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Tibialis posterior insufficiency

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Tibialis posterior insufficiency

  1. 1. Tibialis Posterior Insufficiency
  2. 2. Tibialis Posterior Insufficiency <ul><li>Introduction </li></ul><ul><li>Functional Anatomy </li></ul><ul><li>Etiology </li></ul><ul><li>Clinical Presentation </li></ul><ul><li>Treatment </li></ul>
  3. 3. Introduction <ul><li>Flatfoot – Acquired, congenital </li></ul><ul><li>Acquired </li></ul><ul><ul><li>Tarsal Coalition </li></ul></ul><ul><ul><li>Neurologic </li></ul></ul><ul><ul><li>Tib. Post. Insufficiency </li></ul></ul><ul><ul><ul><li>Frequently not appreciated </li></ul></ul></ul>
  4. 4. Anatomy <ul><li>Deep posterior compartment </li></ul><ul><li>Tendon in fibro-osseous groove </li></ul><ul><li>Multiple insertions –mainly navicular and med. Cuneiform </li></ul><ul><li>Posterior and medial to subtalar and ankle joint – flexes ankle and inverts hindfoot </li></ul><ul><li>Locks subtalar complex in push off </li></ul>
  5. 5. Etiology? <ul><li>Trauma </li></ul><ul><li>Systemic inflammatory process </li></ul><ul><li>Impingement in tunnel </li></ul><ul><li>Hypovascularity </li></ul>
  6. 6. Tibial Posterior Insufficiency
  7. 7. Tibialis Posterior Insufficiency ?Etiology? <ul><li>Tib post has 1.5 cm excursion </li></ul><ul><li>Static supporters become overloaded and painful </li></ul><ul><ul><li>Spring ligament, TN capsule, Plantar Fascia </li></ul></ul><ul><li>Painful Flatfoot develops </li></ul><ul><ul><li>Hindfoot equinus and valgus </li></ul></ul><ul><ul><li>Midfoot collapse and abduction </li></ul></ul>
  8. 8. Tibialis Posterior Insufficiency Presentation <ul><li>40-60 years 15% bilateral </li></ul><ul><li>75% women </li></ul><ul><li>Obese, hypertension </li></ul><ul><li>Vague, insidious onset, activity related medial pain </li></ul><ul><li>50% traumatic event </li></ul><ul><li>Calf pain </li></ul><ul><li>deformity </li></ul>
  9. 9. Tibialis Posterior Insufficiency Presentation <ul><li>Later </li></ul><ul><ul><li>Lateral pain </li></ul></ul><ul><ul><li>Stiffness </li></ul></ul>
  10. 10. Tibialis Posterior Insufficiency Presentation <ul><li>Tenosynovitis </li></ul><ul><li>Deformity </li></ul><ul><ul><li>Rigid or passively correctable </li></ul></ul><ul><li>Equinus contracture </li></ul><ul><li>“ too many toes sign” </li></ul><ul><li>Single limb heel raise </li></ul>
  11. 11. Too Many Toes Sign
  12. 12. Single limb heel raise
  13. 13. Radiographic Analysis
  14. 14. <ul><li>· In adult acquired flatfoot due to tibialis posterior tendon attrition the standing lateral radiographs shows loss of calcaneal angle of inclination and reversal of the talar-first metatarsal angle and on the standing AP divergence of the talar head and anterior calcaneous and lateral positioning of the navicular on the talar head. </li></ul>
  15. 17. <ul><li>U/S </li></ul><ul><li>MRI </li></ul><ul><li>In tendinosis the MRI findings include increased intra-tendinous signal intensity especially on the T2 weighted images, thickening of the tendon and peritendinous fluid. </li></ul><ul><li>Ultrasonography has been advocated by many as a means of evaluating tendinopathy but the success of the technique is very operator dependent and does not provide information with the clarity of an MRI. </li></ul>
  16. 18. Classification <ul><li>Johnson and Strom </li></ul><ul><li>Type 1 – Tenosynovitis, no deformity </li></ul><ul><li>Type 2 – flexible deformity </li></ul><ul><li>Type 3 – Rigid Deformity </li></ul><ul><li>Type 4 – Ankle involvement </li></ul>
  17. 19. Treatment Type1 <ul><li>Non-operative </li></ul><ul><ul><li>NSAIDS, Injections </li></ul></ul><ul><li>Operative </li></ul><ul><ul><li>Debridement </li></ul></ul><ul><ul><li>Medial Displacement Calcaneal Osteotomy </li></ul></ul>
  18. 20. Medial Displacement Calcaneal Osteotomy
  19. 21. Treatment Type 2 Non-operative <ul><li>UCBL heel cup </li></ul>
  20. 22. Treatment Type 2 Non-operative <ul><li>AFO </li></ul>
  21. 23. Treatment Type 2 Non-operative <ul><li>How aggressive surgically should you be ? </li></ul><ul><li>? What percentage will progress to a Type 3? </li></ul>
  22. 24. Treatment Type 2 <ul><li>Triple Arthrodesis </li></ul><ul><ul><li>Older, systemic, gold standard </li></ul></ul><ul><ul><li>Inherent problems in young - Ankle OA </li></ul></ul>
  23. 25. Treatment Type 2 <ul><li>Motion Sparing Procedure </li></ul><ul><ul><li>FDL tendon Transfer </li></ul></ul><ul><ul><li>Calcaneal Osteotomy </li></ul></ul><ul><ul><li>Spring Lig and TN capsule reefing </li></ul></ul><ul><ul><li>Lateral procedure? </li></ul></ul><ul><ul><li>Medial column fusion </li></ul></ul><ul><ul><li>?Combination? </li></ul></ul><ul><ul><li>Tendo-Achilles lengthening </li></ul></ul><ul><ul><li>Can easily be converted to a triple </li></ul></ul><ul><ul><li>Long time to improve </li></ul></ul>
  24. 26. Treatment Type 3 <ul><li>Triple </li></ul><ul><li>Tendo-Achilles lengthening </li></ul>
  25. 27. Treatment Type 4 <ul><li>Pantalar Arthrodesis </li></ul>
  26. 28. <ul><li>Probably more common than we think </li></ul><ul><li>Keep high index of suspicion </li></ul><ul><li>? Aggressive surgically </li></ul><ul><ul><li>Especially in the younger woman </li></ul></ul><ul><li>More study on natural history and what to do with a 1 and 2! </li></ul><ul><li>Pomeroy JBJS 1999 Vol.81-A 1173-1182 </li></ul>

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