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Abstract
Purpose
Posterior tibialis tendon dysfunction (PTTD) is one of the most common causes of acquired flatfoot deformity in western countries. But it was known that they were very rare in eastern countries. So we want to report the clinical features and outcomes of 12 patients with PTTD.
Materials and Methods
We evaluated the results of 12 patients using clinical features and results from March 2000 to January 2007 and mean follow up periods is 32 months.
Results
Average age was 45 years, 8 of 12 patients were female, 2 patient with hypertension and 1 with rheumatoid arthritis. 5 patients were overweighted and 5 patients were obese. 4 patients has a history of last trauma. 4 patients experienced progression of flatfoot. On behalf of Johnson and Strom classifications 6 cases were grade I, 4 cases were grade II, grade III, and grade IV was 1 case, relatively. As a treatment we used tenosynovectomy for 3 cases of grade I, additional FDL transfer was done for 2 cases of grade I and 2 cases of grade II. For other 2 patients of grade II flexor digitorum longus transfer and Medial displacement calcaneal osteotomy was done. Pathologic findings of tendon showed degenerative tendinitis. Lastly conservative treatment group was 3 cases of grade I, III, IV each. Average preoperative and postoperative American Orthopedic Foot and Ankle Society's hindfoot/ankle scoreFAS score was 58 and 90. Initial and follow up AOFAS scores of the conservative group was 38 and 57, relatively.
Figures and Tables
Fig. 1
Staged plain standing radiogram of PTTD. As the stages rise, increase in talonavicular coverage angle and talocalcaneal angle appear on anteroposterior (AP) radiogram, and talus sagging on lateral radiogram. (A) Johnson and Strom classification grade II: Increased talonavicular coverage angle on anteroposterior radiogram and sagging of talus on lateral radiogram. (B) Johnson and Strom classification grade III: Increased sagging of talus on ankle lateral standing radiogram, and fibulo-calcaneal impingement on both ankle anteroposterior standing radiogram. (C) Johnson and Strom classification grade IV: Valgus tilt of talus, decreased total height of the ankle and fibulocalcaneal impingement of left ankle on both ankle standing anteroposterior radiogram. Note the increased sagging of the talus on standing lateral radiogram.
Fig. 2
Single-limb heel raise test: The patient with posterior tibial tendon dysfunction with flatfoot on the right is being tested for strength of the posterior tibial tendon and muscle with a single heel rise test.
Fig. 3
Magnetic resonance imaging scan shows delayed rupture of posterior tibial tendon. (A) Initial MRI represented synovitis of posterior tibial tendon but, the continuity was intact (arrow). (B) Follow up MRI of 5 months later showed loss of posterior tibial tendon continuity (arrow).
Fig. 4
Preoperative and postoperative ankle lateral radiographs of a Johnson and Strom classification grade II PTTD: Preoperative and postoperative radiographs of the FDL transfer and medial calcaneal displacement osteotomy.
Fig. 5
Histologic appearances of posterior tibialis tendon. Tendon shows fibroblastic proliferation, neovascularization and mucinous degeneration. A few scattered lymphocytes are noted (Hematoxilin and Eosin stain, ×200).
Table 1
Summary of the Cases
$/¥, Preoperative/Postoperative; *, Talonavicular agle; †, Talo-1stMT angle; ‡, Talocalcaneal angle; ※, Johnson & Strom Classification; ₣, Tenosynovectomy and Debridement; ₤, FDL transfer with MDCO (Medial Displacement Calcaneal Osteotomy); ₱, conservative Tx; €,FDL transfer with Synovectomy and Debridement.
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