management of posterior tibial tendon dysfunction.

Forty-nine patients with posterior tibial tendon dysfunction (4 patients had bilateral involvement) were treated with orthoses. Forty feet were treated with molded ankle-foot orthoses, and 13 feet were treated with University of California Biomechanics Laboratory shoe inserts with medial posting. A total of 37 women and 12 men were included in the study. The mean follow-up period was 20.3 months (range, 8-60 months). The average age of the patients was 66 years (range, 42-89 years). Sixty-seven percent of patients had good to excellent results, according to a functional scoring system based on pain, function, use of assistive device, distance of ambulation, and patient satisfaction. The average period of orthosis use was 14.9 months (range, 1.5-29 months), with an average length of daily orthosis wear of 12.3 hours. One patient elected to undergo surgical treatment rather than continuing with long-term orthosis use. Thirty-three percent of patients had discontinued using the orthosis at the time of follow-up evaluation. Three patients were unable to wear the orthosis because of concurrent medical conditions. Nine patients stopped wearing the orthosis after experiencing discomfort and inconvenience. Although these patients continued to exhibit signs and symptoms of posterior tibial tendon dysfunction, they were not disabled enough to consider further treatment. Four patients tolerated orthosis treatment poorly and were treated surgically. Patients with posterior tibial tendon dysfunction can be treated by aggressive nonoperative management using molded ankle-foot orthoses or University of California Biomechanics Laboratory shoe inserts with medial posting. Surgical treatment can be reserved for patients who fail to respond to an adequate trial of brace treatment. Nonoperative management using an orthosis is particularly useful for elderly patients with a sedentary lifestyle or for patients at high risk because of medical problems.

Adult↗

PubMed2000

Posterior tibial tendon dysfunction. Diagnosis, evaluation, and treatment.

Posterior tibial tendon dysfunction (PTTD) is a complex multifaceted condition that can affect the lower extremity. Rarely mentioned 20 years ago, today it is the subject of numerous articles, books, and is a topic at most scientific seminars relating to the foot and ankle. It is a muscle imbalance initiated by a rupture, avulsion, or chronic inflammation of the tibialis posterior tendon. With time, it progresses from a flexible to rigid flatfoot deformity. Left untreated, peritalar dislocation and degenerative joint disease may develop. This article discusses the diagnosis, evaluation, and treatment of PTTD.

Flatfoot↗

PubMedDate not supplied

Posterior tibial tendon dysfunction and MRI.

Posterior tibial dysfunction can lead to disabling weightbearing symptoms and progressive pes planovalgus deformity. The different types of pathology are reviewed and three case reports are presented in this article. The use of magnetic resonance imaging (MRI) in diagnosing and in treatment planning is discussed, and emphasis is made for MRI as the preferred study for posterior tibial dysfunction.

Ankle Injuries↗

PubMed2002

Osteolysis of structural autograft after calcaneocuboid distraction arthrodesis for stage II posterior tibial tendon dysfunction.

Surgical treatment of stage II posterior tibial tendon dysfunction that fails nonoperative treatment is amenable to operative treatment. This commonly consists of a medial soft-tissue reconstruction and lateral column lengthening. We report on 32 patients undergoing distraction calcaneocuboid arthrodesis using an autogenous tricortical iliac crest graft. Almost 50% of patients did not go on to complete and uneventful incorporation of the graft at the arthrodesis site. Two different types of failure were noted. The first was classic nonunion which maintained structural integrity of the graft. The second was osteolysis and collapse of the graft accompanying the nonunion. Risk factors included smoking, K-wire fixation and possibly larger deformities requiring Achilles tendon lengthening. Complications of nonunion were salvageable with reoperation.

Adult↗

PubMed2002

Intermediate term follow-up of calcaneal osteotomy and flexor digitorum longus transfer for treatment of posterior tibial tendon dysfunction.

Twenty-three patients with stage II posterior tibial tendon dysfunction who had failed non-surgical therapy were treated with flexor digitorum longus transfer and calcaneal osteotomy. At latest follow-up averaging 35 +/- 7 months (range, 24 to 51 months), 22 patients (96%) were subjectively "better" or "much better." No patient had difficulty with shoe wear; however, four patients (17%) required routine orthotic use consisting of a molded shoe insert. AOFAS scores were available on 21 patients and improved from a preoperative mean of 50 +/- 14 (range, 27 to 85) to a postoperative mean of 89 +/- 10 (range, 70 to 100). Our experience, at an intermediate date follow-up is that calcaneal osteotomy and flexor digitorum longus transfer is a safe and effective form of treatment for stage II posterior tibial tendon dysfunction.

Calcaneus↗

PubMed2001

Posterior tibial tendon dysfunction. Treatment by flexor digitorum longus transfer.

Posterior tibial tendon dysfunction presents the clinician with such a broad spectrum of clinical problems that treatment must be based on the anatomic alignment of the foot as determined by the physical examination. There is no single method to treat PTT dysfunction, but rather a variety of conservative and operative procedures that are based on the pathologic anatomy.

Biomechanical Phenomena↗

PubMed2002

Changes in collagen matrix composition in human posterior tibial tendon dysfunction.

OBJECTIVE: To investigate whether tendon degeneration in posterior tibial tendon dysfunction syndrome is associated with changes in extracellular matrix collagen composition. METHODS: Specimens from grossly abnormal tendon regions from 9 patients with posterior tibial tendon dysfunction syndrome were prepared for routine histology. Collagens I, III and V were typed by immunoblotting and quantified by densitometry after SDS-PAGE. Proline and hydroxyproline residues were determined by liquid chromatography. Four other samples from grossly normal homologous tendon regions and one surgical specimen from a healthy patient undergoing arthrodesis of the ankle after an accident were included as control. RESULTS: In the grossly abnormal surgical posterior tibial tendon specimens we observed three types of histopathologic conditions present to varying degrees: increased mucin content, fibroblast hypercellularity and neovascularization. Analysis of degenerate tendons demonstrated a 79.3% increase in total proline and a 32.4% increase in 4-hydroxyproline. In addition, damaged tissue contained a higher proportion of collagen type III (mean increase: 53.6%) associated with a concomitant increase in type V collagen (mean increase: 26.4%). These alterations were accompanied by a reduction in type I collagen (mean decrease: 41.4%). CONCLUSIONS: In posterior tibial tendon dysfunction syndrome, the degenerative process results from marked changes in both structural organization and molecular composition of matrix collagens. The higher proportion of type V and type IlI collagens in degenerated tendons is likely to contribute to a decrease in the mechanical resistance of the tissue.

Aged↗

PubMed1996

MR imaging of posterior tibial tendon dysfunction.

OBJECTIVE: The purpose of this study was to describe the MR findings of posterior tibial tendon dysfunction. MATERIALS AND METHODS: MR images and medical records were reviewed for 11 patients with surgically proven posterior tibial tendon abnormalities (i.e., tears or tenosynovitis) and for six patients with clinical evidence of posterior tibial tendon dysfunction. Our study group included 16 women and one man from 37 to 70 years old (mean, 53.5 years old). MR examinations used T1-weighted and T2-weighted spin-echo sequences in the oblique axial and sagittal planes. RESULTS: Abnormal MR findings were observed in all 17 patients. The spectrum of MR abnormalities included fluid in the tendon sheath of a normal tendon interpreted as isolated paratenonitis (tenosynovitis, n = 3); tendon thickening and surrounding fluid with normal tendon signal interpreted as tendinosis (degeneration, n = 1); tendon thickening with increased linear or heterogeneous intrasubstance signal interpreted as partial tear (n = 11); tendon discontinuity with fluid-filled tendon sheath interpreted as complete rupture (n = 2). In 11 patients, the posterior tibial tendon was explored at surgery. In these patients, MR imaging accurately showed two cases of isolated paratenonitis, one case of tendinosis, four partial tears, and two complete ruptures. In the remaining two patients, the presumed MR diagnosis did not correlate very closely with the surgical findings: one patient with isolated paratenonitis shown by MR imaging had tendinosis found at surgery; however, the surgery in this patient followed the MR examination by 10 months, a time during which degeneration might have occurred. The other patient had an MR diagnosis of partial tear, which was not found at surgery; however, tendon degeneration was severe and a small tear not reaching the tendon surface could have been missed at inspection. MR imaging characteristics of severe tendinosis and partial tear may overlap. CONCLUSION: MR imaging is effective for detecting abnormalities related to posterior tibial tendon dysfunction. Familiarity with the appearance of these changes facilitates accurate characterization.

Ankle↗

PubMed1999

Treatment of stage I posterior tibial tendon dysfunction with medial soft tissue procedures.

Seven patients with Stage I posterior tibial tendon dysfunction were treated with synovectomy, with or without tendon debridement. At the 11-month followup, six patients were completely pain free. The one patient who eventually required flexor digitorum longus transfer and lateral column lengthening because of progression to Stage II disease had significant intrasubstance tendinous degeneration. Early diagnosis and aggressive treatment are imperative to prevent progression of Stage I posterior tibial tendon dysfunction. Operative treatment is indicated if a reasonable trial of casting or bracing does not relieve symptoms.

Adult↗

PubMed2002

Posterior tibial tendon dysfunction and MR imaging in rheumatoid arthritis.

We present the case of a patient with long-standing rheumatoid arthritis and an acute onset of total dysfunction of the posterior tibial tendon. On MRI, a rupture of the tendon was apparent. Intraoperatively, however, massive tenosynovitis with stricture of the tendon was identified as the cause of posterior tibial tendon dysfunction. This case illustrates a pitfall in MRI imaging with potential diagnostic and therapeutic consequences.

Arthralgia↗

PubMed1997

Diagnostic efficacy of ultrasonography in stage I posterior tibial tendon dysfunction: sonographic-surgical correlation.

The purpose of this study is to evaluate the diagnostic efficacy of ultrasonography in stage I posterior tibial tendon dysfunction. Fourteen of the 17 consecutive patients who underwent tenosynovectomy for stage I posterior tibial tendon dysfunction were included in this study. The preoperative diagnosis was based primarily on the clinical suspicion of dysfunction, which was confirmed by ultrasonography. Two measurements were obtained at the midpoint between the insertion site and the medial malleolus in both feet of the 14 patients: the diameter of the posterior tibial tendon and the diameter of the tendon sheath measured from its inner walls. The mean diameter of the tendon was 4.61 +/- 0.50 mm and that of the tendon sheath in the symptomatic foot was 7.24 +/- 0.75. In the unaffected foot, the mean diameter of the tendon was 3.30 +/- 0.34 mm and that of the tendon sheath was 3.64 +/- 0.35 mm, respectively. In the symptomatic tendon, the increase of peritendinous space was significantly higher than the increase in the tendinous portion (P < 0.0001). Surgical findings proved the accuracy of diagnosis in all patients. Although many cases of stage I posterior tibial tendon dysfunction remain undiagnosed owing to the mild clinical symptoms, this series indicates that ultrasonography is a valuable adjunctive diagnostic tool in the clinical examination and assists in achieving an accurate diagnosis of stage I posterior tibial tendon dysfunction, allowing early treatment.

Adult↗

PubMed1999

The use of magnetic resonance imaging in posterior tibial tendon dysfunction.

The role of magnetic resonance imaging in the evaluation of the patient with posterior tibial tendon dysfunction is discussed. Considerations for the proper positioning of the patient and optimal technique to obtain appropriate images of the posterior tibial tendon and associated joint abnormalities are highlighted. Cases are presented to show the effectiveness of magnetic resonance imaging in different clinical situations. The treatment algorithm for posterior tibial tendon dysfunction should include magnetic resonance imaging as a diagnostic tool when appropriate.

Adult↗

PubMed2003

Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report.

BACKGROUND: The purpose of this study was to evaluate preliminary results with Kalix subtalar arthroereisis in sinus tarsi for stage II posterior tibial tendon dysfunction. METHODS: Twenty-one patients with stage II posterior tibial dysfunction, according to Johnson and Storm, underwent surgical treatment between July 1999 and December 2000. All patients were evaluated clinically using the America Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle score. We performed a tendon repair depending on the type and location of the injury and implanted a Kalix endorthesis in the sinus tarsi. RESULTS: Nineteen patients attended for clinical review with an average follow-up of 27.31 months (range, 19-36). AOFAS scale improved from a preoperative average of 47.2 to an average of 81.6 at revision. The most important improvement was observed in pain (16.3 preoperative to 31.6 postoperative). Two cases required removal of the endorthesis for pain, probably because the endorthesis was too big, without any loss of correction. Patient satisfaction was "satisfied" or "very satisfied" in 17/19. All except three patients would have elected to undergo the same procedure. CONCLUSIONS: Subtalar arthroereisis by means of implantation of a Kalix endorthesis in the sinus tarsi, with prior correction of the deformity and tendon repair, offers an alternative to bone operations such as calcaneal osteotomies, lengthening the external column, or arthodesis in patients with stage II posterior tibial dysfunction.

Adult↗