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 fo
Trang 1The loss of function of the posterior
tibial tendon has been associated
with the development of a
progres-sive flatfoot deformity in adults
and children.1,2 The exact etiology
of this condition remains
contro-versial While rupture of the
pos-terior tibial tendon has been
asso-ciated with various underlying
pathologic conditions, the
idio-pathic nature of this problem in
most patients adds to a growing
level of interest in the problem
among the general orthopaedic community There is a sizable group of patients in whom symp-tomatic discomfort is associated with dysfunction of this tendon as well as concomitant deformities
The purpose of this report is to illustrate the spectrum of posterior tibial tendon insufficiency, to high-light recently described techniques for reconstruction, and to review options for surgical and nonopera-tive management
History
The original description of
posteri-or tibialis insufficiency and its asso-ciated tendinitis is credited to Kulowski in a 1936 article Fowler3
and Williams4 described early series of patients who had apparent tendinitis of the posterior tibialis tendon that required surgical treat-ment However, for many years, few reports were published about this pathologic condition Consid-erable interest in posterior tibial tendon insufficiency has developed over the past 15 years This interest has largely stemmed from efforts to understand the pathomechanics of the hindfoot as well as reports of clinical series describing a variety
of methods for surgical treatment of this condition
Dr Beals is Assistant Professor, Department of Orthopedics, University of Utah School of Medicine, Salt Lake City Dr Pomeroy is Clinical Assistant Professor of Orthopaedic Surgery, University of New England; and Director, Portland Orthopedic Foot and Ankle Center, South Portland, Me Dr Manoli is Professor and Chairman, Department of Orthopedic Surgery, University of South Alabama, Mobile.
Reprint requests: Dr Beals, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132.
Copyright 1999 by the American Academy of Orthopaedic Surgeons.
Abstract
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
radio-graphic 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 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
evi-dence 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 The role of corticosteroid
injections continues to be controversial When nonoperative management
fails, the treatment options consist of soft-tissue procedures alone or in
com-bination 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.
J Am Acad Orthop Surg 1999;7:112-118 Diagnosis and Treatment
Timothy C Beals, MD, Gregory C Pomeroy, MD, and Arthur Manoli II, MD
Trang 2Anatomy and
Biomechanics
The posterior tibial muscle
origi-nates on the posterior aspect of the
tibia, the fibula, and the
interos-seous membrane It courses
poste-riorly and medially around the
ankle in a groove adjacent to the
medial malleolus and inserts on the
midfoot in the area of the navicular
tuberosity The tendon has bands
that attach to the plantar aspect of
the cuneiforms; the second, third,
and fourth metatarsals; and the
sustentaculum tali It runs
posteri-or to the axis of the ankle joint and
medial to the axis of the subtalar
joint Therefore, the tendon
func-tions as a plantar-flexor of the
ankle and as an invertor of the
sub-talar joint complex
The posterior tibial muscle
initi-ates the process of inversion of the
hindfoot during gait, bringing it
into a neutral position and
maxi-mizing the mechanical advantage
of the more laterally positioned
Achilles tendon as the individual
rises onto the forefoot The
poste-rior tibial muscle truly drives the
position of the hindfoot and
deter-mines the flexibility of the foot by
its control over the transverse tarsal
joints The loss of the force of
inversion of the muscle explains
why patients with posterior tibial
tendon insufficiency have only a
limited ability, or are completely
unable, to rise onto their toes from
a position of single-leg stance The
posterior tibial muscle is normally
opposed by the peroneus brevis,
and it has been theorized that it is
the lack of opposition of the
per-oneus brevis muscle that leads to
the clinical deformities recognized
in patients with rupture or
dys-function of the posterior tibial
ten-don The posterior tibial and
per-oneus brevis muscles both function
during the midstance phase of gait
Several pertinent anatomic
fac-tors relate to reconstruction
tech-niques and explain the problems patients experience with insuffi-ciency of the posterior tibial ten-don These include the fact that the posterior tibial muscle is large
in comparison to those that can be transferred to replace it It has a cross-sectional area of 16.9 cm2, compared with 5.5 cm2for the
flex-or digitflex-orum longus muscle and 6.7 cm2 for the peroneus brevis muscle The medial capsular and ligamentous structures of the hind-foot and midhind-foot certainly play a role in the development of flatfoot deformities The talonavicular joint capsule, as well as the spring-ligament5 and deltoid-ligament complexes, have been implicated
in the progressive loss of the
medi-al longitudinmedi-al arch of the foot and the ankle dysfunction seen in long-standing cases of posterior tibial tendon insufficiency
Diagnosis
The diagnosis of posterior tibial tendon insufficiency is primarily a clinical one Patients typically complain of pain medially around the ankle that may radiate into the arch of the foot Some patients in the later stages of the condition complain of pain on the lateral aspect of the foot, where the calca-neus abuts against the fibula, due
to an excessive valgus position of the hindfoot Roughly half of all patients give a history of some sort
of trauma that was initially thought
to be a sprain Patients often expe-rience swelling along the course of the posterior tibial tendon and sig-nificant pain, most typically several centimeters proximal to the inser-tion onto the navicular tuberosity
Pain is exacerbated by activity, and the ability to walk distances de-creases Some patients present simply with pain and apparent inflammation along the tendon without any evidence of clinical
deformity, but most patients have some collapse of the foot
The rate of development of clini-cal deformity is variable, and there are no adequate studies of the nat-ural history of posterior tibial ten-don insufficiency In some pa-tients, the deformity increases, and eventually the hindfoot valgus, notable even during relatively early stages of the condition, be-comes fixed In the latest stages of the condition, the ankle is affected and has a tendency toward valgus tilting from laxity of the medial deltoid complex
Clinical evaluation includes observing the patient in a standing position When viewed from be-hind, the Òtoo many toesÓ sign is typically seen, which is evidence of abduction of the midfoot relative to the hindfoot.6,7 Excessive hindfoot valgus is noted in the affected limb,
as well as loss of the longitudinal arch when viewed from either the side or the front Typically, soft-tissue swelling around the medial aspect of the ankle is evident The tissues below the medial malleolus appear prominent due largely to excessive hindfoot valgus (Fig 1) Patients asked to rise onto their
Fig 1 Clinical appearance of a patient with stage II posterior tibial tendon insuffi-ciency Note the too-many-toes sign on the left, the excessive hindfoot valgus, and medial soft-tissue swelling.
Trang 3toes from a position of single-leg
stance either are completely unable
to comply or can do so only to a
limited degree They may attempt
to compensate by vaulting forward
to raise themselves with use of the
Achilles tendon
While some authors dismiss its
utility, manual testing of muscle
units is helpful for both diagnosis
and the determination of treatment
options Resistance against the
tib-ialis posterior is assessed, as well as
testing of the peroneus brevis,
flex-or hallucis longus, and flexflex-or
digi-torum longus To evaluate the
tib-ialis posterior, the foot is placed in
an everted, plantar-flexed position,
and the patient is asked to invert
the foot This method is more
accurate than testing the foot in an
inverted position; with that
tech-nique, the function of the tibialis
anterior may confuse the examiner
Contracture of the Achilles
ten-don complex is often noted when
the foot is placed in a reduced
posi-tion In cases of excessive hindfoot
valgus, patients are able to achieve
a relatively dorsiflexed position by
rotation through the transverse
tarsal joints into a Òcompensated
equinusÓ position The hindfoot
equinus often seems most directly
related to the gastrocnemius mus-cle and is not necessarily related to the entire gastrocnemius-soleus complex This distinction is made
by testing with the knee extended and flexed During gait evaluation, recruitment of the long extensor tendons can be seen in patients who have a tight Achilles tendon complex
Thorough evaluation is neces-sary to ensure that insufficiency of the posterior tibialis tendon is an isolated problem and not indica-tive of a more generalized condi-tion, such as rheumatoid arthritis
or seronegative arthropathy Ex-amination of the contralateral limb and upper extremities is often helpful
Radiographic evaluation should include four weight-bearing films:
an anteroposterior view of both ankles, an anteroposterior view of both feet, and lateral foot and ankle radiographs of each side This allows comparison in patients who have unilateral disease and often serves as an excellent teaching tool when explaining the nature of the problem to the patient Arthrosis
of the hindfoot joints should be determined, as this may affect treatment Typical deformity
in-cludes apparent shortening of the hindfoot on the weight-bearing anteroposterior ankle radiograph, which is indicative of collapse through the subtalar joint complex
A rare finding in advanced poste-rior tibial tendon insufficiency is an ossicle in the medial ligament com-plex, which seems associated with failure of the deltoid
On weight-bearing lateral radio-graphs, the inclination of the talus
is plantarward in comparison to normal, with collapse typically through the talonavicular joint On some occasions, the collapse seems equally evident through the navic-ulocuneiform and tarsometatarsal articulations Comparison of the inferior portion of the medial cuneiform to the inferior portion of the fifth metatarsal can be helpful
to allow objective measurement of the degree of collapse (Fig 2) Anteroposterior foot radiographs typically demonstrate lateral peri-talar subluxation of the navicular and associated abduction of the midfoot The amount of the talar head that is uncovered appears increased in comparison to the con-tralateral side
Evaluation with adjunctive mo-dalities, such as tomography,
Fig 2 A,Lateral weight-bearing radiograph of a foot with stage II posterior tibial tendon insufficiency The inferior border of the medial
cuneiform (medial column) is even with the base of the fifth metatarsal (lateral column) Note the plantar inclination of the talus B, The
normal contralateral foot is shown for comparison.
Trang 4tion tenography, ultrasonography,
and magnetic resonance imaging,
has been advocated by some
Indeed, there are case reports
docu-menting utility in cases in which the
diagnosis is uncertain Although
this is not routinely recommended,
such tests should be considered
Classification of Posterior
Tibial Tendon
Insufficiency
Johnson and Strom7 initially
de-scribed a classification scheme for
posterior tibial tendon insufficiency
Although the classification is not
predictive and does not consider
the contracted gastrocnemius, the
initial three-stage scheme is useful
in developing algorithms for
treat-ment However, it has been found
helpful to also consider a fourth
stage of the disorder in developing
a treatment plan
Stage I
Stage I is defined as the absence
of a fixed deformity of the foot or
ankle with the possible exception of
a contracted gastrocnemius-soleus
complex The foot is in normal
alignment when the patient is
stand-ing Patients typically present with
pain along the course of the
poste-rior tibialis tendon and evidence of
local inflammatory changes
Stage II
Stage II is characterized by a
dynamic deformity of the hindfoot
The standing patient displays an
increased degree of hindfoot valgus,
apparent weakness of tibialis
poste-rior function, the characteristic
too-many-toes sign, and inability to do a
single-leg heel rise However,
pat-ients still have a relatively normal
arc of subtalar motion, and the foot
can be placed into a neutral
posi-tion, with the possible exception of
contraction of the
gastrocnemius-soleus complex
Stage III
Patients with stage III posterior tibial tendon insufficiency have a fixed deformity of the hindfoot
With the hindfoot in a fixed valgus position, it is not possible to re-duce the talonavicular joint Typi-cally, these patients also have an accompanying fixed forefoot supi-nation deformity that is a compen-satory change to accommodate the hindfoot valgus in order to main-tain a plantigrade foot Patients with stage III disease do not have obvious evidence of ankle abnor-malities
Stage IV
A relatively small subset of patients have ankle involvement secondary to long-standing fixed deformities of the hindfoot They may present with ankle arthritis due to eccentric loading of the ankle Some have a valgus talar tilt with loss of competence of the del-toid ligament complex
Pathophysiology
The etiology of posterior tibial ten-don insufficiency is elusive In an epidemiologic study, Holmes and Mann8 correlated the development
of posterior tibial tendon insuffi-ciency to hypertension and obesity
This condition affects more women than men Controversy exists about the development of posterior tibial tendon insufficiency in patients with rheumatoid arthritis, with some authors emphasizing the role of the tendon and others implying dysfunction secondary to subtalar arthrosis
The blood supply in the region
of tendon failure has been stud-ied.9,10 Some theorize that there is
an area of diminished perfusion at the site of tendon failure, which may have implications regarding the etiology of the injury and its apparent inability to heal
Mechani-cal causes of posterior tibial tendon insufficiency have been described, including an association with a contracted gastrocnemius-soleus complex
Recent immunohistologic stud-ies imply a lack of an inflammatory appearance in stage II disease The histologic appearance is consistent with mechanical failure of the col-lagen architecture of the tendon in the area of elongation and rupture, with mucoid degeneration Com-plete rupture of the tibialis poste-rior tendon is not common, as most patients have longitudinal failure
of the tendon substance In gross appearance, the tendon has been described as being the color of poached fish, often with longitudi-nal tears on the lateral side of the tendon (Fig 3) In cases of chronic posterior tibial tendon insufficiency, the gross appearance and histo-logic structure of the tendon are abnormal
Nonoperative Management
The initial management of patients who present in any stage of poste-rior tibial tendon insufficiency is nonoperative Some success has been achieved by immobilization of patients who have symptoms of acute tendinitis with or without deformity A trial with an accom-modative orthotic device that is supportive of the medial longitudi-nal arch is usually worthwhile Although there are no published studies documenting the efficacy of orthotic devices in the treatment of the various stages of this condition, there is certainly a population of patients who report a decreased level of symptoms associated with the use of such a device An ankle brace or ankle-foot orthosis will be helpful to some patients Nonster-oidal anti-inflammatory medication can decrease pain and associated swelling
Trang 5The role, benefit, and
appropri-ateness of corticosteroid injections
for this problem continue to be
controversial Published reports
associate the use of steroid
injec-tions with rupture of the tendon,
although it is possible that in these
instances rupture might have
occurred without injection due to
the underlying pathologic changes
in the tendon There are no
con-trolled studies of the use of such
injections Therefore, at this time,
routine use of injections in this area
cannot be recommended as part of
the nonoperative treatment of this
condition
Operative Management
The operative treatment of patients
in whom nonoperative
manage-ment has failed consists of either
tissue procedures alone or
soft-tissue procedures combined with
either osteotomies or arthrodesis
It is important to account for all the
fixed and dynamic structural
defor-mities present when defining a
spe-cific operative plan for a given
patient
Stage I
Patients who have stage I poste-rior tibial tendon insufficiency often
do not have a notable clinical defor-mity They have an inflammatory condition involving the tendon, but the tendon remains competent in terms of function, and there are no secondary deformities that have developed due to the tenosynovitis
These patients have been treated with debridement of the tendon and tenosynovectomy around the posterior tibial tendon There is only one recent study providing follow-up, and it supports the con-cept that the combination of debridement and tenosynovectomy
is effective in relieving pain.11
However, there are no published studies on this patient population that provide long-term follow-up data Consideration could be given
to augmentation of the posterior tibial tendon with the flexor digito-rum longus and to a gastrocnemius
or heel-cord lengthening
Stage II
It is in the treatment of this sub-set of patients where there is the greatest degree of controversy
regarding the optimal surgical management The historical foun-dation for treatment of this stage of posterior tibial tendon insufficiency
is provided by a study reporting on the debridement of the posterior tibial tendon and transfer of the flexor digitorum longus to the navic-ular.1 The results in 17 patients with a mean follow-up of less than
3 years have been very acceptable
in terms of relieving pain How-ever, it appears that the soft-tissue transfer does not correct the under-lying deformity
A recent article describes the results in a series of 13 patients fol-lowed up for a mean of 27 months after primary repair of the poste-rior tibial tendon and tenodesis of the flexor digitorum longus.12 The results were considered to support the idea that these procedures re-lieve pain and improve the ability
to ambulate Similarly, good re-sults have been achieved with spring-ligament repair or recon-struction in addition to tendon transfer.5
There is growing interest in oper-ations for stage II disease that attempt to compensate for the under-lying deformities and deforming forces with osteotomies or arthrode-ses The bone procedures are sup-plemented with dynamic transfers to replace the insufficient posterior tib-ial tendon Recent reports13,14have highlighted the early successful results of joint-sparing operations, such as a medializing osteotomy of the calcaneal tuberosity in addition
to tendon transfer and a procedure that combines a medializing cal-caneal osteotomy, a lateral columnÐ lengthening osteotomy through the anterior calcaneus, a flexor digito-rum longus tendon transfer to the medial cuneiform, and heel-cord lengthening (Fig 4) These two stud-ies demonstrate improved radio-graphic appearance, and the study
by Pomeroy and Manoli14 docu-ments statistically significant
im-Fig 3 Gross appearance of a degenerated posterior tibial tendon Note the disruption of
the fibers on the lateral side of the tendon.
Trang 6provement in function as indicated
by the score on the ankle-hindfoot
rating scale of the American
Ortho-paedic Foot and Ankle Society.15 The
early reports of the success of
joint-sparing operations allow optimism
that it may be possible to treat stage
II posterior tibial tendon insufficiency
with procedures that do not
necessi-tate a significant loss of hindfoot
motion and adaptability
Lateral-column lengthening
through the calcaneocuboid
articu-lation with medial soft-tissue
reconstruction has been advocated
The biomechanical and
radio-graphic implications of such
proce-dures have been studied by
Sangeorzan et al16 and Deland et
al.17 Subtalar arthrodesis is still
suggested by many experienced
foot and ankle surgeons, both alone
and in concert with medial
soft-tissue debridement and/or tendon
transfer The results of a study of
patients treated with isolated
talo-navicular arthrodesis demonstrated
improved function and decreased
pain.18 In another study,19 the
implications of a talonavicular
fusion in terms of the effect on
hindfoot motion implied a
signifi-cant loss of mobility
Stage III
The foot with stage III posterior tibial tendon insufficiency has fixed deformities that cannot be corrected
by osteotomies or soft-tissue proce-dures alone Typically, there is some degree of arthrosis present in the subtalar joint complex The proce-dures of choice in this stage of the disease include subtalar arthrodesis, double arthrodesis, and triple ar-throdesis These are frequently done
in conjunction with heel-cord length-ening The arthrodesis selected should be able to correct all of the deformities Once the subtalar joint has been taken out of an excessive degree of hindfoot valgus, fixed fore-foot supination necessitates a talo-navicular arthrodesis to rotate the foot into a plantigrade position In some cases with more extreme defor-mity, it may even be necessary to perform an operation to plantar-flex the first ray if full correction of the deformity cannot be accomplished with a triple arthrodesis The funda-mental goal is a plantigrade foot in a good position that supports the ankle in optimal alignment
Graves et al20reported on 17 patients who had undergone triple arthrodesis, 10 of whom had
poste-rior tibial tendon insufficiency The mean follow-up interval was 31Ú2
years The postoperative complica-tions were significant, and the authors recommended that triple arthrodesis be reserved as a salvage procedure They also emphasized the risk of increased arthrosis in joints adjacent to the arthrodesis
Stage IV
Patients with long-standing severe hindfoot valgus deformities and secondary ankle arthrosis are difficult to treat Fortunately, few patients fall into this category Most commonly, tibiocalcaneal arthrodesis or pantalar arthrodesis
is performed to address all of the deformities simultaneously
Summary
Posterior tibial tendon insufficiency
is a disorder with a broad spectrum
of clinical presentations It is essential that treatment be closely correlated to the particular static and dynamic deformities in the patient The classification system initially outlined by Johnson and Strom7 is helpful in determining
Fig 4 Preoperative (A) and postoperative (B) radiographic appearance of a patient who underwent a medializing calcaneal tuberosity
osteotomy and lateral columnÐlengthening calcaneal osteotomy.
Trang 7the stage of disease and the
treat-ment options available However,
without a documented natural
his-tory of the disorder or a known
time frame for the progression
from one stage to another, it
re-mains a challenge to counsel pa-tients regarding the optimal treat-ment Recently described joint-sparing operations and limited arthrodeses combined with soft-tissue reconstruction allow
opti-mism that patients with this dis-abling hindfoot condition can resume relatively normal function The long-term outcome of patients treated with these techniques re-mains unknown
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