Stage IV posterior tibial tendon insufficiency: the tilted ankle.

Stage IV PTTD is the most challenging of the posterior tibial tendon deficiencies. The combination of a flattened longitudinal arch and a tilted ankle make successful management unpredictable. Conservative management universally fails and surgical options have been limited to pantalar and tibiotalocalcaneal arthrodesis. Alternatives to surgical management included herein are unproven, but provide a potential solution beyond that of arthrodesis.