Biomechanical and Morphological Characterization of PTTD

Official title

Biomechanical and Morphological Characterization of the Foot in Patients With Posterior Tibial Tendon Dysfunction.

Overview

Posterior tibial tendon dysfunction (PTTD) is a progressive condition of the tendon of the tibialis posterior muscle with symptoms of tendinopathy or even rupture. Functionally, it is associated with the inability to lock the mid foot and thus manifests itself as a main contributor to adult acquired flatfoot deformity. Concerning treatment, clinical decision making is currently based on a classification integrating various parameters as pain, flexibility of the foot joints, the condition of the posterior tibial tendon assessed through ultrasound imaging and radiographic assessment of arthritic changes. Surprisingly, this classification does not consider any morphologic characteristics (the shape of a bone or joint) or functional, biomechanical characteristics of the foot and ankle, i.e. based on kinematics (e.g. range of motion) and/or kinetics (center of pressure, angular velocity, moment, power absorption and power generation of a joint). Detailed biomechanical characteristics of the foot and ankle can be reliably collected by instrumented gait analysis wherein a 3D camera system is combined with a force plate and plantar pressure platform. Kinematic studies in the field of PTTD typically considered the foot as a structure consisting of three segments: hind foot, forefoot and hallux. Consequently, the mid foot segment (the Chopart and Lisfranc joints) has been neglected, although it is this segment that is particularly affected in PTTD patients. The aim of this research is to overcome the limitations of the current classification system and treatment of PTTD patients, by complementing the current standard-of-care clinical assessment with better insight in the pathologic changes that occur in PTTD patients.

Detailed description

Posterior tibial tendon dysfunction (PTTD) is a progressive condition of the tendon of the tibialis posterior muscle with symptoms of tendinopathy or even rupture. Functionally, it is associated with the inability to lock the mid foot and thus manifests itself as a main contributor to adult acquired flatfoot deformity. Importantly, this condition is associated with severe pain, inability to walk, collapse of the foot arch and dislocation and destruction of foot joints, causing serious disability with respect to activities of daily living and professional activities.

Concerning treatment, clinical decision making is currently based on a classification integrating various parameters as pain, flexibility of the foot joints, the condition of the posterior tibial tendon assessed through ultrasound imaging and radiographic assessment of arthritic changes. PTTD stage 1 is characterized by tendinopathy and is suggested to be mainly treated conservatively. Stage 2 is characterized by a flexible flat foot deformation, mostly combined with a tear of the posterior tibial tendon. Here, treatment is suggested through osteotomies and soft tissue surgery. Stage 3 encompasses a rigid flat foot deformity associated with a fully dysfunctional posterior tibial tendon and degenerative changes of the hind foot joints. At this stage fusion of the affected joints should be considered. During recent decades, this classification has been extended with additional subgroups as well as a stage 4 which adds onto stage 3 with excessive tibio-talar valgus and is mainly treated by a complementary fusion of the ankle joint.

Surprisingly, this classification does not consider any morphologic characteristics (the shape of a bone or joint) or functional, biomechanical characteristics of the foot and ankle, i.e. based on kinematics (e.g. range of motion) and/or kinetics (center of pressure, angular velocity, moment, power absorption and power generation of a joint).

Detailed biomechanical characteristics of the foot and ankle can be reliably collected by instrumented gait analysis wherein a 3D camera system is combined with a force plate and plantar pressure platform. Kinematic studies in the field of PTTD typically considered the foot as a structure consisting of three segments: hind foot, forefoot and hallux. Consequently, the mid foot segment (the Chopart and Lisfranc joints) has been neglected, although it is this segment that is particularly affected in PTTD patients. While kinematic studies focus on joint motion, kinetic studies focus on the loading and impact associated with motion of the joints.

Besides documenting specific biomechanical characteristics of the different stages of PTTD, it is essential to explore the relation of these biomechanical characteristics with the bone morphology of the involved osseous structures.

The aim of this research is to overcome the limitations of the current classification system and treatment of PTTD patients, by complementing the current standard-of-care clinical assessment with better insight in the pathologic changes that occur in PTTD patients. This will be done by simultaneously acquiring kinematic, kinetic and morphologic characteristics in PTTD patients, with a special interest in the possible connection between these morphological and the biomechanics changes. Through these insights, we will be able to better classify these patients, using the developed biomechanical classification, as a first step towards an optimized, patient-tailored treatment plan which converts these individual pathological characteristics back to normal, giving the patients back their mobility and a live without pain, i.e. gaining back their quality of life.

Interventions

• Diagnostic test Radiography
  X-rays of the ankle; anterior-posterior, lateral, Mortise view and hindfoot alignment view. Standard weight bearing x-rays of the foot; anterior-posterior, lateral and oblique view.
• Diagnostic test Ultrasound
  Ultrasound of the posterior tibial tendon to see if there is an irritation, elongation or rupture.
• Diagnostic test MRI
  MRI when ultrasound is not conclusive to identify an irritation, elongation or rupture of the posterior tibial tendon.
• Diagnostic test CT-scan
  CT-scan to identify arthritis of the tibial-talar, subtalar and/or Chopart joints.
• Diagnostic test Gait analysis
  This lab is equipped with a 10-meter walkway surrounded by a passive optoelectronic motion analysis system consisting of 10 cameras to track the motion of markers. In the middle of the walkway, a force plate is integrated, with a pressure plate placed on top.

Primary outcome measures

• Kinematic characteristics during Gait analysis [Time frame: 1 year]
• Center of pressure during Gait analysis [Time frame: 1 year]
• Angular velocity during Gait analysis [Time frame: 1 year]
• Moment during Gait analysis [Time frame: 1 year]
• Power absorption during Gait analysis [Time frame: 1 year]
• Power generation during Gait analysis [Time frame: 1 year]
• Bone morphology [Time frame: 1 year]

Secondary outcome measures (5)

• American Orthopaedic Foot & Ankle Society (AOFAS) score [Time frame: 1 year]
• European Foot and Ankle Society (EFAS) score [Time frame: 1 year]
• 36-item Short Form Health Survey (SF36) [Time frame: 1 year]
• Visual Analogue Scale (VAS) pain [Time frame: 1 year]
• Visual Analogue Scale (VAS) satisfaction [Time frame: 1 year]

Eligibility criteria

Inclusion criteria

• Patient groups:

• Posterior tibial tendon dysfunction (all clinical stages)
• Age 18-675 year
• ICF obtained
• Control group:

• No pain complaints
• No pes plano valgus, PTTD or pes cavo varus or other foot and ankle pathology
• Age 18-75 year
• ICF obtained

Exclusion criteria patient and control groups:

• Being younger than 18 years
• Inability to walk without mobility aids
• Inability to walk < 100 meter
• Difference in leg length > 3cm
• Subjects with BMI>30 kg/m², due to less accurate gait analysis by absence of anatomical landmarks
• Subjects unable to perform a gait analysis
• Any medical condition possibly affecting normal gait.
• Pregnancy: at the start or during the study

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: Yes

Study design

Allocation

Non-randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Diagnostic

Study locations

Belgium · 1 center

• UZ Leuven — Leuven

Identifiers

NCT: NCT06260813 · S66277

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗