Tibialis posterior dysfunction as a cause of flatfeet in elderly patients

Background: Tibialis posterior is a frequent cause of an acquired flatfoot deformity and the prevalence is not known. If tibialis posterior dysfunction was found to occur frequently, a greater awareness may result leading to earlier patient diagnosis, referral and treatment.Objectives: To validate a screening questionnaire for tibialis posterior dysfunction, and to investigate the prevalence of tibialis posterior dysfunction in a high-risk patient population.Methods: The screening questionnaire was given prospectively to 65 patients (44 females, 21 males; mean age 79.6 years) attending an unrelated care of the elderly appointment. A foot and ankle surgery fellow separately examined all feet for tibialis posterior dysfunction.Results: The survey was 100% sensitive and 98.3 % specific at detecting tibialis posterior dysfunction. Six of the 65 patients (5 females, 1 male) had tibialis posterior dysfunction, and two had bilateral involvement. All six of the patients had longstanding symptoms, all had consulted their doctor and three had seen an orthopaedic surgeon; only one of the six patients had been correctly diagnosed.Conclusions: This study suggests that tibialis posterior dysfunction occurs frequently, but is seldom diagnosed in elderly women. Further epidemiologic studies are needed to determine the true prevalence.     

Tibialis posterior tendon dislocation: A case report

Dislocation of the posterior tibial tendon is a rare event, which may occur after trauma particularly sporting accidents. These injuries are frequently misdiagnosed at the initial presentation leading to a delay in treatment.We describe a case of delayed presentation of an atraumatic dislocation of the posterior tibial tendon which was diagnosed accurately and managed with primary repair of the flexor retinaculum.     

Medial displacement calcaneal osteotomy versus lateral column lengthening to treat stage II tibialis posterior tendon dysfunction,a prospective randomized controlled study

PurposeAdult-acquired flatfoot deformity (AAFD) requires optimum planning that often requires several procedures for deformity correction. The objective of this study was to detect the difference between MDCO versus LCL in the management of AAFD with stage II tibialis posterior tendon dysfunction regarding functional, radiographic outcomes, efficacy in correction maintenance, and the incidence of complications.Patient and methods42 Patients (21 males and 21 females) with a mean age of 49.6 years (range 43–55), 22 patients had MDCO while 20 had LCL. Strayer procedure, spring ligament plication, and FDL transfer were done in all patients. Pre- and Postoperative (at 3 and 12 months) clinical assessment was done using AOFAS and FFI questionnaire. Six radiographic parameters were analyzed, Talo-navicular coverage and Talo-calcaneal angle in the AP view, Talo- first metatarsus angle, Talo-calcaneal angle and calcaneal inclination angle in lateral view and tibio-calcaneal angle in the axial view, complications were reported.ResultsAt 12 months, significant improvement in AOFAS and FFI scores from preoperative values with no significant difference between both groups. Postoperative significant improvements in all radiographic measurements in both groups were maintained at 12 months. However, the calcaneal pitch angle and the TNCA were better in the LCL at 12 months than MDCO, 17̊ ± 2.8 versus 13.95̊ ± 2.2 (p = 0.001) and 13.70̊ ± 2.2 versus 19.05̊ ± 3.2 (p < 0.001) respectively. 11 patients (26.2%) had metal removal, seven (16.6%) in the MDCO, and four (9.6%) in the LCL. Three (7.1%) in the LCL group had subtalar arthritis, only one required subtalar fusion.ConclusionLCL produced a greater change in the realignment of AAFD, maintained more of their initial correction, and were associated with a lower incidence of additional surgery than MDCO, however, a higher incidence of degenerative change in the hindfoot was observed with LCL.     

Results of subtalar arthroereisis for posterior tibial tendon dysfunction stage IIA1. Based on 35 patients

Background

The aim of the study was to evaluate the clinical and radiological results obtained in the treatment of adult flexible flatfoot secondary to posterior tibial dysfunction with subtalar arthroereisis using a Kalix ^® endorthesis.

Histologic grading correlates with inflammatory biomarkers in tibialis posterior tendon dysfunction

BackgroundIt has been theorized that tibialis posterior tendon dysfunction (TPTD) is a degenerative process unrelated to inflammation. The purpose of this study was to determine if inflammatory cytokines, matrix metalloproteases (MMPs), and glutamate were elevated in diseased tibialis posterior tendons (TPTs).MethodsMatched diseased TPT, TPT insertion, and flexor digitorum longus (FDL) samples were collected from 21 patients. The samples were individually incubated in media, which was analyzed for inflammatory cytokines, MMPs, and glutamate. Histology and statistical analyses were performed.ResultsDiseased TPT and TPT insertion were significantly elevated compared to transferred FDL in eight inflammatory markers (p < 0.005). Only the diseased TPT was significantly elevated compared to the transferred FDL tendons for glutamate (p < 0.01). Histologic grading correlated with inflammatory cytokine levels.ConclusionDiseased TPT and TPT insertion demonstrated significantly elevated levels of inflammatory markers compared to the transferred tendons used as controls, suggesting a role for inflammation in the disease process. The amount of inflammation correlated with increased tendon degradation.Level of evidenceLevel III     

Tibialis posterior tendon dysfunction

Dysfunction of the tibialis posterior tendon evolves through a series of stages. The pain symptoms, clinical signs, and roentgenographic changes for each of these stages are characteristic. This staging system permits clarification and individualization of dysfunction, expected pathologic changes, and surgical treatment. The importance of the tibialis posterior tendon in normal hindfoot function and its treatment when injured are now being properly appreciated.     

Total ankle arthroplasty and tibialis posterior tendon transfer for ankle osteoarthritis and drop foot deformity

Total ankle arthroplasty is an alternative to arthrodesis in selected patients with end-stage arthritis of the ankle. We report on the clinical features, radiographic findings, management and results in a 58-year-old man with associated ankle osteoarthritis and drop foot deformity. The patient was managed with a total ankle arthroplasty and tibialis posterior tendon transfer. Three years after the procedure, the patient was able to walk, had no pain, and had a stable joint with 5° dorsiflexion and 20° plantar flexion.     

Tibialis posterior (TP) tendon transfer for foot drop: A single center experience

BackgroundFoot drop defined as a significant weakness of ankle and toe dorsiflexion. It leads to high stepping gait, functional impairment and deformity of the foot. Objective of this study was to assess the functional outcome of tibialis posterior (TP) transfer for patient with foot drop in a single center.MethodsThis is a retrospective study included 20 patients operated for foot drop of >1 year duration in the last 5 years. Preoperative assessment of muscles of all the three compartment of leg along with radiological assessment of ankle to rule out tarsal disintegration and ankle instability was done. Postoperatively gait, active dorsi/plantar flexion and the range of movement of the ankle and toes were assessed.ResultsTibialis posterior transfer was performed on 20 patients (16 males and 4 females, mean age 31.4 years). Commonest cause of foot drop was Hansen’s disease followed by post traumatic peroneal nerve damage and post injection sciatic neuropathy. At mean follow-up of 2 years, all patients, except one, could walk with heel-toe gait without any orthotic support. There was no pain, ruptures or infections of the transferred tendons. 19 of the 20 operated ankles had mean active dorsiflexion of 7.5°, the active plantar flexion of 36.25°, and the total range of movement 43.75°. The active dorsiflexion of the toes ranged from 5-20°.ConclusionDynamic tibialis posterior transfer gives good results in terms of normal gait, high patients’ satisfaction with minimal donor site morbidity and low complication rate.     

Traumatic dislocation of the tibialis posterior tendon

Summary An unusual case of traumatic dislocation of the tibialis posterior tendon, and our method of repair, is described.

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Résumé Présentation d'un cas inhabituel de luxation traumatique du tendon du jambier postérieur ainsi que de la méthode de traitement utilisée par les auteurs.

     

Alternative treatment of posterior tibial tendon dysfunction

Posterior tibial tendon insufficiency is a well-recognized entity. Treatment of this condition, however, is controversial.The process has been categorized into three surgical stages. Stage I disease is usually treated with tenosynovectomy and release of the sheath and retinaculum after failure of conservative methods. Stage II disease is treated with various tendon transfers with or without calcaneal osteotomy, and Stage III disease is most often treated with arthrodesis. This article presents a review of the various historical, physical and radiographic findings associated with this condition. In addition, an alternative approach to the surgical treatment of stage I or II posterior tibial insufficiency is presented. The procedure involves tenosynovectomy, tendon repair, deepening of the tendon groove, and pulley reconstruction. The procedure is simple, requires minimal postoperative immobilization, and by 6 weeks, patients have regained full motion and are able to ambulate with full weight bearing.     

Limited plantar incision for flexor digitorum longus tendon harvest in surgical treatment of tibialis posterior tendon insufficiency

BackgroundSurgical correction of stage II tibialis posterior tendon dysfunction (TPTD) commonly utilises the Flexor Digitorum Longus (FDL) tendon to augment the tibialis posterior tendon. The aim of this study is to present our experience and clinical outcomes harvesting the FDL via a limited plantar incision technique.Methods25 flat foot operations for stage II TPTD were performed harvesting the FDL via a limited plantar incision centred half-way between the base of the heel to the base of the 2nd toe and two-thirds from the lateral border of the foot.ResultsThe FDL was isolated with no inter-tendonous connections requiring surgical division. There were no recorded cases of plantar nerve injury nor any technique-related complications observed.ConclusionsThe plantar harvest technique for FDL is safe, provides a long tendon graft for transfer and limits the need for an extensive medial midfoot dissection.     

Rupture of the tibialis posterior tendon in a closed ankle fracture: a case report

Rupture of the tibialis posterior tendon may occur during a trauma in pronation-external rotation of the foot or, less commonly, during a direct trauma of the ankle. When an isolated fracture of the medial malleolus is present, it is more likely that a direct trauma has occurred. A 36-year-old man with a non-displaced medial malleolar fracture was evaluated. Repair of the tendon and reduction of the fracture were performed. Twenty-four months after the operation, the fracture was completely healed, the patient was asymptomatic, he had a normal ankle range of motion, and the function and strength of the tibialis posterior tendon were equal to those on the contralateral side. Early surgical repair of the tibialis posterior tendon combined with malleolar fracture reduction is recommended to avoid progression to a plano-valgus foot.     

Double-bundle technique: Endoscopic posterior cruciate ligament reconstruction using tibialis posterior allograft

Recently, attention has been given to the double-bundle technique for treating the posterior cruciate ligament (PCL)-deficient knee. We present an arthroscopic PCL reconstruction using a double-bundle technique with 3-stranded tibialis posterior (TP) allograft that has not been described before. The anterolateral bundle of the PCL is reconstructed using 2-stranded TP allograft and the posteromedial bundle using 1-stranded TP allograft. Three-stranded TP allograft will be an alternative graft choice for PCL reconstruction.