Issues relating to failure in the treatment of posterior tibial tendon dysfunction

As our understanding of the underlying cause of flat foot progression improves so will our understanding of how best to catalog and treat the instabilities that are seen. Determining the failure of one type of treatment will be difficult until we can better define the varied pathology and give the treatment methods sufficient time to prove or disprove their premise. If an underlying systemic disease, where either unreliable motor function or unstable ligament support is present, joint arthrodeses are the preferred method of treatment. It is important not to fuse in situ, but rather effect the complete realignment of the foot through the fused joints. At a minimum, I believe that the subtalar fusion is the most appropriate method for gaining a stable correction. Any more stability will warrant a triple arthrodesis. Treatment for the diseased tendon should also be addressed appropriately. Tendon reconstruction alone provides no assurance of weight-bearing deformity correction or lasting function for most patients who have isolated type 2 dysfunction and should be avoided as a stand-alone procedure. It still serves a vital purpose in restoring function to the foot, and, combined with other procedures, aids in the preservation of dynamic response to weight-bearing loads. The choice of adjunctive procedures should be based on the pathology present. Each of the treatment regimens that is discussed in this article has a place in the overall treatment of the clinical disease but none, by itself, seems to correct all of the presentations that are possible for this pathologic entity. The possible exception may be the use of a subtalar realignment and fusion, but this may be overkill in many mild to moderate deformities. Care should be taken in choosing the proper treatment based on the pathology that is presented by each patient.