Open and subcutaneous recent tibialis anterior tendon ruptures: does postoperative immobilization method influence outcome?

Outcomes of Tibialis Anterior Tendon Reconstruction with Autograft or Allograft

BACKGROUND

In cases of tibialis anterior tendon (TAT) ruptures associated with significant tendon defect, an interposition graft is often needed for reconstruction. Both auto- and allograft reconstructions have been described in the literature. Our hypothesis was that both graft types would have a good integrity and provide comparable outcomes.

METHODS

Patients who underwent TAT reconstruction using either an auto- or allograft were identified. Patient-reported outcomes (PROs) were collected using the 12-Item Short Form Health Survey (SF-12) questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot Function Index (FFI), and the Karlsson-Peterson score. Functional outcome was assessed by isokinetic strength measurement. Outcomes were further assessed with magnetic resonance imaging (MRI) evaluation of graft integrity. All measurements were also performed for the contralateral foot.

RESULTS

Twenty-one patients with an average follow-up of 82 months (20-262 months), comprising 12 allograft and 9 autograft TAT reconstructions, were recruited. There were no significant differences in patient-reported outcomes between allograft reconstructions and autografts: SF-12 (30.7 vs 31.1, P = .77); AOFAS (83 vs 91.2, P = .19); FFI (20.7% vs 9.5%, P = .22); and Karlsson-Peterson (78.9 vs 87.1, P = .23). All grafts (100%) were intact on MRI with a well-preserved integrity and no signs of new rupture. There were no major differences in range of motion and functional outcomes as measured by strength testing between the operative and nonoperative side.

CONCLUSION

Reconstructions of TAT achieved good PROs, as well as functional and imaging results with a preserved graft integrity in all cases. There were no substantial differences between allograft and autograft reconstructions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Risk Factors for Anterior Tibial Tendon Pathology

BACKGROUND

Though the tibialis anterior (TA) serves a vital role in ankle dorsiflexion, there is little information regarding risk factors and demographic information that might predispose one to tendinopathy or rupture. This study investigates the features of patients in a single institution who presented with either TA tendinopathy or rupture. The circumstances surrounding rupture were also noted.

METHODS

ICD-9/10 codes were used to find patients who presented with TA pathology to 2 foot and ankle surgeons at 1 academic medical center from 2011 to 2018. Patient characteristics were noted, including age, sex, body mass index, and the presence of a gastrocnemius equinus contracture. Characteristics of patients with traumatic and atraumatic ruptures were compared.

RESULTS

Ninety-four patients presented between 2011 and 2018 (79 cases of tendinopathy and 15 ruptures). The average patient age was 56 years, and the ratio of women to men was 74:20 (3.7:1). With regard to those who experienced rupture, there were 2 ruptures directly related to athletic activity (traumatic), whereas 13 ruptures were found on examination with no overt history of injury (atraumatic). The average age for patients with traumatic ruptures was 39 years compared with 73 years for those with atraumatic rupture (P < .05).

CONCLUSION

This study investigates the features of patients in a single institution who presented with TA pathology. With regard to tendon ruptures, traumatic ruptures tend to occur in younger patients, whereas older patients are more likely to suffer atraumatic ruptures. Nonoperative treatment often appears to be effective for TA pathology.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Management of tibialis anterior tendon rupture: Recommendations based on the literature review

Tibialis anterior tendon (TAT) rupture is a rare injury that commonly diagnosed late due to mild clinical signs and symptoms. Management of TAT rupture is a topic without a clear consensus in the literature. This current concept review tries to shed some light on the data and treatment. Our extensive literature review identified 81 case reports and case series from 1905 to 2018. Several reported management techniques with their advantages and disadvantages were analyzed and our treatment recommendations are given based on current available evidences. LEVELS OF EVIDENCE: IV.

Traumatic extensor tendons injuries of the foot in childhood: a case report

BACKGROUND AND AIM OF THE WORK

Extensor tendon injuries of the foot in children represent a rare foot injury. We report a case of a 9 year-old male who suffered of a traumatic wound laceration in the distal third of the right leg with a glass the day before in another country, getting a combined injury of tibialis anterior (TA), extensor hallucis longus (EHL) and extensor digitorum longus (EDL).

METHODS

After an initial clinical and radiological evaluation, antibiotic prophylaxis was immediately started. Surgery was necessary for the repair of the lesions and after rehabilitation the patient recovered a good function with a complete return to a normal life.

RESULTS

5 years follow-up clinical examination revealed a complete and painless range of movement comparable to the other foot. The patient regained active dorsiflexion without functional limitations, deformity or contracture.

CONCLUSIONS

Early exploration is important to allow full definition of the extent of injury and early surgical repair of tendons is recommended to avoid future disability.

Management of Isolated Anterior Tibial Tendon Rupture: A Systematic Review and Meta-Analysis

Rupture of the tibialis anterior tendon is a rare condition reported to occur most often spontaneously in patients >45 years of age. Diagnosis is often delayed due to transient pain at the time of rupture and the ability of the long extensors to compensate for the lost action of the tibialis anterior. Treatment has been proposed to be based on the activity level of the individual; however, no consensus has been reached on the optimal treatment modality for this rare condition. A systematic review and meta-analysis were performed to determine outcomes obtained with conservative and surgical management. Twenty-four references (155 cases) were identified. Conservative management (21 cases, 13.55%) was associated with poorer outcomes (odds ratio [OR] 0.68; I² = 61%) because of pain and functional limitations related to ankle dorsiflexory weakness. Surgical intervention (134 cases, 86.45%) had a better chance for good outcome (OR 8.40; I² = 63%). Use of an ipsilateral split/turn-down ipsilateral tibialis anterior tendon graft (OR 32.15; I² = 0%) semitendinous autograft (OR 15.25; I² = 44%), or direct repair (OR 12.57; I² = 0%) provided the best postoperative outcomes, whereas extensor hallucis longus autograft was associated with the worst (OR 0.27, I² = 34%). The most common postoperative finding was objective mild dorsiflexory weakness (4/5 muscle strength), which did not translate to subjective functional limitation. Good functional results were found to occur regardless of patient age at the time of intervention. Results of this systematic review and meta-analysis suggests that surgical intervention provides better functional outcomes than conservative management. Use of an extensor hallucis longus autograft is not recommended if surgical intervention is performed.

Traumatic avulsion of tibialis anterior following an industrial accident: A case report

INTRODUCTION

Rupture of the tibialis anterior tendon is uncommon and can occur spontaneously or following trauma. If suspected, it should be diagnosed promptly, enabling early surgical management and good restoration of function.

PRESENTATION OF CASE

A 48 year old male sustained a crush injury to his right foot when it became stuck in a vertical industrial fan at work. He attended A & E complaining of swelling of the dorsum of foot. On examination, there was tenderness at the base of the first metatarsal. X-ray revealed an avulsion fracture of the first metatarsal, and MRI showed rupture of tibialis anterior. The patient underwent surgical repair 10 days later, with post-operative management in a non-weight bearing, then weight bearing cast. X-ray at 8 weeks showed that the fracture had healed. The patient had a course of physiotherapy and was followed up at 6 months to assess pain and function.

DISCUSSION

Tibialis anterior rupture should be considered if the history is suggestive, and can be diagnosed clinically based on the triad of a 'pseudotumour' of the ruptured tendon, loss of tendon contour, and reduced dorsiflexion of the ankle. In our case, the avulsion fracture prompted further imaging to confirm the diagnosis and plan surgery. There are various operative technique described in the literature. We used a whip stitch with anchors to reattach the tendon to the base of first metatarsal.

CONCLUSION

A prompt and early diagnosis of surgical repair of tibialis anterior tendon avulsion is important to ensure that the patients return to work as an industrial worker.