Evaluation and Treatment of Posterior Tibialis Tendon Insufficiency in the Elderly Patients

Tochukwu C Ikpeze, James D Brodell Jr, Raymond E Chen, Irvin Oh, Tochukwu C Ikpeze, James D Brodell Jr, Raymond E Chen, Irvin Oh

Abstract

Introduction: Posterior tibialis tendon insufficiency is the most common cause of adult acquired flatfoot deformity in elderly patients. We performed a literature search of primary and secondary journal articles pertaining to posterior tibialis tendon insufficiency in the geriatric population. We examined relevant data from these articles regarding current evaluation in addition to both conservative and advanced treatment approaches that correspond to disease severity.

Significance: There is a paucity of literature to guide treatment of posterior tibialis tendon insufficiency in the elderly, and this condition may be more prevalent in geriatric patients than previously realized.

Results: Posterior tibialis tendon insufficiency is an acquired defect that affects 10% of the geriatric population and disproportionately affects women. It is typically caused by degenerative changes. There are four primary stages of posterior tibialis tendon with subcategorizations that range from mild to severe. Conservative treatment with a variety of available ankle braces and non-steroidal anti-inflammatory medications are typically used to treat the first and second stage disease. Surgical repair is warranted for advanced second stage and above posterior tendon insufficiency. A variety of techniques have been proposed, and can include tendon transfer, hindfoot fusion, and even total ankle arthroplasty in extreme cases.

Conclusion: Posterior tibialis tendon insufficiency causes marked discomfort and alters normal gait biomechanics. Elderly patients typically present with more severe manifestations of the disease. For patients requiring surgery, and especially geriatric patients, the ideal treatment is thought to be a procedure that is minimally invasive in order to maximize positive outcomes for elderly patients. More work is needed to examine clinical and radiographic outcomes of geriatric patients treated for posterior tibialis tendon insufficiency.

Keywords: foot and ankle surgery; fragility fractures; gait disorders; geriatric medicine; geriatric trauma.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Anteroposterior and lateral radiographs of stages I, II, III, and IV PTTI are shown. The progression from a mild deformity to a severe flattening of the medial arch is apparent. PTTI indicates posterior tibialis tendon insufficiency.
Figure 2.
Figure 2.
A select variety of the bracing and orthotics options available for the treatment of PTTI is shown. PTTI indicates posterior tibialis tendon insufficiency.
Figure 3.
Figure 3.
Pre- and postoperative radiographs of a 73-year-old female who presented with a rigid flatfoot deformity and painful degenerative arthritis of the talonavicular joint (stage 3 PTTI). Intraoperatively, a tear of the posterior tibialis tendon was noted. Left foot Achilles tendon lengthening, talonavicular joint arthrodesis, and medializing calcaneal osteotomy were performed, with improvement in the patient’s deformity and clinical status. PTTI indicates posterior tibialis tendon insufficiency.

References

    1. Ikpeze TC, Elfar JC. The geriatric driver. Geriatr Orthop Surg Rehabil. 2016;7(2):106–109. doi:10.1177/2151458516644818.
    1. Lotz M, Loesser R. Effects of aging on articular cartilage homeostasis. Bone. 2012;51(2):241–248. doi:10.1016/j.immuni.2010.12.017.Two-stage.
    1. Kohls-Gatzoulis J, Angel J, Singh D. Tibialis posterior dysfunction as a cause of flatfeet in elderly patients. Foot. 2004;14(4):207–209. doi:10.1016/j.foot.2004.06.003.
    1. Myerson M. Adult aquired flat foot deformity. J Bone Joint Surg. 1996;78A:780–792.
    1. Mann R. Aquired flatfoot in adults. Clin Orthop Relat Res. 1983;181:46–51.
    1. Kosashvili Y, Fridman T, Backstein D, Safir O, Bar Ziv Y. The correlation between pes planus and anterior knee or intermittent low back pain. Foot Ankle Int. 2008;29(8):910–913. doi:10.3113/FAI.2008.0910.
    1. Richie DH. Biomechanics and clinical analysis of the adult acquired flatfoot. Clin Podiatr Med Surg. 2007;24(4):617–644. doi:10.1016/j.cpm.2007.07.003.
    1. Funk D, Cass J, Johnson K. Acquired adult flat foot secondary to posterior tibial-tendon pathology. J Bone Joint Surg. 1986;68(1):95–102.
    1. Beals TC, Pomeroy GC, Manoli A. Posterior tibial tendon insufficiency: diagnosis and treatment. J Am Acad Orthop Surg. 1999;7(2):112–118.
    1. Kohls-Gatzoulis J, Woods B, Angel JC, Singh D. The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot Ankle Surg. 2009;15(2):75–81. doi:10.1016/j.fas.2008.08.003.
    1. Kohls-Gatzoulis JA, Singh D, Angel JC. Tibialis posterior insufficiency occurring in a patient without peronei: a mechanical etiology. Foot Ankle Int. 2001;22(12):950–952. doi:10.1177/107110070102201203.
    1. Mann R, Thompson F. Rupture of the posterior tibial tendon causing flat foot. J Bone Joint Surg. 1985;67A:556–561.
    1. Holmes GJ, Mann R. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle. 1992;13(2):70–79.
    1. Johnson K, Strom D. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989;(239):196–206.
    1. Guelfi M, Pantalone A, Mirapeix RM, Vanni D. Anatomy, pathophysiology and classification of posterior tibial tendon dysfunction. Eur Rev Med Pharmacol Sci. 2017;21:13–19. .
    1. Bluman EM, Title CI, Myerson MS. Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin. 2007;12(2):233–249. doi:10.1016/j.fcl.2007.03.003.
    1. Deland JT. Adult-acquired flatfoot deformity. J Am Acad Orthop Surg. 2008;16(7):399–406. doi:10.1016/j.cpm.2014.05.001.
    1. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology. 2006;45(5):508–521. doi:10.1093/rheumatology/kel046.
    1. Marzano R. Functional bracing of the adult acquired flatfoot. Clin Podiatr Med Surg. 2007;24(4):645–656. doi:10.1016/j.cpm.2007.06.002.
    1. Steb H, Marzano R. Conservative management of posterior tibial tendon dysfunction, subtalar joint complex, and pes planus deformity. Clin Pod Med Surg. 1999;16(3):439–451.
    1. Sferra J, Rosenberg G. Nonoperative treatment of posterior tibial tendon pathology. Foot Ankle Clin. 1997;(2):261–273.
    1. Bowring B, Chockalingam N. Conservative treatment of tibialis posterior tendon dysfunction – a review. Foot. 2010;20(1):18–26. doi:10.1016/j.foot.2009.11.001.
    1. Augustin J, Lin S, Berberian W, Johnson J. Nonoperative treatment of adult acquired flat foot with the Arizona brace. Foot Ankle Clin. 2003;8(3):491–502.
    1. Kulig K, Reischl SF, Pomrantz AB, et al. Nonsurgical management of posterior tibial tendon dysfunction with orthoses and resistive excercise: a randomized controlled trial. Phys Ther. 2009;89(1):26–37.
    1. Chao W, Wapner K, Lee T, Adams J, Hecht P. . nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int. 1996;17(12):736–741.
    1. Wapner K, Chao W. Nonoperative treatment of posterior tibial tendon dysfunction. Clin Orthop Relat Res. 1999;(365):39–45.
    1. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. Foot Ankle Int. 2006;27(1):2–8. doi:10.1177/107110070602700102.
    1. Lin JL, Balbas J, Richardson EG. Results of non-surgical treatment of stage II posterior tibial tendon dysfunction: a 7- to 10-year followup. Foot Ankle Int. 2008;29(8):781–786. doi:10.3113/FAI.2008.0781.
    1. Houck J, Neville C, Tome J, Flemister A. Randomized controlled trial comparing orthosis augmented by either stretching or stretching and strengthening for stage II tibialis posterior tendon dysfunction. Foot Ankle Int. 2015;36(9):1006–1016. doi:10.1177/1071100715579906.
    1. Ikpeze TC, Omar A, Elfar JH. Evaluating problems with footwear in the geriatric population. Geriatr Orthop Surg Rehabil. 2015;6(4):338–340. doi:10.1177/2151458515608672.
    1. Teasdall R, Johnson K. Surgical treatment of stage I posterior tibial tendon dysfunction. Foot Ankle Int. 1994;15(12):646–648.
    1. Myerson M, Corrigan J. Treatment of posterior tibial tendon dysfuncton with flexor digitorum longus tendon trasfer and calcaneoal osteotomy. Orthopedics. 1996;19(5):383–388.
    1. Silva MGAN, Tan SHS, Chong HC, Su HCD, Singh IR. Results of operative correction of grade IIB tibialis posterior tendon dysfunction. Foot Ankle Int. 2015;36(2):165–171. doi:10.1177/1071100714556758.
    1. Conti MS, Jones MT, Savenkov O, Deland JT, Ellis SJ. Outcomes of reconstruction of the stage II adult-acquired flatfoot deformity in older patients. Foot Ankle Int. 2018;39(9):1019–1027. doi:10.1177/1071100718777459.
    1. Wacker J, Hennessey M, Saxby T. Calcaneal osteotomy and transfer of the tendon of flexor digitorum longus for state II dysfunction of tibialis posterior. three- to five-year results. J Bone Jt Surg. 2002;84(1):54–58.
    1. Fayazi AH, Nguyen H-V, Juliano PJ. Intermediate term follow-up of calcaneal osteotomy and flexor digitorum longus transfer for treatment of posterior tibial tendon dysfunction. Foot Ankle Int. 2002;23(12):1107–1111. doi:10.1177/107110070202301205.
    1. Chadwick C, Whitehouse SL, Saxby TS. Long-term follow-up of flexor digitorum longus transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction. Bone Joint J. 2015;97-B(3):346–352. doi:10.1302/0301-620X.97B3.34386.
    1. Laughlin T, Payette C. Triple arthrodesis and subtalar joint arthrodesis for the treatment of end-stage posterior tibial tendon dysfunction. Clin Pod Med Surg. 1999;16(3):527–555.
    1. Kitoaka H, Patzer G. Subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus. Clin Orthop Relat Res. 1997;(345):187–194.
    1. Hamel M, Henderson W, Khuri S, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc. 2005;53(3):424–429. doi:10.1111/j.1532-5415.2005.53159.x.
    1. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203(6):865–877. doi:10.1016/j.jamcollsurg.2006.08.026.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel