Review Question - QID 212155

This patient has posterior tibial tendon insufficiency (PTTI). The spring ligament complex (aka superomedial calcaneonavicular ligament) is incompetent in late disease and is represented by A in Figure A

PTTI is the most common cause of adult-acquired flatfoot deformity and is caused by attenuation and tenosynovitis of the posterior tibial tendon leading to medial arch collapse. Diagnosis can be made clinically with loss of medial arch of the foot which may progress to hindfoot valgus, forefoot abduction and subsequent development of midfoot osteoarthritis. Treatment is nonoperative with orthotics and ankle braces in the early stages. A variety of surgical options are available and indicated for progressive and rigid deformities, subtalar or midfoot arthritis, and failure of nonoperative management.

Stein et al. reviewed the management of PTTI in adults. They reported that the current focus is on early diagnosis and treatment of this disorder with joint-sparing surgeries, such as corrective osteotomies and tendon transfers, when nonsurgical modalities have been exhausted. They concluded that it is helpful to be familiar with the pertinent pathophysiology and diagnostic pearls associated with PTTI, its treatment options, pertinent literature, and technique tips for the procedures currently being used.

Deland et al. reviewed PTTI. They reported that prompt early, aggressive nonsurgical management is important, and surgical correction should be considered in those who failed conservative management to avoid worsening of the deformity. They concluded that in all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex.

Tankson et al. reviewed stage II PTTI. They reported that this stage is characterized by an incompetent posterior tibial tendon that results in a flexible pes planovalgus deformity. They noted that as the hindfoot drifts into valgus, compensatory varus develops in the forefoot. They concluded that in some cases medial column instability can result in primary forefoot varus that drives the hindfoot into valgus.

Figure A depicts the unlabeled spring ligament complex. Illustration A is the corresponding image with labels

Incorrect Answers:
Answer 2: This is the joint capsule
Answer 3: These are the plantar ligaments
Answer 4: This is the plantar fascia
Answer 5: This is the tibialis posterior tendon