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Posterior Tibial Tendon Dysfunction (PTTD) /
Adult Acquired Flatfoot
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Stage I - Posterior Tibial Tendon Dysfunction

Stage I Posterior Tibial Tendon Dysfunction may be characterized by inflammation and medial arch pain, with no positional change in the arch (1,2,6). Tenosynovitis will be apparent on an MRI, as well as fluid around the tendon appearing on an ultrasound; however, no degenerative changes will be present on an X-ray. The objective in Stage I PTTD is to minimize excessive midfoot movement. Stage I is successfully treated with non-surgical methods, such as biomechanical orthotics or heel elevators (2). However, subtalar extra-articular arthroereisis may be used if non-surgical methods are not successful.

Next Commonly Performed Soft Tissue Surgical Procedures

Next Commonly Performed Surgical Procedures

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Commonly Performed Soft Tissue Surgical Procedures

  • Tenosynovectomy / Debridement
    • A synovectomy of the Posterior Tibial Tendon sheath is performed to reduce inflammation around the tendon, a possible cause of dysfunction. Debridement is performed in combination with the synovectomy to remove any dead or necrotic tissue in the surrounding area. Augmentation with TenoGlide® can be performed to protect the repaired Posterior Tibial Tendon and provide a gliding surface for the surrounding tissue.
  • Tendon Transfer
    • Tendon transfers can be used to relieve stress on the Posterior Tibial Tendon. These often include transfer of the Flexor Digitorum Longus (FDL), or the Flexor Hallucis Longus (FHL). Because the Posterior Tibial Tendon has antagonist tendons that are stronger than the FDL or FHL, a Medializing Calcaneal Osteotomy is often performed in conjunction with the transfer. This biomechanically alters the foot, therefore avoiding long term failure of the new tendon.
  • Gastrocnemius Recession (e.g., Strayer procedure)
    • Equinus is a tightening of the complex including the achilles tendon, gastrocnemius, and soleus muscles. Gastrocnemius Recession (Open or Endoscopic) is used to release the tension on this complex, thereby returning the Posterior Tibial Tendon to functioning ability.
  • Tendo-Achilles Lengthening (TAL)
    • A tight achilles tendon can be a cause of a flatfoot. To relieve pressure on the Posterior Tibial Tendon, the achilles can be lengthened percutaneously, or by “Z” lengthening.
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Commonly Performed Surgical Procedures

  • Arthrodesis
    • A subtalar implant is placed within the sinus tarsi to limit excessive pronation of the subtalar joint. It is often referred to as an “internal orthotic” and is a minimally invasive procedure. Solutions (Subtalar MBA® Implant / bioBLOCK® Resorbable Subtalar Implant)
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*For product full prescribing information, see package insert.

References:

1. Kelly, Ian P, Mark E. Easly, TREATMENT OF STAGE 3 ADULT ACQUIRED FLATFOOT Foot and Ankle, Clin. Mar 2001: 153-166.

2. DiPaola M, Raikin SM, TENDON TRANSFERS AND REALIGNMENT OSTEOTOMIES FOR TREATMENT OF STAGE II POSTERIOR TIBIAL TENDON DYSFUNCTION, Foot Ankle Clin. 2007 June; 12(2): 273-85, vi.

3. Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd., ACQUIRED FLATFOOT IN ADULTS DUE TO DYSFUNCTION OF THE POSTERIOR TIBIAL TENDO,N J Bone Joint Surg Am. 1999 Aug; 81(8):1173-82.

4. Mann RA, Thompson FM, RUPTURE OF THE POSTERIOR TIBIAL TENDON CAUSING FLAT FOOT. SURGICAL TREATMENT, J Bone Joint Surg Am. 1985 Apr; 67(4): 556-61.

5. Bluman EM, Title CI, Myerson MS, POSTERIOR TIBIAL TENDON RUPTURE: A REFINED CLASSIFICATION SYSTEM, Foot Ankle Clin. 2007 June; 12(2):233-49,v.

6. Wacker JT, Hennessy MS, Saxby TS, CALCANEAL OSTEOTOMY AND TRANSFER OF THE TENDON OF FLEXOR DIGITORUM LONGUS FOR STAGE II DYSFUNCTION OF TIBIALIS POSTERIOR. THREE TO FIVE YEAR RESULTS, J Bone Joint Surg Br. 2002 Jan; 84(1):54-8.


 
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