Anterior tibial tendon rupture

A three-dimensional analysis of the tibialis anterior tendon: emphasizing tendon insertion patterns for effective repair and understanding hallux valgus development

PURPOSE

The present study aimed to evaluate the insertion site of the tibialis anterior tendon three-dimensionally.

METHODS

Seventy lower limbs were dissected. The tibialis anterior tendon was dissected to verify the insertion site to the medial cuneiform and the base of the first metatarsal bone. The three-dimensional (3D) territory of the tibialis anterior tendon insertion on the medial cuneiform and the first metatarsal bones was measured on a reconstructed 3D model.

RESULTS

The insertion pattern of the tibialis anterior tendon was classified into three types, the most common being Type I: a single tibialis anterior tendon dividing into two equal-sized bands to the medial cuneiform and base of the first metatarsal bone (57.1%, 40/70 of cases). The 3D territory of the tibialis anterior tendon was larger in the plantar aspect than in the medial side of both the medial cuneiform and the base of the first metatarsal bone. The width of the tendon inserted into the medial cuneiform was wider than that inserted into the first metatarsal bone.

CONCLUSION

The tibialis anterior tendon was more commonly attached to the plantar part than the medial part in both the medial cuneiform and the base of the first metatarsal bone. This anatomical information will help surgeons perform anatomical reconstruction of the tibialis anterior tendon, reduce further tendon damage in the first metatarsocuneiform joint area and also provide valuable knowledge to improve understanding of hallux valgus pathogenesis.

Anatomical study of type classification and surface area of attachment sites for tibialis anterior tendon

BACKGROUND

The purpose of this study was to clarify the attachment types of the tibialis anterior tendon (TAT) in Japanese fixed cadavers and to determine the attachment site area in three dimensions.

METHODS

We examined 100 feet from 50 Japanese cadavers. The TAT was classified according to differences in the number of fiber bundles as: Type I, with one fiber bundle; Type II, with two fiber bundles; and Type III, with three fiber bundles. The attachment site area of the TAT was measured using a three-dimensional scanner.

RESULTS

Cases were Type II in 95% and Type III in 5%, with no cases of Type I identified. In Type II, mean attachment site areas were 85.2 ± 18.2 mm2 for the medial cuneiform bone (MCB) and 72.4 ± 19.0 mm2 for the first metatarsal bone (1 MB), showing a significantly larger area for MCB than for 1 MB.

CONCLUSIONS

These findings suggest the possibility of ethnic differences in TAT attachment types and suggest that TAT attachments in Japanese individuals are highly likely to be Type II, with rare cases of Type III. Accurate measurement of attachment site areas is possible with appropriate three-dimensional measurements.

Tibialis Anterior Tendon Rupture Surgical Treatments and Outcomes: A Systematic Review and Meta-Analysis

Tibialis anterior tendon ruptures are a rare condition with an often-delayed diagnosis due to transient pain and compensation of remaining anterior compartment tendons. Previous systematic reviews have limited their recommendations to surgical treatment over nonoperative cares given the relatively small sample size in the literature. This current systematic review and meta-analysis was performed to compare the outcomes amongst the various surgical techniques and define factors that may affect long term patients results. Twenty-six references (217 cases) were identified. Use of extensor tendon autograft (odds ratio [OR] 5.55; I²=46%), autograft repair through semitendinosus/gracilis/ plantaris/ Achilles tendon/ peroneus longus ([OR] 4.14; I²=71%), or direct repair ([OR] 3.59; I²=57%), provided the best postoperative outcomes, whereas allograft repair ([OR] .52; I²=77%),and ipsilateral split/ turn-down tibialis anterior tendon ([OR] .69; I²=71%), were associated with poorer outcomes. Ruptures fixed in the acute phase ([OR] 8.3; I²=26%), were associated with statistically significant better outcomes when compared to these ruptures fixed in the chronic phase ([OR] .52; I²=77%). Results of this systematic review and meta-analysis suggests that ruptures should be surgically repaired in the acute phase whenever possible and comparable outcomes can be achieved through extensor tendon autograft repair, autograft repair, and direct repair.

Delayed Bilateral Tibialis Anterior Tendon Repair in an Older Man: A Case Report

CASE

We report a 67-year-old healthy man who sustained bilateral hyper-plantarflexion injuries falling off a ladder that resulted in bilateral tibialis anterior tendon tears one month prior to presentation. His injuries were effectively managed with bilateral delayed operative treatment. After non-weightbearing for three months, the patient was subsequently permitted to full weight bear in CAM boots for three months. At three-year follow-up he was fully functional with excellent Foot and Ankle Ability Measure (FAAM scores).

CONCLUSION

The management delayed tibialis anterior tendon ruptures, whether due to traumatic or degenerative mechanisms is challenging and surgical repair can be effective when this injury occurs bilaterally.

Running on the Edge: Rupture of the Tibialis Anterior Muscle During an Ultramarathon

A 47-year-old male ultramarathon runner presented with persistent discomfort in the anterior region of the left leg. The patient reported a snapping sensation in his left leg four weeks earlier while running an ultramarathon, followed by ecchymosis and functional impairment the next day. Physical examination revealed a palpable area of fibrosis in his anterior left leg. Ultrasound of the left leg identified a partially organized rupture of the distal third of the tibialis anterior muscle. The rupture had an extension of 36 x 10 x 27mm with associated muscle edema. The patient was treated non-surgically with a customized rehabilitation program and later returned to ultramarathon running. This case illustrates the importance of proper differential diagnosis and individualized rehabilitation programs to achieve optimum clinical and functional results.

Clinical results of distal anterior tibial tendon decompression

BACKGROUND

Distal tibialis anterior tendinopathy (DTAT) is condition which is infrequently described in literature and is usually treated with conservative means. If resistant to a rehabilitation protocol and unloading, a surgical treatment could be proposed. The aim of this research is to report on the history and clinical image of DTAT and present the clinical results of a simple surgical decompression of the tendon with local debridement and release of the distal extensor retinaculum.

METHODS

Seventeen patients diagnosed with DTAT in 18 feet underwent surgery between 2008 and 2018. Upon initial presentation, all patients reported a persistent history of pain over the tibialis anterior (TA) insertion. Ultrasound was routinely performed to confirm the diagnosis. In patients with confirmed diagnosis of DTAT, persistent despite conservative treatment, we proceeded with surgical intervention during which we released the tendon by opening the distal extensor retinaculum. Retrospective chart review was performed, and functional outcomes were assessed using the AOFAS midfoot score. AOFAS score results were collected postoperatively with at least one-year follow-up.

RESULTS

All patients experienced pain on palpation of the distal aspect of the TA tendon. Most patients experienced pain at night and were frequent hikers. Our study population consisted of mostly female and overweight patients. All patients reported pain relief with a significant improvement of VAS for pain from 6.7 ± 1.1 preoperatively to 1.1 ± 1.2 postoperatively (p < 0.05). The postoperative AOFAS midfoot score was 97 ± 3.7. Fifteen patients were completely satisfied, two satisfied with minor reservations.

CONCLUSION

Simple distal TA tendon release by division of a consistently present constricting distal extensor retinaculum represents a surgical alternative in the treatment of chronic DTAT. Our study shows good clinical outcomes with low complications.

LEVEL OF EVIDENCE

Level IV - retrospective case series.

Anatomical Variations of the Tibialis Anterior Tendon Insertion: An Updated and Comprehensive Review

The tibialis anterior muscle originates on the lateral condyle of the tibia, on the upper two-thirds of the lateral surface of this bone, on the anterior surface of the interosseous membrane and on the deep surface of the fascia cruris. The distal attachment is typically at the medial cuneiform and first metatarsal. However, the tibialis anterior tendon can vary morphologically in both adults and fetuses. Different authors have created new classification systems for it. The main aim of this review is to present condensed information about the tibialis anterior tendon based on the available literature. Another aim is to compare classification systems and the results of previous studies.

Management of Anterior Tibialis Tendon Ruptures

Anterior tibialis tendon ruptures, while relatively infrequent ruptures, are commonly identified in delayed fashion, which can lead to significant impairments in patient gait and function. Surgical treatment is typically required to restore ankle dorsiflexion function and proper gait. Depending on various patient-specific factors, tendon quality and excursion, and chronicity, a range of treatment options are available to manage these patients, from nonsurgical care to surgical treatment. Surgical options include direct repair, local tendon transfer, autograft tendon reconstruction, and allograft tendon reconstruction. Additional procedures may need to be considered. Despite the variety of described surgical procedures, limited evidence-based guidelines are available to direct surgeons in the most optimal treatment for their patients. In addition to the relevant anatomy, biomechanics, and pathoanatomy, the reconstructive armamentarium is detailed and reviewed here, along with outcomes and potential complications, to guide surgeons in the most appropriate treatment for their patients.

Surgical treatment of tibialis anterior tendon rupture

BACKGROUND

Ruptures of the anterior tibial tendon can be both acute and chronic. The acute lesion can be caused by a sharp cutting trauma or by blunt or hyperplantarflexion trauma. Spontaneous ruptures are rare, and most ruptures are due to degenerative changes mainly affecting the distal avascular 5-30 mm of the tendon. Surgical repair is the preferred treatment for physically active patients. Overall, the literature shows that operative repair results in a very good outcome in most patients. This study compares the clinical outcome in patients with anterior tibial tendon rupture, treated with different surgical techniques.

METHODS

This multicenter cohort study was conducted at four different Foot and Ankle specialized clinics. The study was approved by the local ethical committee. A total of 48 patients with surgically treated tibialis anterior rupture was included. The study protocol included the demographic and clinical data of each patient and the surgical treatment. The VAS-FA PROM was recorded pre- and postoperative in all patients. The mean follow-up were 30 (20.8-48.5) months.

RESULTS

A significant difference was found in age between patients who stated "good" versus "fair" (p = 0.002) and "very good" versus "fair", i.e. younger age for "fair" p = 0.036, thus showing that younger patients do worse than older patient after surgery when rating the results. However there was no significant difference for older versus younger age looking at the results "poor", "fair, good and very good". The group with chronic tendon ruptures had a significantly higher preoperative VAS-FA than the group sustaining non-traumatic rupture (p = 0.048). There was no significant linear relation between age, postoperative VAS-FA and VAS-FA improvement. Also, we did not find a significant linear relation between age and outcome. Please see Tables 2-4 for results.

CONCLUSION

The tibialis anterior tendon rupture can be both acute and chronic. We could not identify any significant differences in clinical outcome or PROM between acute and delayed suture of the tibialis anterior tendon rupture.

LEVEL OF EVIDENCE

Level II. Prospective controlled cohort study.

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.

Tendon Turndown to Bridge a Tibialis Anterior Gap and Restore Active Dorsiflexion After Degloving Foot Injury in a Child: A Case Report

CASE

A child with a severe degloving injury to the dorsum of the foot and ankle had segmental loss of the tibialis anterior tendon and toe extensors. A tendon turndown procedure was used, and the repaired tendon was covered with a latissimus muscle free flap to restore active ankle dorsiflexion. Details of the procedure are described, and active dorsiflexion and functional ambulation were restored.

CONCLUSIONS

The tendon turndown method is a simple and effective way to overcome segmental tendon loss of tibialis anterior and allowed restoration of active dorsiflexion in this case without relying on tendon transfers or grafting.

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.

Tibialis anterior tendinosis: Clinical characterization and surgical treatment

BACKGROUND

Tibialis anterior (TA) tendinosis is rarely reported on in the literature. It is seen in patients older than 45 and causes weakness in dorsiflexion. This paper aims to describe surgical treatment and clinical outcomes.

METHODS

Between 2015 and 2018, nine patients (six females, three males) with severe TA tendinosis with no tear (2), partial (1), or complete (6) underwent operative treatment. Patients underwent debridement and direct repair without augmentation, direct repair with fiber tape augmentation, tibialis posterior tendon (PTT) transfer, or tibialis anterior tendon (TAT) augmentation with a tendon autograft (n=4). Autografts consisted of extensor digitalis longus (EDL) tendon, plantaris tendon, or both.

RESULTS

Mean postoperative follow-up was 21.3 (range 8-31) months. All patients had a concomitant gastrocnemius recession, and three had hindfoot arthrodesis. Preoperative dorsiflexion strength was 0/5 for all and improved to 5/5 postoperatively in seven. The only current smoker developed wound dehiscence 2 weeks postoperatively and healed by 4. One developed marginal skin necrosis 3 weeks postoperatively and was treated successfully with casting.

CONCLUSION

Surgery reestablished function in individuals with TA tendinosis and allowed high level of satisfaction. Direct repair is possible. If the tendon gap is too large an autograft of EDL and plantaris tendon can be utilized.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

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.

A cadaveric and sonographic study of the morphology of the tibialis anterior tendon - a proposal for a new classification

Background

The tibialis anterior tendon (TAT) presents little morphological variation. The tibialis anterior muscle originates at the lateral condyle of the tibia, the proximal one-third to two-thirds of the lateral surface of the tibia shaft, and the anterior surface of the interosseous membrane and inserts to the medial cuneiform bone and first metatarsal. The aim of our work is to classify types of TAT insertion by two complimentary methods - anatomical dissection and ultrasound examination.

Methods

In the first part, classical anatomical dissection was performed on 100 lower limbs (50 right, 50 left) fixed in 10% formalin solution. The morphology of the insertion of the tendon was evaluated and the muscle was subjected to the appropriate morphometric measurements. In the second part, the morphology of the TAT insertion was evaluated in 50 volunteers with ultrasound.

Results

The tibialis anterior muscle was present in all specimens. In the cadavers, five types of insertion were observed, the most common being Type V: a single band attaching to the medial cuneiform bone (32%). In the sonographic part, Type IV was not observed; however, an additional insertion type was recognised (Type VI), which was characterized by two identical bands attached only to the medial cuneiform bone. The most common type identified by ultrasound was Type II (35%).

Conclusion

The tibialis anterior tendon presents high morphological variability that can be observed both in cadavers and in vivo by ultrasound examination.

Level of evidence

II Prospective Comparative Study

Electronic supplementary material

The online version of this article (10.1186/s13047-019-0319-0) contains supplementary material, which is available to authorized users.

Decompressive Medial Cuneiform Exostectomy for Resistant Tibialis Anterior Insertional Tendinopathy

Distal tibialis anterior tendinopathy, as a clinical entity, has only recently been documented in foot and ankle studies. We report our experience with medial cuneiform decompressive exostectomy and superficial tendon debridement in 14 cases of recalcitrant tibilalis anterior insertional pain. We reviewed 13 patients (14 feet; 12 females, 1 male; mean age 67.9 ± 7.5; range 55 to 80 years) in whom conservative treatment had failed who had undergone debridement of the insertional tibialis anterior tendon and decompressive exostectomy of the medial cuneiform. Pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale and visual analog scale (VAS) pain scores, local clinical findings, and dorsiflexion power at an average follow-up period of 28 ± 17.9 (range 6 to 55) months were assessed. All patients had experienced burning, nocturnal, medial midfoot pain and disability. The symptom longevity preoperatively was 8.5 ± 3.1 (range 6 to 17) months. Peritendinous or intrasubstance signal changes were noted on magnetic resonance imaging in 10 feet (71%). The mean preoperative VAS pain score was 8.7 ± 1.3 (range 5 to10), whereas postoperative it was 0.4 ± 0.5 (range 0 to1) (p = .001). The mean preoperative and postoperative AOFAS midfoot scale score was 54 ± 14.5 (range 20 to 70) and 91 ± 6.8 (range 79 to 100), respectively (p = .001). Postoperative ankle dorsiflexion power was normal and local tenderness had resolved in all patients. One patient (7.1%) stumbled at 2 weeks, resulting in avulsion of the tibialis anterior tendon, requiring transosseous fixation and gastrocnemius recession. All patients reported satisfaction with the surgical outcome and willingness to undergo the surgery again if necessary. A combination of medial cuneiform mechanical decompression and insertional tendon debridement can offer successful outcomes in resistant insertional tibialis anterior tendinopathy.

Zancolli Technique for Delayed Repair of Tibialis Anterior Tendon Rupture: A Case Report and Literature Review

BACKGROUND

Several techniques for repair of tibialis anterior tendon ruptures (TATRs) are reported, although it is a rare lesion. We describe a case of TATR, discuss our treatment, and review the criteria for the choice of treatment.

METHODS

In November 2015, a 61-year-old woman presented to our department 13 days after an injury to her left ankle, with avulsion of TAT. Because of the stump retraction, we performed a Zancolli-like plasty, anchoring the tendon to the navicular bone. Evidence about the timing and type of surgery has been reviewed.

RESULTS

The patient was followed up for 16 months before being discharged. The American Orthopaedic Foot and Ankle Society score improved from an initial value of 32 to a final score of 90.

CONCLUSIONS

The choice of treatment depends on several factors. Patients' physical demands and the type of rupture guide the choice of surgical technique.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Retrospective.

Tibialis Anterior Reconstruction With Hamstring Autograft Using a Minimally Invasive Approach

BACKGROUND

Tibialis anterior tendon ruptures are rare and can cause significant dysfunction. Often, conservative measures are prescribed because of the morbidity of a tendon transfer as an operative solution. We present a novel reconstruction technique using hamstring autograft, which may obviate the need for local tendon transfer and long-term bracing.

METHODS

Patients who underwent tibialis anterior reconstruction with hamstring autograft between 2011 and 2015 were screened for inclusion. Eight were included. Functional outcomes were assessed pre-and-postoperatively using the Foot and Ankle Outcome Score (FAOS), Visual Analog Pain Scale (VAS), and Short-Form-12 (SF-12) general health questionnaire. Isokinetic testing using a dynamometer (Biodex System 4 Pro) was performed at 60 and 120 degrees/s, respectively, for inversion/eversion and plantarflexion/dorsiflexion on both ankles at a minimum of 6 months postoperatively to determine peak torque, average power, and total work. Range of motion (ROM) testing was also performed, using a goniometer, at a minimum of 6 months postoperatively. Average follow-up was 17.3 (6.0-40.0) months for strength testing and ROM testing, and 18.5 (12.0-26.0) months for functional outcome scores.

RESULTS

Average postoperative functional scores improved for all tests. ROM was similar between the uninvolved and involved ankles for inversion/eversion and plantarflexion/dorsiflexion. Patients showed deficits in dorsiflexion strength in all measures tested and improvements in inversion strength. All patients were able to ambulate without a brace.

CONCLUSION

Use of a hamstring autograft for tibialis anterior reconstruction resulted in good clinical outcomes. This procedure successfully restored ankle ROM postoperatively and tendon strength in inversion and dorsiflexion, with most patients showing little deficit when comparing their involved and uninvolved sides.

LEVEL OF EVIDENCE

Level IV, Case series.

Presentation, Diagnosis, and Nonsurgical Treatment Options of the Anterior Tibial Tendon, Posterior Tibial Tendon, Peroneals, and Achilles

Disorders of the anterior tibial tendon (ATT) are rare, and relatively few series have been described in the literature. Ruptures of the ATT are more common than tendinopathies of the ATT. For those patients with a tendinopathy, initial treatment may include activity and shoe-wear modifications.

Treatment of Acute and Chronic Tibialis Anterior Tendon Rupture and Tendinopathy

Tibialis anterior (TA) tendon rupture is a rare injury that has been described and studied in orthopedic literature through case reports and low-volume case studies. This article reviews the current literature on TA tendinosis and acute and chronic ruptures. It discusses the patient presentation, physical examination, nonoperative management, surgical treatment options, and outcomes.

A pseudotumoral lesion diagnosed for a hypertrofic fibrosis at the proximal stump in anterior tibialis tendon missed rupture: a case report

The Anterior Tibialis is the most important muscle in ankle dorsiflexion. The anterior tibialis tendon (ATT)'s rupture is an infrequent condition which can be both traumatic and spontaneous. Clinic is poor and it is necessary to confirm the suspect by US or MRI. The reported case refers to a 40 years old man who had a direct trauma at ankle and midfoot which was originally conservatively treated for an ankle sprain. Three months later he returned with pain, swelling and paresthesia. MRI was performed showing a neoformation in the contest of ATT's rupture. The patient underwent open excisional biopsy which was diagnostic for hypertrofic fibrosis. After two weeks, the symptoms were completely decreased and patient didn't want to undergo surgery for tendon reconstruction because he had no limitation in daily activity life.

Postoperative Foot and Ankle MR Imaging

MR imaging has an important role in the evaluation of the postoperative foot and ankle. In this article, a variety of operative techniques and postoperative findings in the foot and ankle are described, including tendon and ligament reconstruction, as well as the treatment of tarsal coalition and Morton neuroma. The role of MR imaging in the assessment of complications of foot and ankle surgery is also detailed.

Tibialis Anterior Tendon Reconstruction Using Augmented Half-Thickness Tendon Segment Transposition

Tibialis anterior tendon rupture causes substantial morbidity. The present study describes the outcomes of augmented, half-thickness tibialis anterior tendon segment transposition, a novel reconstruction technique. This was an institutional review board-approved retrospective review of 3 patients with surgically treated attritional distal rupture with 1-year follow-up. The postdebridement tendon defect prohibited primary repair and was managed by distal transposition of a half-thickness healthy segment. This repair was augmented with human acellular dermal matrix allograft (Graftjacket, Wright Medical Technology, Memphis, TN). The mean age was 68 years (range, 59-73 years). Mean interval between injury and surgery was 59.3 days (range, 15-146 days). All patients regained symmetrical range of motion, motor power, and the ability to heel walk. Mean pain scores improved from 4.6 (range, 2.5-8.5) preoperatively to 0.7 (range, 0-2) postoperatively. Mean Foot and Ankle Ability Measure scores increased from 30.6 (range, 23.8-43.8) preoperatively to 78.7 (range, 72.6-97.6) postoperatively. No postoperative complications occurred. One patient was satisfied and 2 were very satisfied with their outcome. Although limited, the present findings appear to indicate that this technique produces short-term clinical results comparable to those described for other techniques for tibialis anterior tendon reconstruction.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

Repair of Chronic Tibialis Anterior Tendon Rupture With a Major Defect Using Gracilis Allograft

BACKGROUND

Tibialis anterior tendon (TAT) rupture is an uncommon injury, however, it can cause substantial deficit. Diagnosis is often delayed due to lack of initial symptoms; yet loss of function over time typically causes the patient to present for treatment. This delay usually ends up with major defects creating a great technical challenge for the operating surgeon. We present a novel technique and operative algorithm for the management of chronic TAT ruptures with a major gap after a delayed diagnosis not otherwise correctable with currently described techniques in the literature. This technique has been performed in 4 cases without any complications with fairly successful functional outcomes.

METHODS

For the reconstruction of chronic TAT rupture with an average delay of nine weeks after initial injury and gap of greater than 10 cm, a thorough operative algorithm was implemented in 4 patients using a double bundle gracilis allograft. Patients were then kept nonweightbearing for 6 weeks followed by weightbearing as tolerated. They began physical therapy with a focus on ankle exercises and gradual return to normal activity at 8 weeks, with resistance training exercises allowed at 12 weeks.

RESULTS

At a mean follow-up time of 24.5 months, all patients reported significant pain relief with normal gait pattern. There were no reported intra- or postoperative complications. The average Foot and Ankle Ability Measure score increased to 90 from 27.5 in the postoperative period. All patients were able to return their previous activity levels.

CONCLUSIONS

Gracilis allograft reconstruction as used in this study is a viable and reproducible alternative to primary repair with postoperative results being favorable without using complex tendon transfer techniques or autograft use necessitating the functional sacrifice of transferred or excised tendon. To the best of our knowledge, this is the first study demonstrating a successful technique and operative algorithm of gracilis allograft reconstruction of the TAT with a substantial deficit of greater than 10 cm with favorable results.

LEVELS OF EVIDENCE

Level IV: Operative algorithm with case series.

Allograft Reconstruction of Chronic Tibialis Anterior Tendon Ruptures

BACKGROUND

Chronic ruptures of the tibialis anterior tendon are often associated with tendon retraction and poor-quality tissue, resulting in large segmental defects that make end-to-end repair impossible. Interpositional allograft reconstruction has previously been described as an operative option in these cases; however, there are no reports of the clinical outcomes of this technique in the literature.

METHODS

Eleven patients with chronic tibialis anterior tendon ruptures underwent intercalary allograft recon-struction between 2006 and 2013. Patient demographics, injury presentation, and details of surgery were reviewed. Postoperative outcomes at a mean follow-up of 43.8 (range, 6-105) months included the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, Short Form-12 (SF-12) physical health score, Lower Extremity Functional Score (LEFS), visual analog scale (VAS) pain rating, dorsiflexion strength, gait analysis, and complications.

RESULTS

The average postoperative dorsiflexion strength, as categorized by the Medical Council grading scale, was 4.8 ± 0.45. The average postoperative VAS score was 0.8 ± 1.1. The average LEFS was 66.9 ± 17.2, SF-12 physical health score was 40.1 ± 14.4, and AOFAS score was 84.3 ± 7.7. One complication occurred, consisting of transient neuritic pain in the superficial peroneal nerve distribution. There were no postoperative infections, tendon reruptures, reoperations, or allograft-associated complications.

CONCLUSION

Allograft reconstruction of chronic irreparable tibialis anterior tendon ruptures yielded satisfactory strength, pain, and patient-reported functional outcomes. This technique offers a safe and reliable alternative, without the donor site morbidity associated with tendon transfer or autograft harvest.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Soft tissue repair for tibialis anterior tendon ruptures using plate and screw fixation technique in combination with anterolateral thigh flaps transplantation

Background

Traumatic ruptures of the tibialis anterior tendon are rare but can cause substantial functional deficiencies. This study aimed to evaluate the feasibility of a surgery for soft tissue repair of traumatic rupture of the tibialis anterior tendon by using a plate and screw fixation repair in combination with the free anterolateral thigh flaps transplantation.

Methods

Eight consecutive patients with anterior tibialis tendon ruptures who visited orthopedics departments from February 2008 to February 2012 were included in our study. The ruptured tendon was reconstructed with plate and screw fixation technique, and the tissue defects were repaired with anterolateral thigh free flaps. The complications and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were evaluated. Postoperative manual strength test was performed using a 0 to 5 scale.

Results

All flaps survived without any complications. The average preoperative and postoperative AOFAS ankle-hindfoot scores of the patients were 51 and 95, respectively. Good ankle dorsiflexion strength against strong resistance was observed in eight ankles postoperatively (manual strength of one patient was 4/5, the others were 5/5), and a substantial improvement in strength was noted compared with the preoperative examination.

Conclusion

Soft tissue repair for tibialis anterior tendon rupture using plate and screw fixation technique in combination with anterolateral thigh flaps transplantation is a feasible technique and yield satisfactory results.

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.

Minimally invasive repair of the tibialis anterior tendon using a semitendinosus autograft

BACKGROUND

Ruptures of the tibialis anterior tendon are rare but can cause substantial functional deficiencies. The literature regarding the treatment of such injuries is very limited. Atraumatic ruptures often occur in the presence of an abnormal tendon structure, and retraction often makes end-to-end repair impossible. With traumatic lesions, the risk of developing both adhesions and scar tissue is high.

METHODS

This study assesses the results of a surgical reconstruction using the interposition of a semitendinosus tendon autograft in 12 patients. Three patients had a traumatic rupture, and 9 patients had an atraumatic rupture. In 8 patients, the procedure was carried out using a minimally invasive technique.

RESULTS

The average postoperative American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score was 95.7 in the atraumatic group and 94.7 in the traumatic group. Active dorsiflexion was possible after 2 to 3 weeks. We believe that the interposition of a strong, healthy tendon facilitated healing and allowed early weight bearing. All patients had good recovery of dorsiflexion and gait.

CONCLUSIONS

Repairing a ruptured tibialis anterior tendon using a semitendinosus autograft was a reliable technique and offered a good result. With the minimally invasive approach, there was no need to divide the extensor retinaculum, which we believe allowed faster recovery and reduced the risk of adhesions and wound healing problems.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Reconstruction using an autograft with near complete preservation of the extensor retinaculum for chronic tibialis anterior tendon disruption

We present the case of a 42-year-old woman with chronic disruption of the tibialis anterior tendon who was treated by reconstructive surgery using autologous semitendinosus tendon grafting. Two incisional approaches, proximal and distal of the degenerative scar tissue between each ruptured stump, made it possible to preserve most of the extensor retinaculum, except for the inferior Y-shaped medial segment that was excised to prevent adhesion between the reconstructed tendon and the extensor retinaculum. Furthermore, by placing the proximal and distal suture knots far from the ends of the extensor retinaculum, impingement could be avoided between the knots using the Pulvertaft weave technique, and of the extensor retinaculum through movement of the ankle joint. Although some types of tendon transfer technique or interpositional autologous tendon grafting have been reported to show good outcomes for chronic tibialis anterior tendon disruption with a large defect, the recent trend has been toward reconstructive surgery using autografts. The surgical technique presented seems applicable for achieving minimum surgical complications in this rare condition.

Chronic tibialis anterior tendon tear treated with an Achilles tendon allograft technique

Tibialis anterior tendon tear is an uncommon injury. Nontraumatic or degenerative tears are usually seen in the avascular zone of the tendon. Treatment can be conservative or surgical. Conservative treatment is adequate for low-demand older patients. For active patients, surgical treatment can be challenging for the surgeon because after debridement of degenerative tissue, a gap may be formed that can make side-to-side suture impossible. The authors present allograft Achilles tendon insertion for reconstruction of chronic degenerative tears. Using Achilles tendon allograft has the advantage of bone-to-bone fixation, allowing rapid incorporation and earlier full weight bearing.

Simultaneous surgical repair of a tibialis anterior tendon rupture and diabetic charcot neuroarthropathy of the midfoot: a case report

The combination of simultaneous rupture of a tibialis anterior tendon and Charcot neuroarthropathy of the midfoot in a diabetic patient is a rare and challenging condition that can lead to major complications if not addressed appropriately. This article discusses a tibialis anterior tendon rupture that may have developed before or after the incidence of the diabetic Charcot neuroarthropathy midfoot deformity and raises awareness to potential spontaneous tendon ruptures that may be associated with the diabetic Charcot foot.

Allograft reconstruction of peroneal tendons: operative technique and clinical outcomes

BACKGROUND

Irreparable peroneal tendon tears are uncommon and require complex surgical decision making. Intercalary segment allograft reconstruction has been previously described as a treatment option; however, there are no reports of the outcomes of this technique in the literature. We describe our technique and present our results using this method.

METHODS

A retrospective chart review was conducted to identify all patients who underwent intercalary allograft reconstruction of the peroneal tendons. Mechanism of injury, concomitant operative procedures, pertinent radiographic findings, pre- and postoperative physical examination, intercalary graft length, medical history, visual analog scale (VAS) score for pain, Short Form-12 (SF-12) physical health survey, Lower Extremity Functional Score (LEFS), and complications were reviewed.

RESULTS

Fourteen patients with peroneal tendon ruptures requiring reconstruction were identified. Mean follow-up was 17 months (range, 7-47 months; median, 12 months). The average length of the intercalary segment reconstructed was 10.8 ± 3.8 cm (range, 6-20 cm). The average postoperative VAS score decreased to 1.0 ± 1.4 (P = .0005). No patient had a higher postoperative pain score than preoperative pain score. Average postoperative eversion strength as categorized by the Medical Research Council grading scale improved to 4.8 ± 0.5 (P = .001). The average SF-12 score improved to 48.8 ± 7.8 (P = .02). The average LEFS improved to 86.4. ± 14.9 (P = .00001). Four patients experienced sensory numbness in the sural nerve distribution, and 2 of these were transient. There were no postoperative wound healing complications, infections, tendon reruptures, or reoperations. No allograft associated complications were encountered. All patients returned to their preinjury activity levels.

CONCLUSION

Allograft reconstruction of the peroneal tendons can improve strength, decrease pain, and yield satisfactory patient-reported outcomes. It can be performed without incurring the deleterious effects associated with tendon transfer procedures. We believe that allograft reconstruction is a safe and useful alternative in the treatment of irreparable peroneal tendon ruptures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Traumatic rupture of the tibialis anterior tendon: A case report

Objective: The autors report a case of a traumatic rupture of the tibialis anterior tendon (TTA) that was early diagnosed and treated in the emergency service. This is a rare clinical entity with few cases reported in the literature. Case report: A 66-year old female presented at the emergency service complaining about pain at the anterior aspect of her ankle and inability to walk normally, after a fall. Physical examination revealed clinical signs for TTA rupture, which was later confirmed by ultrasound. Surgical treatment was performed immediately – the tendon was anchored into the medial cuneiform with a soft tissue-to-bone anchor. The follow-up revealed good functional result. Conclusion: Physical examination and a high index of suspicion are important when facing a patient who had sustained an ankle trauma. The TTA rupture is a diagnosis to consider because unrecognized ruptures led to important functional deficits and poor functional results.

Gait analysis after tibialis anterior tendon rupture repair using Z-plasty

Other than limited reports regarding surgical outcomes, little information is available regarding whether Z-plasty of the tibialis anterior results in normal gait kinematics. We included 5 patients with spontaneous ruptures in the present retrospective study. The mean interval between rupture and operative treatment was 2.6 ± 2.6 months (standard deviation). The mean age of the patients was 63 (range 40 to 80) years. All patients were treated operatively with Z-plasty. Gait analysis was used to study the outcome, comparing the operated and nonoperated limbs. The patients were tested after a mean follow-up of 22 (range 12 to 33) months. No repeat ruptures were noted. Plantarflexion was significantly diminished during the preswing phase and initial swing phase in the operated limbs compared with the uninjured limbs. Plantarflexion was significantly increased during the terminal swing phase on the operated side. Knee flexion was nearly symmetrical. No significant differences regarding the temporospatial parameters were noted. We recommend Z-plasty for ruptures of the tibialis anterior tendon as a safe and effective procedure. However, this technique does not fully restore a physiologic gait pattern.

Regional stiffening with aging in tibialis anterior tendons of mice occurs independent of changes in collagen fibril morphology

The incidence of tendon degeneration and rupture increases with advancing age. The mechanisms underlying this increased risk remain unknown but may arise because of age-related changes in tendon mechanical properties and structure. Our purpose was to determine the effect of aging on tendon mechanical properties and collagen fibril morphology. Regional mechanical properties and collagen fibril characteristics were determined along the length of tibialis anterior (TA) tendons from adult (8- to 12-mo-old) and old (28- to 30-mo-old) mice. Tangent modulus of all regions along the tendons increased in old age, but the increase was substantially greater in the proximal region adjacent to the muscle than in the rest of the tendon. Overall end-to-end modulus increased with old age at maximum tendon strain (799 ± 157 vs. 1,419 ± 91 MPa) and at physiologically relevant strain (377 ± 137 vs. 798 ± 104 MPa). Despite the dramatic changes in tendon mechanical properties from adulthood to old age, collagen fibril morphology and packing fraction remained relatively constant in all tendon regions examined. Since tendon properties are influenced by their external loading environment, we also examined the effect of aging on TA muscle contractile properties. Maximum isometric force did not differ between the age groups. We conclude that TA tendons stiffen in a region-dependent manner throughout the life span, but the changes in mechanical properties are not accompanied by corresponding changes in collagen fibril morphology or force-generating capacity of the TA muscle.

Bilateral atraumatic sequential rupture of tibialis anterior tendons

Tibialis anterior tendon ruptures are rare but debilitating injuries. A high index of suspicion is warranted in patients presenting with atraumatic anterior ankle pain, especially in conjunction with diabetes or inflammatory disease. The authors present a case report of bilateral sequential rupture of tibialis anterior tendons, a discussion of management, and a review of the literature.

Bone tunnel fixation for repair of tibialis anterior tendon rupture

Atraumatic rupture of the tibialis anterior tendon is rare, and due to the mild nature of pain symptoms, affected patients often present weeks or months after rupture. Surgical management is advocated to restore function in active patients, and historically suture anchors have been the preferred method for repairing the ruptured tendon directly to bone. We present a case of acute, atraumatic tibialis anterior tendon rupture that was anatomically repaired using a novel application of a bone tunnel fixation technique. We describe the surgical procedure and the outcome measures used to evaluate post-operative results in this case.

Surgical outcome following tibialis anterior tendon repair

BACKGROUND

Tibialis anterior tendon rupture is an uncommon injury that can cause significant functional deficit. Recent series have supported surgical reconstruction in younger, more active patients. We investigated our clinical outcomes of patients having undergone surgical management of tibialis anterior tendon ruptures.

MATERIALS AND METHODS

Fifteen tibialis anterior tendon ruptures in 14 patients were retrospectively reviewed after surgical management. Five had primary repair, while 10 had tendon transfers. Average age at time of surgery was 70.6 years with an average followup of 27.2 months. Patients were evaluated with American Orthopaedic Foot and Ankle Society (AOFAS) and SF-36 clinical outcome scores. Strength measurements utilizing a dynamometer and range of motion (ROM) were documented on the operative and non-operative ankles. Patient satisfaction surveys were performed.

RESULTS

Average postoperative AOFAS hindfoot score was 88.8 and SF-36 score was 76.4. There was a statistically significant difference in average dorsiflexion strength of 21.8 lbs/in(2) on the operative side and 28.8 lbs/in(2) on the non-operative limb, and in dorsiflexion ROM of patients that received a gastrocnemius recession. There was no statistically significant difference between primary tendon repair versus tendon transfer groups nor plantarflexion strength or ROM among any group. Patient surveys revealed that seven patients were completely satisfied, six had minor reservations, and one had major reservations. There were no complications.

CONCLUSION

This study supports the surgical repair or reconstruction of the tibialis anterior tendon ruptures to restore functional strength and ROM.

Operative management of distal tibialis anterior tendinopathy

BACKGROUND

The results of operative management for distal tibialis anterior tendinopathy (DTAT) without rupture have not previously been described in the literature. We present the results of 12 operative procedures.

MATERIALS AND METHODS

Of 40 patients diagnosed clinically and radiographically with DTAT, we reviewed 11 patients who underwent surgery for failure of nonoperative management. Assessment included pre and postoperative AOFAS midfoot scores, clinical examination and postoperative VAS pain scoring, at a mean followup of 29 months.

RESULTS

Ten women (ten feet) and one man (2 feet) underwent surgery. The mean age at surgery was 59 years. The mean duration of symptoms prior to surgery was 1 year. The mean preoperative AOFAS score was 52. Preoperative MRI showed tendinosis in two tendons and tendinosis with longitudinal split tears in ten tendons. Six of the twelve cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Six tendons were augmented with an extensor hallucis longus (EHL) transfer into the medial cuneiform. All patients improved postoperatively, with a mean improvement in AOFAS score of 33 and the mean postoperative pain VAS of 0.9 out of 10. Two patients underwent concomitant procedures on the same foot. Three of the six treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In six cases the patient was completely satisfied. Three were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe-catching when walking barefoot. No patient regretted having had the surgery.

CONCLUSION

Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provided a high level of patient satisfaction after nonoperative management failed in this series.