Effect of Extra-osseous Talotarsal Stabilization on Posterior Tibial Tendon Strain in Hyperpronating Feet

Published:September 12, 2011DOI:


      Posterior tibial tendon dysfunction is considered one of the most common causes of progressive adult acquired flatfoot deformity. The etiology leading to the dysfunction of posterior tibial tendon remains controversial. The purpose of this study was to quantify strain on the posterior tibial tendon in cadaver feet exhibiting hyperpronation caused by flexible instability of the talotarsal joint complex. We hypothesized that posterior tibial tendon strain would decrease after a minimally invasive extra-osseous talotarsal stabilization procedure. A miniature differential variable reluctance transducer was used to measure the elongation of posterior tibial tendon in 9 fresh-frozen cadaver specimens. The elongation was measured as the foot was moved from its neutral to maximally pronated position, before and after intervention with the HyProCure® extra-osseous talotarsal stabilization device. The mean elongation of the posterior tibial tendon (with respect to a fixed reference point) was found to be 6.23 ± 2.07 mm and 3.04 ± 1.85 mm, before and after intervention, respectively (N = 27; variation is ± 1 SD). The average elongation reduced by 51% and was statistically significant with p < .001. Strain on the posterior tibial tendon is significantly higher in hyperpronating feet. An extra-osseous talotarsal stabilization procedure reduces excessive abnormal elongation of the posterior tibial tendon by minimizing excessive abnormal pronation. This minimally invasive procedure may thus provide a possible treatment option to prevent or cure posterior tibial tendon dysfunction in patients exhibiting flexible instability of the talotarsal joint complex.

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        • Bloome D.M.
        • Marymont J.V.
        • Varner K.E.
        Variations on the insertion of the posterior tibialis tendon: a cadaveric study.
        Foot Ankle Int. 2003; 24: 780-783
        • Richie D.H.
        Biomechanical and clinical analysis of the adult acquired flatfoot.
        Clin Podiatr Med Surg. 2007; 24: 617-644
        • Smith C.F.
        Anatomy, function and pathophysiology of the posterior tibial tendon.
        Clin Podiatr Med Surg. 1999; 16: 399-406
        • Funk D.A.
        • Cass J.R.
        • Johnson K.A.
        Acquired adult flat foot secondary to posterior tibial-tendon pathology.
        J Bone Joint Surg Am. 1986; 68: 95-102
        • Mann R.A.
        Rupture of the tibialis posterior tendon.
        Inst Course Lect. 1984; 33: 302-309
        • Mann R.A.
        • Thompson F.M.
        Rupture of the posterior tibial tendon causing flatfoot. Surgical treatment.
        J Bone Joint Surg Am. 1985; 67: 556-561
        • Pomeroy G.C.
        • Pike R.H.
        • Beals T.C.
        • Manoli 2nd, A.
        Acquired flat foot in adults due to dysfunction of the posterior tibial tendon.
        J Bone Joint Surg Am. 1999; 81: 1173-1182
        • Beals T.C.
        • Pomeroy G.C.
        • Manoli A.
        Posterior tibial tendon insufficiency: diagnosis and treatment.
        J Am Acad Orthop Surg. 1999; 7: 112-118
        • Geideman W.M.
        • Johnson J.E.
        Posterior tibial tendon dysfunction.
        J Orthop Sports Phys Ther. 2000; 30: 68-77
        • Johnson K.A.
        Tibialis posterior tendon rupture.
        Clin Orthop Relat Res. 1983; 177: 140-147
        • Supple K.M.
        • Hanft J.R.
        • Murphy B.J.
        • Janecki C.J.
        • Kogler G.F.
        Posterior tibial tendon dysfunction.
        Semin Arthritis Rheum. 1992; 22: 106-113
        • Butler M.T.
        Tibialis posterior dysfunction.
        Aus J Podiatr Med. 2003; 37: 35-42
        • Deland J.T.
        Adult-acquired flatfoot deformity.
        J Am Acad Orthop Surg. 2008; 16: 399-406
        • Hintermann B.
        • Gächter A.
        The first metatarsal rise sign: a simple, sensitive sign of tibialis posterior tendon dysfunction.
        Foot Ankle Int. 1996; 17: 236-241
        • Johnson K.A.
        • Strom D.E.
        Tibialis posterior tendon dysfuncton.
        Clin Orthop Relat Res. 1989; 239: 196-206
        • Mendicino S.S.
        Posterior tibial tendon dysfunction. diagnosis, evaluation and treatment.
        Clin Podiatr Med Surg. 2000; 17: 33-54
        • Myerson M.S.
        Adult acquired flatfoot deformity. Treatment of dysfunction of the posterior tibial tendon.
        J Bone Joint Surg Am. 1996; 78: 780-792
        • Popovic N.
        • Lemaire R.
        Acquired flatfoot deformity secondary to dysfunction of the tibialis posterior tendon.
        Acta Orthop Belg. 2003; 69: 211-221
        • Grogan D.P.
        • Gasser S.I.
        • Ogden J.A.
        The painful accessory navicular: a clinical and histopathological study.
        Foot Ankle. 1989; 10: 164-169
        • Frey C.
        • Shereff M.
        • Greenidge N.
        Vascularity of the posterior tibial tendon.
        J Bone Joint Surg Am. 1990; 72: 884-888
      1. Jahss MH. Tendon disorders of the foot and ankle. In Disorders of the Foot and Ankle. Medical and Surgical Management, ed 2, pp 1461–1513, edited by MH Jahss, WB Saunders, Philadelphia, 1991.

        • Deland J.T.
        • Page A.
        • Sung I.H.
        • O'Malley M.J.
        • Inda D.
        • Choung S.
        Posterior tibial tendon insufficiency results at different stages.
        HSS J. 2006; 2: 157-160
        • Alvarez R.G.
        • Marini A.
        • Schmitt C.
        • Saltzman C.L.
        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: 2-8
        • Karges D.E.
        Current concepts for treatment of the painful flatfoot in the elderly.
        Mo Med. 2005; 102: 236-239
        • Sobel E.
        • Levitz S.J.
        • Caselli M.A.
        Orthoses in the treatment of rearfoot problems.
        J Am Podiatr Med Assoc. 1999; 89: 220-233
        • Zaw H.
        • Calder J.D.
        Operative management options for symptomatic flexible adult acquired flatfoot deformity: a review.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 135-142
        • Banks A.S.
        • McGlamry E.D.
        Tibialis posterior tendon rupture.
        J Am Podiatr Med Assoc. 1987; 77: 170-176
        • Dyal C.
        • Feder J.
        • Deland J.T.
        • Thompson F.M.
        Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot.
        Foot Ankle Int. 1997; 18: 85-88
        • Jahss M.H.
        Spontaneous rupture of the tibialis posterior tendon: clinical findings, tenographic studies, and a new technique of repair.
        Foot Ankle. 1982; 3: 158-166
        • Kohls-Gatzoulis J.A.
        • Singh D.
        • Angel J.C.
        Tibialis posterior insufficiency occurring in a patient without peronei: a mechanical aetioogy.
        Foot Ankle Int. 2001; 22: 950-952
        • Yeap J.S.
        • Singh D.
        • Birch R.
        Tibialis posterior tendon dysfunction: a primary or secondary problem?.
        Foot Ankle Int. 2001; 22: 51-55
        • Stovitz S.D.
        • Coetzee J.C.
        Hyperpronation and foot pain. Steps towards pain-free feet.
        Phys Sportsmed. 2004; 32: 19-26
        • Landorf K.
        Tibialis posterior dysfunction. Early identification is the key to success.
        Aust Podiatr. 1995; 29: 9-14
        • Lanham R.H.
        Indications and complications of arthroereisis in hypermobile flatfoot.
        J Am Podiatry Assoc. 1979; 69: 178-185
        • Chang T.J.
        • Lee J.
        Subtalar joint arthroereisis in adult-acquired flatfoot and posterior tibial tendon dysfunction.
        Clin Podiatr Med Surg. 2007; 24: 687-697
        • Schon L.C.
        Subtalar arthroereisis: a new exploration of an old concept.
        Foot Ankle Clin. 2007; 12: 329-339
        • Graham M.E.
        • Jawrani N.T.
        • Goel V.K.
        The effect of HyProCure® sinus tarsi stent on tarsal tunnel compartment pressures in hyperpronating feet.
        J Foot Ankle Surg. 2011; 50: 44-49
        • Niki H.
        • Ching R.P.
        • Kiser P.
        • Sangeorzan B.J.
        The effect of posterior tibial tendon dysfunction on hindfoot kinematics.
        Foot Ankle Int. 2001; 22: 292-300
        • Fujii T.
        • Uchiyama E.
        • Kitaoka H.B.
        • Luo Z.P.
        • Zhao K.D.
        • An K.N.
        The influence of flatfoot deformity on the gliding resistance of tendons about the ankle.
        Foot Ankle Int. 2009; 30: 1107-1110
        • Prado M.P.
        • de Carvalho A.E.J.
        • Rodrigues C.J.
        • Fernandes T.D.
        • Mendes A.A.
        • Salomao O.
        Vascular density of the posterior tibial tendon: a cadaver study.
        Foot Ankle Int. 2006; 27: 628-631
        • Myerson M.S.
        • Badekas A.
        • Schon L.C.
        Treatment of stage II posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy.
        Foot Ankle Int. 2004; 25: 445-450
        • Maxwell J.R.
        • Carro A.
        • Sun C.
        Use of the Maxwell-Brancheau arthroereisis implant for the correction of posterior tibial tendon dysfunction.
        Clin Podiatr Med Surg. 1999; 16: 479-489
        • Viladot R.
        • Pons M.
        • Alvarez F.
        • Omaña J.
        Subtalar arthroereisis for posterior tibial tendon dysfunction: a preliminary report.
        Foot Ankle Int. 2003; 24: 600-606
        • Zaret D.I.
        • Myerson M.S.
        Arthroereisis of the subtalar joint.
        Foot Ankle Clin Northj Am. 2003; 8: 605-617