Association of estrogen receptor ß polymorphisms with posterior tibial tendon dysfunction.

Posterior tibial tendon (PTT) dysfunction is three times more common in females, and some patients may have a predisposition without a clinically evident cause, suggesting that individual characteristics play an important role in tendinopathy. The present study investigated the association of rs4986938 (+ 1730G > A; AluI RFLP) and rs1256049 (- 1082G > A; RsaI RFLP) single nucleotide polymorphisms (SNPs) of estrogen receptor-beta (ER-ß) gene with PTT dysfunction. A total of 400 participants were recruited. The PTT dysfunction group: these patients underwent surgery, with PTT tendinopathy confirmed by histopathology and magnetic resonance image (MRI). The control group was composed of participants with no clinical or MRI evidence of PTT dysfunction. Each group was composed of 100 postmenopausal women, 50 premenopausal women, and 50 men. Genomic DNA was extracted from saliva samples, and genotypes were obtained by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP). Concerning the ER-ß SNP rs4986938, there were significant differences in the frequencies of alleles between test and control groups of all the cases, only postmenopausal women and only men (p < 0.0001, p = 0.0016 and p = 0.0001). Considering the PTT dysfunction group and comparing postmenopausal women versus premenopausal women adding men, the analysis showed significant differences in the allelic distribution (p = 0.0450): the allele A in postmenopausal women is a risk factor. The ER-ß SNP rs1256049 did not show differences in the frequencies of alleles and genotypes between groups. The ER-ß SNP rs4986938, but not ER -ß SNPs rs1256049, may contribute to PTT insufficiency in the Brazilian population, with additional risk in postmenopausal women. Addition, in men the genetic factor could be more determinant.

Tibialis posterior muscle pain effects on hip, knee and ankle gait mechanics.

BACKGROUND: Tibialis posterior (TP) dysfunction is a common painful complication in patients with rheumatoid arthritis (RA), which can lead to the collapse of the medial longitudinal arch. Different theories have been developed to explain the causality of tibialis posterior dysfunction. In all these theories, pain is a central factor, and yet, it is uncertain to what extent pain causes the observed biomechanical alterations in the patients. The aim of this study was to investigate the effect of experimental tibialis posterior muscle pain on gait mechanics in healthy subjects. METHODS: Twelve healthy subjects were recruited for this randomized crossover study. Experimental pain was induced by ultrasound-guided injection of 1 mL hypertonic saline into the upper part of the right tibialis posterior muscle with the use of isotonic saline as non-pain-inducing control. Subsequently, kinematic data during three self-paced over ground walking for each condition were collected. Ground reaction forces and external moments were measured from force plates installed in the floor. Painful areas were evaluated using body charts and pain intensity scoring via a verbal numerical rating scale. FINDINGS: Decreased hip internal rotation was observed during the pain condition at the end of the stance phase. There were no changes in gait velocity and duration of stand phase between the pain and no pain conditions. Reduced external joint moment was found for external knee rotation and for external hip rotation. INTERPRETATION: The study has demonstrated that induced pain in the TP muscle evokes kinematic alteration in the hip and the knee joints, but not in the ankle, which suggest an underlying early stage joint compensatory mechanism. These findings suggest the need to include those joints in current physical evaluations of tibialis posterior dysfunction.

Three-Dimensional Morphometric Modeling Measurements of the Calcaneus in Adults with Stage IIB Posterior Tibial Tendon Dysfunction: A Pilot Study.

Background: The pathophysiology of adult-acquired flatfoot deformity (AAFD) is not fully explained by degeneration of the posterior tibial tendon alone. While a shortened or dysplastic lateral column has been implicated in flatfoot deformity in pediatrics, there is no study that has quantified the degree of dysplasia in adults with a stage IIb flatfoot deformity, or if any exists at all. Methods: An institutional radiology database was queried for patients with posterior tibial tendon dysfunction (PTTD) who had computed tomography (CT) performed. Controls were patients receiving CT scan for an intra-articular distal tibia fracture without preexisting foot or calcaneal pathology. Clinical notes, physical examination, and weightbearing radiographs were used to find patients that met clinical criteria for stage IIb PTTD. Morphometric measurements of the calcanei were performed involving the length of the calcaneal axis (LCA), height of the anterior process (HAP), and length of the anterior process (LAP). All measurements were performed independently by separate observers, with observers blinded to group assignment. We considered a difference of ±4 mm as our threshold. Results: 7 patients and 7 controls were available for reconstruction and analysis. On average, the LCA was 3.1 mm shorter in patients with stage IIb PTTD compared with controls (P < .05). The LAP was shorter in PTTD patients compared with controls 3.4 mm (P < .001). Conclusions: Our results support the hypothesis that the calcaneus of adult patients with stage IIb AAFD is dysplastic when compared with healthy controls, which further supports the utility of lateral column lengthening. Levels of Evidence: Level III: Case-control study.

Posterior tibial tendon dysfunction: Clinical and magnetic resonance imaging findings having histology as reference standard.

OBJECTIVE: To investigate the correlation between MRI, clinical tests, histopathologic features of posterior tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot deformity surgically treated with medializing calcaneal osteotomy and flexor digitorum longus tendon transposition. MATERIALS AND METHODS: Nineteen patients (11 females; age: 46 ±â€¯15 year, range 18-75) were pre-operatively evaluated using the single heel rise (HR) and the first metatarsal rise (FMR) sign tests. Two reviewers graded the PTT tears on a I-III scale and measured the hindfoot valgus angle on the pre-operative MRI of the ankle. The specimens of the removed portion of PTT were histologically analysed by two pathologists using the Bonar and Movin score. Linear regression, Spearman's rank-order, and intraclass correlation coefficient (ICC) statistics were used. RESULTS: ICC for MRI was excellent (0.952). Correlation between FMR and HR tests was at limit of significance (r = 0.454; P = 0.051). The HR and FMR tests were significantly correlated to the Movin score (r = 0.581; P = 0.009 and r = 0.538; P = 0.018, respectively) and were not significantly correlated to the Bonar score (both with a r = 0.424; P = 0.070). PTT tendinopathy grading at MRI was significantly correlated to the FMR test (p = 0.041) but not to the hindfoot valgus angle (p = 0.496), the HR test (p = 0.943), the Bonar score (p = 0.937), and the Movin score (p = 0.436). The hindfoot angle was not correlated to any of the other variables (p > 0.264). CONCLUSION: For PTT dysfunction, there is high correlation between HR and FMR test and histology evaluated using the Movin score, while no correlation was seen for the Bonar score. Semiquantitative grading of PTT dysfunction at MRI only correlates to the FMR and not to histology. The hindfoot valgus angle is not correlated to any of the considered variables.

Imaging of posterior tibial tendon dysfunction--Comparison of high-resolution ultrasound and 3T MRI.

PURPOSE: Posterior tibial tendon dysfunction is the most common cause of acquired asymmetric flatfoot deformity. The purpose of this study was to determine and compare the diagnostic value of MRI and high-resolution ultrasound (HR-US) in posterior tibial tendon dysfunction (PTTD), and assess their correlation with intraoperative findings. MATERIALS AND METHODS: We reviewed 23 posterior tibial tendons in 23 patients with clinical findings of PTTD (13 females, 10 males; mean age, 50 years) with 18MHz HR-US and 3T MRI. Surgical intervention was performed in nine patients. RESULTS: HR-US findings included 2 complete tears, 6 partial tears, 10 tendons with tendinosis, and 5 unremarkable tendons. MRI demonstrated 2 complete tears, 7 partial tears, 10 tendons with tendinosis, and 4 unremarkable tendons. HR-US and MRI were concordant in 20/23 cases (87%). Image findings for HR-US were confirmed in six of nine patients (66.7%) by intraoperative inspection, whereas imaging findings for MRI were concordant with five of nine cases (55.6%). CONCLUSION: Our results indicate that HR-US can be considered slightly more accurate than MRI in the detection of PTTD.

Is advanced imaging necessary before surgical repair.

Posterior tibial tendon dysfunction (tendinitis, tendinosis, or rupture) and adult acquired flatfoot deformity can manifest with a wide array of bony and soft tissue abnormalities visible on plain radiographs, ultrasound, and magnetic resonance imaging. Imaging abnormalities include various combinations of malalignment, anatomic variants, and enthesopathic and tendinopathic changes. A thorough understanding of differences between anatomic and pathologic presentations of structures in various imaging modalities is an essential tool for clinical and surgical planning.

Surgical management of stage 2 adult acquired flatfoot.

Adult acquired flatfoot deformity is a progressive disorder with multiple symptoms and degrees of deformity. Stage II adult acquired flatfoot can be divided into stage IIA and IIB based on severity of deformity. Surgical procedures should be chosen based on severity as well as location of the flatfoot deformity. Care must be taken not to overcorrect the flatfoot deformity so as to decrease the possibility of lateral column overload as well as stiffness.

Posterior tibial tendon dysfunction: a silent but disabling condition.

Posterior tibial tendon dysfunction is common and a major cause of flat foot (pes planus) and functional impairment in adults. It is frequently undiagnosed and therefore inappropriately managed. This review raises awareness of posterior tibial tendon dysfunction with the intention of improving patient management.

3-Tesla magnetic resonance imaging evaluation of posterior tibial tendon dysfunction with relevance to clinical staging.

The posterior tibial tendon (PTT) is the most important dynamic stabilizer of the medial ankle and longitudinal arch of the foot. PTT dysfunction is a degenerative disorder of the tendon, which secondarily involves multiple ligaments, joint capsules, fascia, articulations, and bony structures of the ankle, hindfoot, midfoot, and forefoot. When the tendon progressively attenuates, the patient develops a painful, progressive collapsed flatfoot or pes planovalgus deformity. This comprehensive review illustrates the 3-Tesla magnetic resonance imaging (3T MRI) features of PTT dysfunction. In addition, the reader will gain knowledge of the expected pathologic findings on MRI, as they are related to clinical staging of PTT dysfunction.

Treatment of posterior tibial tendon dysfunction without flexor digitorum tendon transfer: a retrospective study of 34 patients.

A retrospective study of patients who underwent gastrocnemius recession, double calcaneal osteotomy (Evans osteotomy and percutaneous calcaneal displacement osteotomy), and medial column fusion for the treatment of posterior tibial tendon dysfunction was conducted. The senior author performed the procedures between November 2002 and January 2009 on 34 patients who displayed at least Johnson and Strom stage II deformity and had undergone 12 months of failed conservative treatment. The coauthors evaluated the patients' radiographs before and after the operation. At a mean of 14 (range 3 to 44) months after surgery, radiographic measurements demonstrated statistically significant changes in the structural alignment of the feet. Based on our experience with these patients, we believe that a double calcaneal osteotomy combined with a gastrocnemius recession and stabilization of the medial column for the treatment of posterior tibial tendon dysfunction provides satisfactory correction, stability, and realignment of the foot. Furthermore, we feel that the use of flexor digitorum longus transfer, as well as triple arthrodesis, can be avoided without compromising the outcome when surgically treating posterior tibial tendon dysfunction.

Isolated talonavicular arthrodesis in patients with rheumatoid arthritis of the foot and tibialis posterior tendon dysfunction.

BACKGROUND: The foot is often affected in patients with rheumatoid arthritis. Subtalar joints are involved more frequently than ankle joints. Deformities of subtalar joints often lead to painful flatfoot and valgus deformity of the heel. Major contributors to the early development of foot deformities include talonavicular joint destruction and tibialis posterior tendon dysfunction, mainly due to its rupture. METHODS: Between 2002 and 2005 we performed isolated talonavicular arthrodesis in 26 patients; twenty women and six men. Tibialis posterior tendon dysfunction was diagnosed preoperatively by physical examination and by MRI. Talonavicular fusion was achieved via screws in eight patients, memory staples in twelve patients and a combination of screws and memory staples in six cases. The average duration of immobilization after the surgery was four weeks, followed by rehabilitation. Full weight bearing was allowed two to three months after surgery. RESULTS: The mean age of the group at the time of the surgery was 43.6 years. MRI examination revealed a torn tendon in nine cases with no significant destruction of the talonavicular joint seen on X-rays. Mean of postoperative followup was 4.5 years (3 to 7 years). The mean of AOFAS Hindfoot score improved from 48.2 preoperatively to 88.6 points at the last postoperative followup. Eighteen patients had excellent results (none, mild occasional pain), six patients had moderate pain of the foot and two patients had severe pain in evaluation with the score. Complications included superficial wound infections in two patients and a nonunion developed in one case. CONCLUSIONS: Early isolated talonavicular arthrodesis provides excellent pain relief and prevents further progression of the foot deformities in patients with rheumatoid arthritis and tibialis posterior tendon dysfunction.

A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot.

BACKGROUND: Biomechanical models have been used to study stress in the metatarsals, subtalar motion, lateral column lengthening and subtalar arthroereisis. Posterior tibial tendon dysfunction has been associated with increased loads in the arch of the acquired flat foot. We examine whether a 10 millimeter (mm) medial displacement calcaneal osteotomy and flexor digitorum longus transfer to the navicular reduces these increased loads in the flat foot. METHODS: The response of a normal foot, a foot with posterior tibial tendon dysfunction, and a flat foot to an applied load of 683Newton was analyzed using a multi-segment biomechanical model. The distribution of load on the metatarsals, the moment about each joint, the force on each of the plantar ligaments and the muscle forces were computed. FINDINGS: Posterior tibial tendon dysfunction results in increased load on the medial arch, which may cause the foot to flatten. A 10mm medial displacement calcaneal osteotomy substantially decreases the load on the first metatarsal and the moment at the talo-navicular joint and increases the load on the fifth metatarsal and the calcaneal-cuboid joint. Adding the flexor digitorum longus transfer to the medial displacement calcaneal osteotomy has only a small effect on the flattened foot. INTERPRETATION: Our biomechanical analysis illustrates that when the foot becomes flat, the force on the talo-navicular joint increases substantially from its value for the normal foot, and that medial displacement calcaneal osteotomy can reduce this increased force back toward the value occurring in the normal foot. This study provides a biomechanical rationale for medial displacement calcaneal osteotomy treatments for posterior tibial tendon dysfunction.

Shell brace for stage II posterior tibial tendon insufficiency.

BACKGROUND: The nonoperative treatment of posterior tibial tendon insufficiency (PTTI) can lead to unsatisfactory functional results. Short-term results are available but the impact on the evolution of the deformity is not known. To address these problems, a new brace for the flexible Stage II deformity was developed, and midterm followup was obtained. MATERIALS AND METHOD: In a prospective case series, eighteen patients (mean age 64.2 years; range, 31 to 82; four male, 14 female) with flexible Stage II PTTI were fitted with the new custom-molded foot orthosis. At latest followup of a mean of 61.4 (range, 20 to 87) months, functional results were assessed with the AOFAS ankle hindfoot score and clinical or radiographic progression was recorded. RESULTS: The score improved significantly from a mean of 56 points (range, 20 to 64) to a mean of 82 points (range, 64 to 100, p < 0.001). Three patients (3/18, 16%) had a clinical progression to a fixed deformity (Stage III) and a radiographic increase of their deformity. All the other patients were satisfied with the brace's comfort and noted an improvement in their mobility. Complications were seen in three patients (3/18, 16%), and consisted of the development of calluses. CONCLUSION: The "shell brace" is a valuable option for nonoperative treatment of the flexible Stage II PTTI. Hindfoot flexibility was conserved throughout the observation period in all but three patients. Functional outcome and patient acceptance was above average. Problems were few, and closely associated with a progression to a fixed, Stage III deformity.

Changes in histoanatomical distribution of types I, III and V collagen promote adaptative remodeling in posterior tibial tendon rupture.

INTRODUCTION: Posterior tibial tendon dysfunction is a common cause of adult flat foot deformity, and its etiology is unknown. PURPOSE: In this study, we characterized the morphologic pattern and distribution of types I, III and V collagen in posterior tibial tendon dysfunction. METHOD: Tendon samples from patients with and without posterior tibial tendon dysfunction were stained by immunofluorescence using antibodies against types I, III and V collagen. RESULTS: Control samples showed that type V deposited near the vessels only, while surgically obtained specimens displayed type V collagen surrounding other types of collagen fibers in thicker adventitial layers. Type III collagen levels were also increased in pathological specimens. On the other hand, amounts of collagen type I, which represents 95% of the total collagen amount in normal tendon, were decreased in pathological specimens. CONCLUSION: Fibrillogenesis in posterior tibial tendon dysfunction is altered due to higher expression of types III and V collagen and a decreased amount of collagen type I, which renders the originating fibrils structurally less resistant to mechanical forces.

Changes in histoanatomical distribution of types I, III and V collagen promote adaptative remodeling in posterior tibial tendon rupture

INTRODUCTION: Posterior tibial tendon dysfunction is a common cause of adult flat foot deformity, and its etiology is unknown. PURPOSE: In this study, we characterized the morphologic pattern and distribution of types I, III and V collagen in posterior tibial tendon dysfunction. METHOD: Tendon samples from patients with and without posterior tibial tendon dysfunction were stained by immunofluorescence using antibodies against types I, III and V collagen. RESULTS: Control samples showed that type V deposited near the vessels only, while surgically obtained specimens displayed type V collagen surrounding other types of collagen fibers in thicker adventitial layers. Type III collagen levels were also increased in pathological specimens. On the other hand, amounts of collagen type I, which represents 95 percent of the total collagen amount in normal tendon, were decreased in pathological specimens. CONCLUSION: Fibrillogenesis in posterior tibial tendon dysfunction is altered due to higher expression of types III and V collagen and a decreased amount of collagen type I, which renders the originating fibrils structurally less resistant to mechanical forces.

Tendon transfers and realignment osteotomies for treatment of stage II posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction (PTTD) has been approached with a multitude of surgical techniques. This article outlines the current understanding of the flexor digitorum longus transfer and flexor hallucis longus transfer in the context of various osteotomy techniques for the correction of stage II PTTD. Pertinent clinical literature and scientific evidence will also be compared and analyzed.

Stage IV posterior tibial tendon rupture.

Adult acquired flatfoot deformity progresses through well defined stages as set out by Johnson and Strom. Myerson modified this classification system with the addition of a fourth, more advanced stage of the disease. This stage describes the involvement of the tibiotalar joint in addition to the hindfoot malalignment seen in stages II and III. This most advanced stage is comprised of a hindfoot valgus deformity, resulting from degeneration of the posterior tibial tendon, with associated valgus tilting of the talus within the mortise. The deformity at the tibiotalar joint may or may not be rigid. Although rigid deformities are still best treated with fusions of the ankle and hindfoot, supple tibiotalar deformity may be treated with joint sparing procedures involving reconstructive procedures of the foot and deltoid ligaments.

The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction.

BACKGROUND: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). METHODS: Twelve patients were divided into two groups, depending on whether the PT tendon was excised (Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. RESULTS: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. CONCLUSION: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.