Tendoscopy in stage I posterior tibial tendon dysfunction

Stage I posterior tibial tendon dysfunction (PTTD) is defined as tenosynovitis or tendinitis whereby tendon length remains normal, there is no hindfoot deformity, and diagnosis is basically clinical, characterized by swelling and tenderness posterior to the medial malleolus. This condition is often misdiagnosed as ankle sprain, which delays correct diagnosis and early treatment that may improve symptoms, stop the disease process, and prevent the development of adult acquired flatfoot deformity. Posterior tibial tendoscopic synovectomy is a minimally invasive and effective surgical procedure to treat patients with stage I PTTD.     

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.     

Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program

BACKGROUND: Posterior tibial tendon dysfunction (PTTD) is a relatively common problem of middle-aged adults that usually is treated operatively. The purpose of this study was to identify strength deficits with early stage PTTD and to assess the efficacy of a focused nonoperative treatment protocol. METHODS: Forty-seven consecutive patients with stage I or II posterior tibial tendon dysfunction were treated by a structured nonoperative protocol. Criteria for inclusion were the presence of a palpable and painful posterior tibial tendon, with or without swelling and 2) movement of the tendon with passive and active nonweightbearing clinical examination. The rehabilitation protocol included the use of a short, articulated ankle foot orthosis or foot orthosis, high-repetition exercises, aggressive plantarflexion activities, and an aggressive high-repetition home exercise program that included gastrocsoleus tendon stretching. Isokinetic evaluations were done before and after therapy to compare inversion, eversion, plantarflexion, and dorsiflexion strength in the involved and uninvolved extremities. Criteria for successful rehabilitation were no more than 10% strength deficit, ability to perform 50 single-support heel rises with minimal or no pain, ability to ambulate 100 feet on the toes with minimal or no pain, and ability to tolerate 200 repetitions of the home exercises for each muscle group. RESULTS: Before therapy weakness for concentric and eccentric contractures of all muscle groups of the involved ankle was significant (p<0.001). After a median of 10 physical therapy visits over a median period of 4 months, 39 (83%) of the 47 patients had successful subjective and functional outcomes, and 42 patients (89%) were satisfied. Five patients (11%) required surgery after failure of nonoperative treatment. CONCLUSION: This study suggests that many patients with stage I and II posterior tibial tendon dysfunction can be effectively treated nonoperatively with an orthosis and structured exercises.     

Acquired adult flat foot secondary to posterior tibial-tendon pathology

Nineteen patients with the clinical diagnosis of dysfunction of the posterior tibial tendon underwent surgical exploration. Four types of lesions were identified: avulsion of the tendon at the insertion (Group I), mid-substance rupture of the tendon (Group II), an in-continuity tear of the tendon (Group III), and no tendon tear, tenosynovitis only (Group IV). These conditions could not be separated preoperatively by clinical or radiographic means. The patients in Group I were treated by reinsertion of the tendon; in Group II, by flexor tendon transfer; and in Groups III and IV, by synovectomy. At follow-up, most patients in Group I reported no improvement, but the patients in Groups II, III, and IV showed both subjective and objective improvement. The signs and symptoms of dysfunction of the posterior tibial tendon are not specific for mid-substance ruptures of the tendon but also can occur with avulsions or synovitis, or perhaps from other, as yet undefined lesions.     

Effect of extra-osseous talotarsal stabilization on posterior tibial tendon strain in hyperpronating feet

Posterior tibial tendon dysfunction is considered one of the most common causes of progressive adult acquired flatfoot deformity. The etiology leading to the dysfunction of posterior tibial tendon remains controversial. The purpose of this study was to quantify strain on the posterior tibial tendon in cadaver feet exhibiting hyperpronation caused by flexible instability of the talotarsal joint complex. We hypothesized that posterior tibial tendon strain would decrease after a minimally invasive extra-osseous talotarsal stabilization procedure. A miniature differential variable reluctance transducer was used to measure the elongation of posterior tibial tendon in 9 fresh-frozen cadaver specimens. The elongation was measured as the foot was moved from its neutral to maximally pronated position, before and after intervention with the HyProCure(?) extra-osseous talotarsal stabilization device. The mean elongation of the posterior tibial tendon (with respect to a fixed reference point) was found to be 6.23 ± 2.07 mm and 3.04 ± 1.85 mm, before and after intervention, respectively (N = 27; variation is ± 1 SD). The average elongation reduced by 51% and was statistically significant with p < .001. Strain on the posterior tibial tendon is significantly higher in hyperpronating feet. An extra-osseous talotarsal stabilization procedure reduces excessive abnormal elongation of the posterior tibial tendon by minimizing excessive abnormal pronation. This minimally invasive procedure may thus provide a possible treatment option to prevent or cure posterior tibial tendon dysfunction in patients exhibiting flexible instability of the talotarsal joint complex.     

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.     

Posterior tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.     

The Cotton osteotomy: indications and techniques

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by an incompetent posterior tibial tendon that results in a flexible pes planovalgus deformity. As the hindfoot drifts into valgus, compensatory varus develops in the forefoot. Alternatively, in some cases medial column instability can result in primary forefoot varus that drives the hindfoot into valgus. Recently, there has been increasing awareness of the importance of forefoot varus in PTTD.     

Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis

BACKGROUND: The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. METHODS: The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. RESULTS: Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. CONCLUSIONS: Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.     

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.     

Adult flatfoot/posterior tibial tendon dysfunction: classification and treatment

The authors provide a comprehensive classification and treatment algorithm for the adult flatfoot/posterior tibial tendon dysfunction. As well, the article provides a discussion as to the etiology, biomechanical implications, conservative treatment and surgical pearls of posterior tibial tendon dysfunction.     

Modifications de la composition de la matrice de collagène dans les tendinopathies du jambier postérieur

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%). Conclusion. 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 III collagens in degenerated tendons is likely to contribute to a decrease in the mechanical resistance of the tissue.     

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.     

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.     

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.     

Recovery of the posterior tibial muscle after late reconstruction following tendon rupture

The purpose of this study was to determine the recovery potential of the posterior tibial muscle after late reconstruction following tendon rupture in stage II of posterior tibial tendon dysfunction. Fourteen patients (18 women, 6 men; mean age 59.8 years) were investigated 47 months (range, 24-76 months) after surgical reconstruction of a completely ruptured posterior tibial tendon (end-to-end anastomosis, side-to-side augmentation with the flexor digitorum longus tendon) in combination with a distal calcaneal osteotomy with a tricortical iliac crest bone graft for lengthening of the lateral column. At follow-up, clinical and radiological investigations were performed, including strength measurement and qualitative and quantitative MRI investigation. The overall clinical results were graded excellent in 12 patients, good in one, fair in one, and poor in none. The average ankle-hindfoot score (American Orthopaedic Foot and Ankle Society) improved from preoperatively 49.1 (range, 32-60) to 93.1 (range, 76-100) at follow-up. The functional result correlated with patient's satisfaction and sports activities (p <.05). All patients showed a significant strength of the posterior tibial muscle on the affected side, but it was smaller than on non-affected side (p <.05). The mean posterior tibial muscle strength was 75.1 N on affected and 104.9 N on nonaffected side, corresponding to a ratio of 0.73 between the two legs. The mean area of the posterior tibial muscle was 1.89 cm(2) on affected side, and 3.48 cm(2) on nonaffected side, corresponding to a ratio of 0.55 between the two legs. While fatty degeneration for the posterior tibial muscle was found in all patients, it was found to decrease with increasing strength of the posterior tibial muscle (p <.05) and muscular size (p <.05). On postoperative MRI, the posterior tibial tendon could be found to be intact in all patients. The recovery potential of the posterior tibial muscle was shown to be significant even after delayed repair of its ruptured tendon. A ruptured and/or diseased posterior tibial tendon should not be transected as it excludes any recovery possibilities of the posterior tibial muscle.     

Probleme bei komplexen R��ckfu?korrekturen

This article discusses the intraoperative and postoperative problems seen in the treatment of posterior tibial tendon dysfunction. Problems associated with tendon transposition procedures, osteotomy and arthrodesis are discussed. The preoperative, intraoperative and postoperative problems and complications and how to avoid or treat them will be addressed. The individual procedures are often part of other complex hindfoot reconstructions. For this reason the general and special aspects of treating posterior tibial dysfunction can often be transferred to avoiding and resolving problems in hindfoot surgery.     

Problems in complex hindfoot corrections

This article discusses the intraoperative and postoperative problems seen in the treatment of posterior tibial tendon dysfunction. Problems associated with tendon transposition procedures, osteotomy and arthrodesis are discussed. The preoperative, intraoperative and postoperative problems and complications and how to avoid or treat them will be addressed. The individual procedures are often part of other complex hindfoot reconstructions. For this reason the general and special aspects of treating posterior tibial dysfunction can often be transferred to avoiding and resolving problems in hindfoot surgery.     

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.     

Ultrasound diagnosis of the posterior tibial tendon

Standardized sonographic delineation of the posterior tibial tendon using high-frequency ultrasonography with quantitative evaluation of the transverse section may confirm or exclude the clinical suspicion of posterior tibial tendon dysfunction and can serve as a complement to magnetic resonance imaging.