posterior tibial tendon insufficiency (ptti) - foot & ankle - orthobullets
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5/15/2014 Posterior Tibial Tendon Insufficiency (PTTI) - Foot & Ankle - Orthobullets.com
http://www.orthobullets.com/foot-and-ankle/7020/posterior-tibial-tendon-insufficiency-ptti 1/5
Author: Deborah Allen Topic updated on 03/15/14 3:47pm
15Posterior Tibial Tendon Insufficiency (PTTI)
Introduction
Posterior tibial tendon insufficiency is the most commoncause of adult-acquired flatfoot deformityEpidemiology
demographicsmore common in womenoften presents in the sixth decade
risk factorsobesityolder athletesinflammatory disorders
Mechanismexact etiology is unknown, but is assumed to be multifactorial
20% report an acute injuryPathoanatomy
tendon degeneration occurs in the watershed region distal to the medial malleolusbegins as tenosynovitis and progresses to significant tendinosis with an incompetent, painfultendon that lacks excursion fixed bony deformities occur at later stages
Associated conditionsyoung males with mild pes planus may have one of the following conditions
seronegative spondyloarthropathyinflammatory arthropathy
Anatomy
Muscletibialis posterior
originates from posterior fibula, tibia, and interosseous membraneinnervated by posterior tibial nerve (L4-5)
Tendonposterior tibial tendon (PTT) lies posterior to the medial malleolus before dividing into 3 limbs
anterior limbinserts onto navicular tuberosity and first cuneiform
middle limbinserts onto second and third cuneiforms, cuboid, and metatarsals 2-5
posterior limbinserts on sustentaculum tali anteriorly
Blood supplybranches of the posterior tibial artery supply the tendon distallya watershed area of poor intrinsic blood supply exists between the navicular and distal medialmalleolus (2-6 cm proximal to navicular insertion)
BiomechanicsPTT lies in an axis posterior to the tibiotalar joint and medial to the axis of the subtalar joint
functions as a primary dynamic support for the archacts as a hindfoot invertoradducts and supinates the forefoot during stance phase of gaitacts as secondary plantar flexor of the ankle
major antagonist to PTT is peroneus brevis activation of PTT allows locking of the transverse tarsal joints creating a rigid lever arm for thetoe-off phase of gait
Classification
Deformity Physical exam Radiographs
Stage I Tenosynovitis (+) single-leg toe raise Normal
Foot & Ankle
Introduction
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Posterior Tibial TendonInsufficiency (PTTI)
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5/15/2014 Posterior Tibial Tendon Insufficiency (PTTI) - Foot & Ankle - Orthobullets.com
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Stage I Tenosynovitis
No deformity
(+) single-leg toe raise Normal
Stage IIA Flatfoot deformity
Flexible hindfoot
Normal forefoot
(-) single-leg heel raise
Mild sinus tarsi pain
Arch collapse deformity
Stage IIB Flatfoot deformity
Flexible hindfoot
Forefoot abduction ("too many
toes", >40% talonavicular
uncoverage)
Stage III Flatfoot deformity
Rigid forefoot abduction
Rigid hindfoot valgus
(-) single-leg heel raise
Severe sinus tarsi pain
Arch collapse deformity
Subtalar arthritis
Stage IV Flatfoot deformity
Rigid forefoot abduction
Rigid hindfoot valgus
Deltoid ligament compromise
(-) single-leg heel raise
Severe sinus tarsi pain
Ankle pain
Arch collapse deformity
Subtalar arthritis
Talar tilt in ankle mortise
Presentation
Symptomsmedial ankle/foot pain and weakness is seen earlyprogressive loss of archlateral ankle pain due to subfibular impingement is a late symptom
Physical examinspection & palpation
pes planuscollapse of the medial longitudinal arch
hindfoot valgus deformityflexible stage IIrigid stage III, IV
forefoot abduction (Stage IIB disease)"too many toes" sign >40% talonavicular uncoverage
tenderness just posterior to tip of medial malleolusoften associated with an equinus contracture
range of motionsingle-limb heel rise
unable to perform in stages II, III, and IVdetermine whether deformity is flexible or fixed
flexible deformities are passively correctable to a plantigrade foot (stage II)rigid deformities are not correctable (stages III and IV)
Imaging
Radiographsrecommended views
weight bearing AP and lateral foot ankle mortise
findingsAP foot
increased talonavicular uncoverageincreased talo-first metatarsal angle (Simmon angle)
seen in stages II-IVweight bearing lateral foot
increased talo-first metatarsal angle (Meary angle)angles >4 indicate pes planus seen in stages II-IV
decreased calcaneal pitchnormal angle is between 17-32indicates loss of arch height
decreased medial cuneiform-floor heightindicates loss of arch height
subtalar arthritis
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5/15/2014 Posterior Tibial Tendon Insufficiency (PTTI) - Foot & Ankle - Orthobullets.com
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subtalar arthritis seen in stages III and IV
ankle mortisetalar tilt due to deltoid insufficiency
seen in stage IVMRI
findingsvariable amounts of tendon degeneration and arthritic changes in the talonavicular,subtalar, and tibiotalar joints
Ultrasoundincreasing role in the evaluation of pathology within the PTT
Differential
Pes planus secondary to midfoot pathology (osteoarthritis or chronic Lisfranc injury)
treat with midfoot fusion and a realignment procedureincompetence of the spring ligament (primary static stabilizer of the talonavicular joint) in theabsence of PTT pathology
treat with adjunctive spring ligament reconstruction in addition to standard flatfootreconstruction
Treatment
Nonoperativeimmobilization in walking cast/boot for 3-4 months
indicationsfirst line of treatment in stage I disease
custom-molded in-shoe orthosis
indicationsstage I patients after a period of immobilizationstage II patients
techniquemedial heel lift and longitudinal arch support
medial forefoot post indicated if fixed forefoot varus is present
UCBL with medial posting ankle foot orthosis
indicationsstage II, III, and IV patients who are not operative candidates, are sedentary and lowdemand (age > 60-70)
techniqueAFO family of braces (Arizona, molded, articulating)
AFO found to be most effective want medial orthotic post to support valgus collapseArizona brace is a molded leather gauntlet that provides stability to thetibiotalar joint, hindfoot, and longitudinal arch
Operativetenosynovectomy
indicationsindicated in stage I disease if immobilization fails
FDL transfer, calcaneal osteotomy, TAL, +/- forefoot correction osteotomy, +/- springligament repair, +/- PTT debridement
indicationsstage II disease
contraindicationshypermobilityneuromuscular conditionssevere subtalar arthritisobesity (relative)age >60-70 (relative)
triple arthrodesis and TAL indications
stage III disease stage II disease with severe subtalar arthritis
triple arthrodesis and TAL + deltoid ligament reconstruction
indicationsstage IV disease with passively correctable ankle valgus
tibiotalocalcaneal arthrodesisindications
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5/15/2014 Posterior Tibial Tendon Insufficiency (PTTI) - Foot & Ankle - Orthobullets.com
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Next Question
indicationsstage IV disease with a rigid hindfoot, valgus angulation of the talus, and tibiotalarand subtalar arthritis
Surgical Techniques
FDL transferindications
FDL is synergistic with tibialis posterior and therefore transfer can augment function ofdeficient PT
techniqueinsert FDL into navicular near insertion of PTvs. FHL transfer
FHL is more complicated to mobilize and has not shown improved resultsin the midfoot, FHL runs under FDL
Calcaneal osteotomy
indicated to correct hindfoot valgus techniques include
medial displacement calcaneal osteotomy (MDCO) used in stage IIA (insignificant forefoot abduction)
Evans lateral column lengthening osteotomy used in stage IIB (significant forefoot abduction)may require additional MDCO to correct the deformityoverlengthening may be corrected by a first TMT fusion or medial cuneiformosteotomy
TAL or gastrocnemius recessionindicated for equinus contracture
Forefoot correction osteotomy indicated for fixed forefoot supination/varus (stage IIC)techniques
plantarflexion (dorsal opening-wedge) medial cuneiform (Cotton) osteotomy used with a stable medial column (navicular is colinear with first MT)corrects residual forefoot varus after hindfoot correction is made surgically
medial column fusion (isolated first TMT fusion, isolated navicular fusion, or combinedTMT and navicular fusions)
used with an unstable medial column (plantar sag at first TMT and/ornaviculocuneiform joint)
Spring ligament repairindicated with spring ligament rupture in some cases
PTT debridementmay also be required
Triple arthrodesis
triple arthrodesis includes calcaneocuboid, talonavicular, subtalar joints additional medial column stabilization may be required
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Qbank (15 Questions)
Question: 1 of 13
TAG
(OBQ11.222) A 54-year-old female has a painful flatfoot that has not improved with over 8 months of conservative managementwith orthotics. Preoperatively, she was unable to perform a single-heel rise and her hindfoot was passively correctable. Figures Aand B are radiographs of the affected left foot. She undergoes FDL tendon transfer to the navicular, medial slide calcanealosteotomy, and tendoachilles lengthening procedures. Following these procedures, the appearance of the foot is demonstrated inFigure C. What is the next most appropriate intraoperative procedure to be performed during her foot reconstruction? ReviewTopic
FIGURES: A B C
1. Dorsiflexion closing wedge medial cuneiform osteotomy
2. In-situ 1st-3rd tarsometatarsal joint arthrodesis
3. Plantarflexion opening wedge medial cuneiform osteotomy
4. Lateral column closing wedge shortening osteotomy
5. Subtalar arthrodesis
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5/15/2014 Posterior Tibial Tendon Insufficiency (PTTI) - Foot & Ankle - Orthobullets.com
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Triple Arthrodesis in patient with Stage 3B PTTD.
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Plantarflexion opening wedge medial cuneiform osteotomy for
correction of fixed forefoot varus associated with flatfoot deformity.
Hirose CB, Johnson JE
Foot Ankle Int. 2004 Aug;25(8):568-74. PMID: 15363379 (Link to Pubmed)
Foot & Ankle - Journal Club - Posterior Tibial Tendon Insufficiency (PTTI)
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Nonoperative treatment of adult acquired flat foot with the Arizona
brace.
Augustin JF, Lin SS, Berberian WS, Johnson JE
Foot Ankle Clin. 2003 Sep;8(3):491-502. PMID: 14560901 (Link to Pubmed)
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Stage I and II posterior tibial tendon dysfunction treated by a
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Alvarez RG, Marini A, Schmitt C, Saltzman CL
Foot Ankle Int. 2006 Jan;27(1):2-8. PMID: 16442022 (Link to Pubmed)
Foot & Ankle - Journal Club - Posterior Tibial Tendon Insufficiency (PTTI)
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43 responses
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5. Subtalar arthrodesis
PREFERRED RESPONSE
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Oral Boards: Posterior TIbial Tendon Insufficiency (PTTI)
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