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Tibialis Posterior Insufficiency

Tibialis Posterior Insufficiency. Dr. N. Craig Stone Nov 21, 2002. Tibialis Posterior Insufficiency. Introduction Functional Anatomy Etiology Clinical Presentation Treatment. Tibialis Posterior Insufficiency Introduction. Flatfoot – Acquired, congenital Acquired Tarsal Coalition

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Tibialis Posterior Insufficiency

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  1. Tibialis Posterior Insufficiency Dr. N. Craig Stone Nov 21, 2002

  2. Tibialis Posterior Insufficiency • Introduction • Functional Anatomy • Etiology • Clinical Presentation • Treatment

  3. Tibialis Posterior InsufficiencyIntroduction • Flatfoot – Acquired, congenital • Acquired • Tarsal Coalition • Neurologic • Tib. Post. Insufficiency • Frequently not appreciated

  4. Tibialis Posterior InsufficiencyAnatomy • Deep posterior compartment • Tendon in fibro-osseous groove • Multiple insertions –mainly navicular and med. Cuneiform • Posterior and medial to subtalar and ankle joint – flexes ankle and inverts hindfoot • Locks subtalar complex in push off

  5. Tibialis Posterior Insufficiency?Etiology? • Trauma • Systemic inflammatory process • Impingement in tunnel • Hypovascularity

  6. Tibial Posterior Insufficiency

  7. Tibialis Posterior Insufficiency?Etiology? • Tib post has 1.5 cm excursion • Static supporters become overloaded and painful • Spring ligament, TN capsule, Plantar Fascia • Painful Flatfoot develops • Hindfoot equinus and valgus • Midfoot collapse and abduction

  8. Tibialis Posterior InsufficiencyPresentation • 40-60 years 15% bilateral • 75% women • Obese, hypertension • Vague, insidious onset, activity related medial pain • 50% traumatic event • Calf pain • deformity

  9. Tibialis Posterior InsufficiencyPresentation • Later • Lateral pain • Stiffness

  10. Tibialis Posterior InsufficiencyPresentation • Tenosynovitis • Deformity • Rigid or passively correctable • Equinus contracture • “too many toes sign” • Single limb heel raise

  11. Too Many Toes Sign

  12. Single limb heel raise

  13. Radiographic Analysis

  14. Radiographic Analysis

  15. Radiographic Analysis

  16. Radiographic Analysis • U/S • MRI

  17. Classification • Johnson and Strom • Type 1 – Tenosynovitis, no deformity • Type 2 – flexible deformity • Type 3 – Rigid Deformity • Type 4 – Ankle involvement

  18. Treatment Type1 • Non-operative • NSAIDS, Injections • Operative • Debridement • Medial Displacement Calcaneal Osteotomy

  19. Medial Displacement Calcaneal Osteotomy

  20. Treatment Type 2Non-operative • UCBL heel cup

  21. Treatment Type 2Non-operative • AFO

  22. Treatment Type 2Non-operative • ? How aggressive surgically should you be ? • ? What percentage will progress to a Type 3?

  23. Treatment Type 2 • Triple Arthrodesis • Older, systemic, gold standard • Inherent problems in young - Ankle OA

  24. Treatment Type 2 • Motion Sparing Procedure • FDL tendon Transfer • Calcaneal Osteotomy • Spring Lig and TN capsule reefing • Lateral procedure? • Medial column fusion • ?Combination? • Tendo-Achilles lengthening • Can easily be converted to a triple • Long time to improve

  25. Treatment Type 3 • Triple • Tendo-Achilles lengthening

  26. Treatment Type 4 • Pantalar Arthrodesis

  27. Summary • Probably more common than we think • Keep high index of suspicion • ? Aggressive surgically • Especially in the younger woman • More study on natural history and what to do with a 1 and 2! • Pomeroy JBJS 1999 Vol.81-A 1173-1182

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