Posterior Tibial Tendon SURGICAL SOLUTIONS · The brochure has been developed with the contribution of Stephen Conti, MD and Richard M. Jay, DPM. Table Of Contents What is Posterior

S U RG I C A L S O LU T I O N SPosterior Tibial Tendon

PRODUCTS FOR SALE IN EUROPE, MIDDLE-EAST AND AFRICA ONLY

The brochure has been developed with the contribution of Stephen Conti, MD and Richard M. Jay, DPM.

Table Of Contents

What is Posterior Tibial Tendon Dysfunction? ��4Stage I ��5Stage II ▪ Early ��6Stage II ▪ Late �� 7Stage III ��8Stage IV ��9Integra SolutionsMBA™ Subtalar Implants �� 10Kalix® II Implant �� 10Uni-CP™ Compression Plate �� 11QWIX® ▪ Large QWIX® Fixation & Positioning Screws �� 11I�CO�S�® Ideal COmpression Screw �� 12Advansys® Plating System �� 12Panta® Arthrodesis Nail ��13Integra OS™ Osteoconductive Scaffold Putty �� 14Trel-X™ ▪ Trel-XC™* Demineralized Bone Matrix �� 14

Surgical SolutionsPosterior Tibial Tendon

3Surgical Solutions Posterior Tibial Tendon PRODUCTS FOR SALE IN EUROPE, MIDDLE-EAST AND AFRICA ONLY

What is Posterior Tibial Tendon Dysfunction?

When the Posterior Tibial Tendon becomes irritated from overuse, the gliding motion of the tendon becomes impaired, thus leading to Posterior Tibial Tendon Dysfunction (PTTD)� PTTD may be a slow or abrupt progression resulting in inflammation, overstretching, partial, or complete rupture of the tendon�1 The Posterior Tibial Tendon begins in the calf, runs along the medial aspect of the foot, and inserts into the navicular bone and lesser tarsus (ie� metatarsal bases, cuneiform, and cuboid)�2,3 The Posterior Tibial Tendon not only stabilizes the medial arch of the foot, it also plantar-flexes the foot which provides support during the toe-off phase of gait�1,2,3 Symptoms of PTTD may include pain, inflammation, an inward rolling of the ankle, and hindfoot valgus with forefoot abduction (a flattening of the medial arch of the foot)�1,2,3,4

Posterior Tibial Tendon Dysfunction is the leading contributor of Adult Acquired Flatfoot (Pes Planus)�1,2,3,4,5 Additional contributing factors to the onset of PTTD may include hypertension, diabetes, peripheral neuropathy, smoking, or arthritis� The demographic most associated with Posterior Tibial Tendon Dysfunction and Adult Acquired Flatfoot are women over 50 and athletes, who present with an aggravated Posterior Tibial Tendon�

A common test to evaluate Posterior Tibial Tendon Dysfunction is the “too many toes sign�” The “too many toes sign” measures abduction (deviation away from the midline of the body) of the forefoot� With damage to the Posterior Tibial Tendon, the forefoot will abduct or move out in relation to the rest of the foot� When the foot is viewed from behind in cases of PTTD, the toes appear as too many on the outside of the foot, also known as hindfoot valgus with forefoot abduction�

Several classifications have been developed to describe and treat Posterior Tibial Tendon Dysfunction�3,5 Treatment of PTTD is determined based upon the clinical stage and health of the patient�5 If PTTD is diagnosed and treated early, non-surgical methods may be applied, such as biomechanical orthotics or heel elevators, medications, and/or casting�1 Such shoe gear will decrease the functioning load of the Posterior Tibial Tendon by supporting the arch of the foot and stabilizing the hindfoot�

In cases where Posterior Tibial Tendon Dysfunction has significantly progressed, or in circumstances where non-surgical applications have failed, surgical treatment may be required to correct the damage to the Posterior Tibial Tendon� Integra LifeSciences Corporation offers innovative and comprehensive products, designed for the surgical procedures associated with the treatment of Posterior Tibial Tendon Dysfunction and Adult Acquired Flatfoot�

Flattening Of The Medial Arch

Surgical SolutionsHindfoot And Ankle Arthritis

Too Many Toes Sign

Forefoot AbductionHindfoot Valgus

Surgical Solutions Posterior Tibial Tendon PRODUCTS FOR SALE IN EUROPE, MIDDLE-EAST AND AFRICA ONLY

4

Stage I

Stage I Posterior Tibial Tendon Dysfunction may be characterized by inflammation and medial arch pain, with no positional change in the arch�1,2,6 Tenosynovitis will be apparent on an MRI, as well as fluid around the tendon appearing on an ultrasound; however, no degenerative changes will be present on an X-ray� The objective in Stage I PTTD is to minimize excessive midfoot movement� Stage I is successfully treated with non-surgical methods, such as biomechanical orthotics or heel elevators�2 However, subtalar extra-articular arthroereisis may be used if non-surgical methods are not successful�

Commonly Performed Soft Tissue Surgical Procedures

• Tenosynovectomy / Debridement A synovectomy of the Posterior Tibial Tendon sheath is performed to reduce inflammation around the tendon, a possible cause of dysfunction� Debridement is performed in combination with the synovectomy to remove any dead or necrotic tissue in the surrounding area�

• Tendon Transfer Tendon transfers can be used to relieve stress on the Posterior Tibial Tendon� These often include transfer of the Flexor Digitorum Longus (FDL), or the Flexor Hallucis Longus (FHL)� Because the Posterior Tibial Tendon has antagonist tendons that are stronger than the FDL or FHL, a Medializing Calcaneal Osteotomy is often performed in conjunction with the transfer� This biomechanically alters the foot, therefore avoiding long term failure of the new tendon�

• Gastrocnemius Recession (Strayer procedure) Equinus is a tightening of the complex including the achilles tendon, gastrocnemius, and soleus muscles� Gastrocnemius Recession (Open or Endoscopic) is used to release the tension on this complex, thereby returning the Posterior Tibial Tendon to functioning ability�

• Tendo-Achilles Lengthening (TAL) A tight achilles tendon can be a cause of a flatfoot� To relieve pressure on the Posterior Tibial Tendon, the achilles can be lengthened percutaneously, or by “Z” lengthening�

Commonly Performed Surgical Procedures

• Arthroereisis A subtalar implant is placed within the sinus tarsi to limit excessive pronation of the subtalar joint� It is often referred to as an “internal orthotic” and is a minimally invasive procedure� - MBA™, Kalix® II

Kalix® II MBA™ Subtalar Implant


Stage II ▪ Early

Stage II Early Posterior Tibial Tendon Dysfunction may be characterized by inflammation, medial hindfoot pain, warmth to the area, and/or a flexible hindfoot valgus with forefoot abduction (“too many toes sign”)�1,2,3 The patient may not be able to rise off their heel and onto their toes�3 The tendon may be partially or completely ruptured� An X-ray will present peritalar subluxation and an increased Talar 1st Metatarsal angle� Tenosynovitis, attenuation of the tendon, and tendinosis will be apparent on an MRI and ultrasound�


• Tenosynovectomy / Debridement

• Tendon Transfer

• Gastrocnemius Recession (Strayer procedure)

• Tendo-Achilles Lengthening (TAL)


• Arthroereisis - MBA™, Kalix® II

• Osteotomy Osteotomies are procedures that cut bone to lengthen, shorten, or change alignment� There are various osteotomy procedures that can be performed to realign and reposition bones in the foot that can help to reduce the symptoms of PTTD, such as Medial Column Fusion, Cotton Osteotomy and/or Evans/Dwyer Calcaneal Osteotomy� - Uni-CP™, Large QWIX®, and I�CO�S�®

Uni-CP™ Compression Plate

Also Available

Kalix® IIAnkle Arthroplasty

I.CO.S.® Ideal COmpression Screw dia� 4�0 mm Ideal COmpression Screw dia� 6�5 mm

Large QWIX® dia� 5�5 & 7�5 mm Fixation & Positioning Screw

MBA™ Subtalar Implant


6

Stage II ▪ Late

Stage II Late Posterior Tibial Tendon Dysfunction may be characterized by many of the same symptoms as in Stage II Early, with the addition of a positional change in the arch, and pain in the sinus tarsi�1 The patient may not be able rise off their heel and onto their toes�3 The tendon may be partially or completely ruptured� An X-ray may present the same findings as Stage II Early, as well as a progressive angular change� The same findings as Stage II Early may be apparent on an MRI, as well as a TP Rupture and Early DJD (subchondral edema)� The same findings as Stage II Early may also be apparent on an ultrasound, as well as a tendon rupture� In this stage, the patient may not have responded to non-surgical methods, thus surgical intervention should be considered�



• Tendon Transfer




• Arthroereisis - MBA™, Kalix® II

• Osteotomy - Large Uni-Clip®, Uni-CP™,

Large QWIX® and I�CO�S�®

• Isolated Arthrodesis Arthrodesis prevents the motion of a joint to reduce pain associated with movement� It is performed using plates and screws to stop joint motion and often uses bone grafts to aid bony fusion� There are various isolated arthrodesis procedures to aid in the reduction of PTTD symptoms, such as Lapidus Fusion, Talar-Navicular Arthrodesis, Calcaneal-Cuboid Arthrodesis, and Subtalar Arthrodesis� To provide a framework for bone fusion through the osteotomy site, Integra offers Integra OS™ Osteoconductive Scaffold Putty, Trel-X™* Demineralized Bone Matrix, and Trel-XC™* Demineralized Bone Matrix with cancellous bone� - Uni-CP™, Large QWIX®, QWIX®, I�CO�S�®

Large QWIX® dia� 5�5 & 7�5 mm Fixation & Posi-tioning Screw



QWIX® Fixation Screw

Kalix® IIAnkle Arthroplasty

Osteobiologics: Integra OS™

Trel-X™*/Trel-XC™*

MBA™ Subtalar Implant

Also Available


Stage III

Stage III Posterior Tibial Tendon Dysfunction may be characterized by predominant lateral symptoms, a rigid or fixed hindfoot valgus and/or fixed forefoot abduction deformity� 1,2,3,5,6 The patient is unable to rise off their heel and onto their toes�1,3 The tendon will likely have severe degeneration and/or a rupture� An X-ray may present the same findings as Stage II Late, as well as degenerative changes in the hindfoot� The findings on an MRI and ultrasound may also be the same as Stage II Late� Surgical management may be an initial treatment option in this advanced stage of PTTD�



• Tendon Transfer




• Osteotomy - Large Uni-Clip®, Uni-CP™, Large

QWIX® and I�CO�S�®

• Isolated Arthrodesis - Uni-CP™, Large QWIX®, QWIX®, I�CO�S�®

• Multiple Arthrodesis Multiple Arthrodesis, such as Triple Arthrodesis Medial column fusion, prevents the motion of two or more joints to further reduce pain and excessive movement� To provide a framework for bone fusion through the osteotomy site, Integra offers Integra OS™ Osteoconductive Scaffold Putty, Trel-X™* Demineralized Bone Matrix, and Trel-XC™* Demineralized Bone Matrix with cancellous bone� - Uni-CP™, Large QWIX®, QWIX®, I�CO�S�®




* Availability of these products might vary from a given country or region to another, as a result of specific local regulatory approval or clearance requirements for sale in such country or region



I.CO.S.® Ideal COmpression Screw dia. 4.0 mm Ideal COmpression Screw dia. 6.5 mm

Also Available


8

Stage IV

Stage IV Posterior Tibial Tendon Dysfunction may be characterized by many of the same symptoms as in Stage III, with the addition of ankle valgus and instability� An X-ray, MRI, and ultrasound may present the same findings as in Stage III, in addition to severe ankle valgus and deformity�3 Arthritis of the ankle may be significant and secondary to the PTTD�2,3,5 Surgical management may be an initial treatment option in this advanced stage of PTTD�


• Isolated Arthrodesis - Uni-CP™, Large QWIX®, QWIX®, I�CO�S�®

• Multiple Arthrodesis Multiple Arthrodesis, such as Pantalar Arthrodesis, prevents the motion of two or more joints to further reduce pain and excessive movement� To provide a framework for bone fusion through the osteotomy site, Integra offers Integra OS Osteoconductive Scaffold Putty, Trel-X™ Demineralized Bone Matrix*, and Trel-XC™* Demineralized Bone Matrix with cancellous bone� - Panta®, Advansys®, QWIX®, Uni-CP,

Large QWIX®, I�CO�S�®




Panta® and Panta® XL Arthrodesis Nail

Advansys® Plating System Tibio-Talo-Calca-neal fusion Plate

Tibiaxys® Plating System Ankle Arthrodesis Plates



Also Available







MBA™ Subtalar Implants

Features:

• Material: Titanium Alloy

• Barrel shape provides optimal medial support

• Uniform implant diameter minimizes lateral discomfort

• Patented slotted design helps prevent extrusion

• Available in sizes 6, 8, 9, 10, and 12mm

Kalix® II

Features:

• Reinforced body (Titanium)

• UHWPE (Ultra High Weight Polyethylene) mantle

• Anti-expulsion flanges

• Expansion slots

• 1mm of expansion of the mantle

• Anatomical shape with an angle of 7° degree: similar to the Sinus tarsi Shape�



10

Qwix® / Large Qwix® Fixation & Positioning Screws

Titanium fixation screws for small bone fragments and arthrodesis in foot surgery:

• Arthrodesis in foot and ankle surgery

• Fracture management in the foot

• Mono or bi-cortical osteotomies in the foot

• Fixation of bone fragments in long bone or small bone fractures

The size of the chosen screw should be adapted to the specific indication�

Features:

• Self-drilling, self-tapping

• Reproducible compression

• Partially and fully-threaded designs


• Qwix® 4�3mm diameter: lengths 22-40mm in 2mm increments lengths 40-60mm in 5mm increments

• Large Qwix® 5�5mm diameter: lengths 30-80mm in 5mm increments

• Large Qwix® 7�5mm diameter: lengths 40-120mm in 5mm increments


The Uni-CP™ Compression Plate incorporates the Surfix® Locking Technology which provides the ability to LAG the plate to the bone, and then independently LOCK the plate� This technology creates a monoblock construct screw/plate/bone, which evenly distributes the force through all screw/plate interfaces� Uni-CP™ Compression Plate is indicated for fixation of bone fractures or for bone reconstruction:

• Arthrodesis in foot and ankle surgery

• Fracture management in the foot

• Mono or bi-cortical osteotomies in the foot

Features:

• Diamond bridge design for controlled and adjustable manual compression

• Material: Plate: Stainless Steel Screws: Titanium Alloy

• Available in 2 and 4 screw design each with interaxis sizes 20, 25, and 30mm

• Available 4 hole T-shape design with interaxis size 20mm

• 3�5mm diameter Surfix® locking screws lengths: 12-40mm in 2mm increments



I.CO.S.® Ideal COmpression Screw

The I�CO�S�® Ideal COmpression Screw is indicated for fixing the elective osteotomies of the forefoot and/or midfoot bones and for fracture fixation in the forefoot and/or midfoot and/or hindfoot:

• Arthrodesis, osteotomies, or fracture fixation in the forefoot and/or midfoot and/or hindfoot

• Navicular-cuneiform arthrodesis

• Lapidus arthrodesis

• Talus osteochondritis

• Ankle arthrodesis

The size of the chosen screw should be adapted to the specific indication�

Features:

• True compression, adjustable and controlled

• Static compression achieved with (initial) screw insertion

• Dynamic compression achieved by external head (advancement)


• 4�0mm diameter: lengths 26–40mm in 2mm increments lengths 40–60mm in 5mm increments

• 6�5mm diameter: lengths 40–150mm in 5mm increments

Advansys® Plating System - T.T.C. P late(Tibio-Talo-Calcaneal Plate)

Advansys® Plating System is intended for arthrodesis of the ankle joint and distal tibia, fractures, osteotomies, fusions, and replantations of small bones in the foot and ankle�

Advansys® Plating System incorporates the Surfix® Locking Technology which provides the ability to LAG the plate to the bone, and then independently LOCK the plate� This technology creates a monoblock screw/plate/bone construct, which evenly distributes the force through all screw/plate interfaces�

Features:

• Designed specifically for tibio-talo-calcaneal fusion

• Compression can be applied using an external compression clamp and then fine-tuned using a dynamic compression hole

• Material: Plate: Stainless steel 316L Screws and lock screws: Titanium alloy

• Available in left and right orientations each with 6, 7, 8, 9 hole configurations


12

Panta®-Panta® XL: Arthrodesis Nail System

The Panta® Arthrodesis Nail is intended for use in tibio-talo-calcaneal arthrodesis and treatment of trauma to the hindfoot and distal tibia�

Examples include:

• Post-traumatic and degenerative arthritis involving both ankle and subtalar joints

• Rheumatoid arthritis

• Revision of failed ankle arthrodesis with subtalar involvement or with insufficient talar body

• Revision of failed total ankle arthroplasty with subtalar intrusion

• Talar deficiency conditions (requiring a tibiocalcaneal arthrodesis)

• Avascular necrosis of the talus

• Neuroarthropathy or neuropathic ankle deformity

• Severe deformity as a result of talipes equinovarus, cerebral vascular accident, paralysis or other neuromuscular disease

• Severe pilon fractures with trauma to the subtalar joint

Features

• Compression is applied equally on the medial and lateral sides to avoid the introduction of torque and coronal twist

• Allows up to 12mm of bilateral axial compression across the ankle and subtalar joints


• Available in sizes 10, 11, 12, and 13mm by 150 and 180mm lengths

• Panta XL: 11, 12 et 13 mm diam� - 210 and 240 mm lengths

• Ideal amount of compression is dialed-in using the wheel mechanism


Integra OS™ Osteoconductive Scaffold Putty

Integra OS™ Osteoconductive Scaffold Putty, combined with bone marrow aspirate, is intended for use as a bone void filler to fill voids or gaps of the skeletal system in the extremities, spine and pelvis not intrinsic to the stability of the bony structure� Integra OS™ Osteoconductive Scaffold Putty is also indicated for use in the treatment of surgically treated osseous defects, or osseous defects created from traumatic injury to the bone� Following placement in the bony void or gap (defect), Integra OS™ Osteoconductive Scaffold Putty is resorbed and replaced with bone during the healing process�

Features:

• Material: 20% Highly Purified Type-1 Collagen and 80% ß-Tricalcium Phosphate

• Type-1 Collagen: provides excellent handling characteristics and demonstrated biocompatibility

• ß-Tricalcium Phosphate: provides localized mineral content to foster bone formation

• Available in sizes 2�5cc putty and 5cc putty

Trel-X™* and Trel-XC™* Demineralized Bone Matrix

Trel-X™ and Trel-XC™ Demineralized Bone Matrix are indicated for orthopedic applications as filler for gaps or voids that are not intrinsic to the stability of the bony structure� Trel-X™ and Trel-XC™ are indicated to be packed gently into bony gaps in the skeletal system as a bone graft extender (extremities, spine, and pelvis) and as a bony void filler of the extremities and pelvis� These defects may be surgically created or from the result of traumatic injury to the bone�

Highly malleable for maximum surgical flexibility�

Each lot is validated to confirm osteoinductive potential via in vitro assay, thus ensuring bone-forming potential�

Trel-X™ DBM Features:

• Material: Demineralized Bone Matrix in Poloxamer Reverse Phase Medium

• Available in 1cc, 5cc, and 10cc gel

Trel-XC™ DBM with Cancellous Bone

• Material: Demineralized Bone Matrix with Cancellous Bone in a Poloxamer Reverse Phase Medium

• Available in 1cc, 3cc, and 8cc paste




14

Integra LifeSciences Services (France) SASSales & Marketing EMEA Immeuble Séquoia 2 ▪ 97 allée Alexandre Borodine Parc technologique de la Porte des Alpes 69800 Saint Priest ▪ FRANCE +33 (0)4 37 47 59 00 ▪ fax +33 (0)4 37 47 59 99 emea�info@integralife�com ▪ integralife.com

Customer ServiceInternational: +33 (0)4 37 47 59 50 ▪ +33 (0)4 37 47 59 25 (Fax) ▪ csemea@integralife�comInternational (for Trel-X™ & Trel-XC™): +1(949)5958710•Fax:+1(949)5958717•[email protected] Kingdom : csuk�ortho@integralife�comFrance: +33 (0)4 37 47 59 10 ▪ +33 (0)4 37 47 59 29 (Fax) ▪ cs-ortho@integralife�comBenelux: +32 (0)2 257 4130 ▪ +32 (0)2 253 2466 (Fax) ▪ custsvcbenelux@integralife�com Switzerland: +41 (0)2 27 21 23 30 ▪ +41 (0)2 27 21 23 99 (Fax) ▪ custsvcsuisse@integralife�com

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©2011 Integra LifeSciences Corporation� All rights reserved� ILS 08-01-115-01-10 PRODUCTS FOR SALE IN EUROPE, MIDDLE-EAST and AFRICA ONLY

Availability of these products might vary from a given country or region to another, as a result of specific local regulatory approval or clearance requirements for sale in such country or region� ▪ Always refer to the appropriate instructions for use for complete clinical instructions� ▪ Non contractual document� The manufacturer reserves the right, without prior notice, to modify the products in order to improve their quality� ▪ WARNING: Applicable laws restrict these products to sale by or on the order of a physician� ▪ MBA, Trel-X, Trel-XC, Integra OS, Kalix, Uni-Clip, Uni-CP™, ICOS, Qwix, Large Qwix, Tibiaxys, Advansys, Panta & Panta XL, Surfix and the Integra logo are trademarks or registered trademarks of Integra LifeSciences Corporation or its subsidiaries�

References1� Kelly IP, Easley ME

TREATMENT OF STAGE 3 ADULT ACQUIRED FLATFOOT Foot Ankle Clin� 2001;6(1)153-166�

2� DiPaola M, Raikin SM TENDON TRANSFERS AND REALIGNMENT OSTEOTOMIES FOR TREATMENT OF STAGE II POSTERIOR TIBIAL TENDON DYSFUNCTION Foot Ankle Clin� 2007; 12(2): 273-285, vi�

3� Pomeroy GC, Pike RH, Beals TC, Manoli A 2nd ACQUIRED FLATFOOT IN ADULTS DUE TO DYSFUNCTION OF THE POSTERIOR TIBIAL TENDON J Bone Joint Surg Am� 1999; 81(8):1173-1182�

4� Mann RA, Thompson FM RUPTURE OF THE POSTERIOR TIBIAL TENDON CAUSING FLAT FOOT. SURGICAL TREATMENT J Bone Joint Surg Am� 1985; 67(4): 556-561�

5� Bluman EM, Title CI, Myerson MS POSTERIOR TIBIAL TENDON RUPTURE: A REFINED CLASSIFICATION SYSTEM Foot Ankle Clin� 2007; 12(2):233-249,v�

6� Wacker JT, Hennessy MS, Saxby TS CALCANEAL OSTEOTOMY AND TRANSFER OF THE TENDON OF FLEXOR DIGITORUM LONGUS FOR STAGE II DYSFUNCTION OF TIBIALIS POSTERIOR. THREE TO FIVE YEAR RESULTS J Bone Joint Surg Br� 2002; 84(1):54-58�

Related SourcesBasmajian JV, Stecko G THE ROLE OF MUSCLES IN ARCH SUPPORT OF THE FOOT J Bone Joint Surg Am� 1963; 45:1184-1190�

Dockery, Gary L., and Mary E. Crawford THE MAXWELL-BRANCHEAU ARTHROEREISIS (MBA) IMPLANT IN PEDIATRIC AND ADULT FLEXIBILE FLATFOOT CONDITIONS Foot and Ankle Quarterly Winter 1999: 107-120�

Mann RA ADULT ACQUIRED FLAT FOOT DEFORMITY: TREATMENT OF DYSFUNCTION OF THE POSTERIOR TIBIAL TENDON J Bone Joint Surg Am� 1997; 79(9): 1434�

Mosier SM, Lucas DR, Pomeroy G, Manoli A2nd PATHOLOGY OF THE POSTERIOR TIBIAL TENDON IN POSTERIOR TIBIAL TENDON INSUFFIENCY Foot Ankle Int� 1998; 19(8): 520-524�

Mosier SM, Pomeroy G. Manoli A2nd PATHOANATOMY AND ETIOLOGY OF POSTERIOR TIBIAL TENDON DYSFUNCTION Clin Orthop Relat Res� 1999; (365):12-22�

Myerson, MS ADULT ACQUIRED FLATFOOT DEFORMITY: TREATMENT OF DYSFUNCTION OF THE POSTERIOR TIBIAL TENDON Instr� Course Lect� 1997; 46: 393-405�

Teasdall RD, Johnson KA SURGICAL TREATMENT OF STAGE I POSTERIOR TIBIAL TENDON DYSFUNCTION Foot Ankle Int� 1994;15(12):646-648�


Documents

Posterior Tibial Tendon SURGICAL SOLUTIONS · The brochure has been developed with the contribution of Stephen Conti, MD and Richard M. Jay, DPM. Table Of Contents What is Posterior