Rupture of the posterior tibial tendon associated with closed ankle fracture

Ultrasound assessment of the spring ligament and posterior tibial tendon in healthy subjects: A descriptive study

BACKGROUND

The main aim of this study was to ultrasonographically analyse the thickness and the relationship between the Superomedial Bundle of the Spring Ligament and the Posterior Tibial Tendon in healthy subjects and its relationship with different epidemiological variables.

METHODS

Fifty-five healthy feet with a mean of 47 years old measuring the same ultrasound model and researcher. Demographic variables (age, sex, laterality, BMI, type of sports activity performed, and type of work activity) were collected from all participants. The thickness of the PTT and the Spring Ligament was measured in both longitudinal and transverse diameters. The intraclass correlation coefficient (ICC) was also analysed to assess the agreement of the measurements between a researcher and the ultrasound specialist radiologist.

RESULTS

The mean thickness of the Spring ligament was 5.07 mm (95 % CI 4.75-5.38), while that of the PTT in its long axis was 3.58 mm (95 % CI 3.37-3.79). Regarding the interobserver agreement analysis, the intraclass correlation coefficient for measurements between observers was 0.91 (CI95 %: 0.698-0.977) which denotes a high degree of similarity between the clinician and the radiologist.

CONCLUSION

This study describes the relationships between the thickness of the posterior tibial tendon and the superomedial Bundle of the Spring ligament in healthy subjects, as well as their variability according to certain epidemiological variables such as age, gender, occupation, and sport. On the other hand, the measurements taken by a researcher high agreement with those taken by a radiologist specialized in ultrasound.

Rupture of the Tibialis Posterior Tendon With Associated Bimalleolar Ankle Fracture

The acute traumatic rupture of the tibialis posterior tendon in association with closed ankle fractures is rare and often under-recognised. If recognised early, outcomes can be excellent. There are 28 known cases in the literature, and we report two further cases associated with bimalleolar ankle fracture dislocation. A 49-year-old presented with valgus deformity at the ankle joint and global tenderness following a work injury as a mechanic. A plain radiograph showed a displaced oblique comminuted fracture of the lateral malleolus with valgus angulation at a syndesmosis, with significant talar shift. The patient underwent open reduction and internal fixation with a seven-hole, one-third tubular plate and screws. A 35-year-old involved in a motorcycle collision with a car presented with swollen left ankle and valgus deformity. Plain radiographs revealed bimalleolar fracture subluxation. Closed reduction was unsuccessful and hence direct medial approach demonstrated a complete rupture of the posterior tendon. The medial malleolus was fixed using lag screws and washers. The tendon was repaired using the modified Kessler technique in both cases. The tibialis posterior plays a significant role in foot and ankle biomechanics due to its broad tendinous insertion. Acute traumatic rupture is rare, as it is protected due to its deep-seated anatomic location within the deep posterior compartment of the leg. Preoperative diagnosis of this injury is challenging and hence this diagnosis is often made intraoperatively. In both cases, there was a retraction of the proximal end beyond incision margins, and this can make tendon rupture difficult to identify intraoperatively as well. Upon identification, assessment of the tendon for degenerative changes was key to deciding upon suitability for primary repair. Despite its rarity, a high index of suspicion should be maintained in fracture dislocation of the ankle joint, especially when the mechanism is known to be pronation-external rotation.

Posterior tibialis tendon rupture concomitant with a closed medial malleolar fracture: A case report and literature review

Traumatic rupture of the posterior tibialis tendon is an extremely infrequent condition, which mostly occurred due to a traumatic mechanism of pronation and external rotation, less commonly in direct trauma on the medial side of the ankle. This lesion is overlooked preoperatively most of the time because of the limitation of physical examination owing to acute pain and swelling secondary to a medial malleolar fracture. Early diagnosis and treatment of this injury are very important to prevent the complications like acquired flatfoot deformity. Few cases have been described in the literature for the posterior tibialis tendon rupture associated with a closed ankle fracture. Here we report an acute rupture of the posterior tibialis tendon associated with a closed medial malleolar fracture after a high-energy trauma in a healthy 33-year-old man. We fixed the medial malleolar fracture with two screws and repaired the tendon with a direct end-to-end suture. We hope that our study can be helpful for other colleagues to consider this lesion in similar circumstances.

Posterior Tibial Tendon Rupture Associated With Anterolateral Distal Tibial and Medial Malleolar Fracture and a Novel Pattern of Tibiofibular Syndesmotic Injury: A Case Report and Review of the Literature

A posterior tibial tendon (PTT) rupture associated with ankle fractures is a very rare condition. Ankle pronation and external rotation (PER) movement are the typical traumatic mechanism. This injury is frequently overlooked preoperatively. Early diagnosis and treatment are very important to prevent the serious consequences related to functional PTT insufficiency on biomechanics of the foot. Few cases have been described in the literature that highlight the relationship between PTT rupture and PER type ankle fracture with a medial malleolar fracture. We present a case of a complete PTT rupture in a closed atypical ankle fracture in which a medial malleolar fracture was associated with a very large fragment from the anterolateral distal tibia (Tillaux-Chaput fragment) and a concomitant avulsion fracture from the anteromedial portion of the fibula (Lefort-Wagstaffe fragment), with a novel pattern never described before.

Biologically Enhanced Hamstring Tendon Transfer for Treatment of Acute Rupture of Posterior Tibialis Tendon in an Athlete: Case Report

We report the case of a 32-year-old basketball player who presented with an acute flatfoot deformity after performing a unipodal power jump. Rupture of the posterior tibial tendon within the foot was diagnosed and then treated by hamstring tendon transfer combined with application of autologous biologic preparations. The functional outcome at 18 months was good. To our knowledge, this is the first reported case of posterior tibial tendon rupture treated by hamstring tendon transfer.

Ankle Fracture Fixation: Medial or Lateral First?

In unstable ankle fractures, the importance of reducing the lateral malleolus first to obtain an anatomic reduction of the talus is well established. Although this is a time-tested and common surgical approach, current surgical practice does not always follow the established dogma. Medial-first fixation may be a worthwhile alternative to lateral-first fixation in select instances. We performed a retrospective, cohort study in an urban level I trauma center to compare medial malleolus-first fixation of unstable ankle fractures with lateral malleolus-first fixation. Patient demographics, injury characteristics, and radiographic metrics including pre-, intra-, and final postoperative talocrural angles, medial clear space, and tibiofibular overlap were assessed. Complications were also reviewed. A total of 280 adult patients with operative bimalleolar ankle fractures from January 2010 to January 2015 met inclusion criteria. There were more open fractures (23.2% vs 9.4%, p = .01) and less isolated injuries in the medial-first group (59.2% vs 71.0%, p = .02). There were less isolated operative procedures (80.3% vs 89.1%, p = .04) and more intramedullary screw placement of the lateral malleolus (11.2% vs 4.3% p = .02) in the medial-first fixation group. There was also a strong trend in identifying more posterior tibial tendon injuries in the medial-first group compared with the lateral-first group (3.5% vs 0%, p = .06). There were no significant differences in fluoroscopy times or radiographic variables in the preoperative, intraoperative, or most recent postoperative images between either group. This approach demonstrates equivalent radiographic outcomes to lateral-first fixation and may be appropriate in select cases.

Passive engineering mechanism enhancement of a flexor digitorum longus tendon transfer procedure

Standard treatments of adult acquired flatfoot deformity (AAFD) fail to correct associated dysfunction of the posterior tibial tendon (PTT). This study aimed to determine if a novel passive engineering mechanism (PEM) enhanced flexor digitorum longus (FDL) tendon transfer procedure would better restore physiologic PTT function to improve AAFD gait parameters compared to standard treatment. We evaluated the kinetic, pedobarographic, and kinematic effects of a pulley-based PEM-enhancement system utilizing a cadaveric flatfoot model and robotic gait simulator. FDL tendon force, FDL tendon excursion, regional peak plantar pressures, center of pressure, and foot bone/joint motions were quantified. Throughout the stance phase of gait, PEM-enhancement significantly increased FDL tendon forces, resulting in gait cycle medial column unloading, lateral column loading, forefoot adduction, hindfoot inversion, and increased plantar flexion (p < 0.05). This proof-of-concept study demonstrated that an innovative PEM-enhanced FDL tendon transfer procedure better restored physiologic PTT function, resulting in improved correction of the distinctive AAFD gait characteristics-medial column collapse, hindfoot eversion, and forefoot abduction. Clinical significance: Novel PEM-enhancement of a FDL tendon transfer procedure holds promise as a method for improved treatment of AAFD. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3033-3042, 2018.

Incarceration of the Posterior Tibial Tendon in an Isolated Comminuted Medial Malleolus Fracture

Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not universally accepted, although many have agreed that any displacement warrants anatomic reduction and fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention. The patient was treated with prompt open reduction and internal fixation and had an excellent functional outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough exploration of the zone of injury is required to identify and adequately address any surrounding pathologic features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never been previously reported and emphasizes the importance of understanding the local anatomy and how restoration of the distorted anatomy is vital to optimize patient function.

Posterior tibialis tendon rupture associated with closed medial malleolus fracture and avulsion of anterior talofibular ligament: A case report and review of the literature

Introduction:

Traumatic rupture of posterior tibialis tendon in association with medial malleolus fracture is extremely rare.

Case Presentation:

We demonstrate our experience in the management of a complete posterior tibialis tendon (PTT) rupture and anterior talofibular ligament avulsion fracture from the talus in association with medial malleolus fracture in a 30-year-old male motorcyclist without any open wounds.

Discussion:

We believe this to be the first reported injury of this type in the literature. Closed ankle fractures may obscure surrounding tendon rupture and the clinician may be tempted to focus on the osseous injuries rather than the significance of associated soft tissue injures.

Conclusion:

This particular case demonstrates the importance of assessing for PTT injury in situations where high velocity impact to the ankle results in malleolar fracture.

Posterior Tibialis Tendon Rupture in a Closed Bimalleolar-Equivalent Ankle Fracture: Case Report

Ankle fractures with an associated posterior tibialis tendon (PTT) rupture are rare injuries and have only been described in a number of case reports. These prior reports include patients that had an open fracture and/or an associated medial malleolar fracture component. In this unique case report, we present a patient that sustained a closed bimalleolar-equivalent ankle fracture/dislocation without medial malleolar involvement which was irreducible due to a PTT rupture and subsequent distal segment interposition in the tibiotalar joint. Identification of acute PTT rupture with associated ankle fracture is important because early repair is associated with significantly better functional outcomes compared with late repair. These injury patterns may easily be missed due to the limitations with physical examination and standard imaging often encountered during initial evaluation of routine ankle fractures. Therefore, physicians should maintain a high level of suspicion in the appropriate clinical setting in order to provide appropriate diagnosis and timely surgical intervention.

LEVELS OF EVIDENCE

Descriptive, Level V: Single case report.

Posterior tibial tendinopathy: what are the risk factors?

BACKGROUND

Posterior tibial tendinopathy (PTT) is the most common cause of acquired (progressive) flatfoot deformity in adults. To date, PTT research has mainly focused on management rather than on causal mechanisms. The etiology of PTT is likely to be multifactorial because both intrinsic and extrinsic risk factors have been reported. We sought to critically evaluate reported etiologic factors for PTT and consider the concept of genetic risk factors.

METHODS

A detailed review of the literature published after 1936 was undertaken using English-language medical databases.

RESULTS

No clear consensus exists as to the relative importance of the risk factors reported, and neither has any consideration been given to a possible genetic basis for PTT.

CONCLUSIONS

To date, studies have examined various intrinsic and extrinsic risk factors implicated in the etiology of PTT. The interaction of these factors with an individual's genetic background may provide valuable data and help offer a more complete risk profile for PTT. A properly constructed genetic association study to determine the genetic basis of PTT would provide a novel and alternative approach to understanding this condition.

Partial Rupture of the Tibialis Posterior Tendon Associated with a Closed Medial Malleolar FractureA Case Report

Rupture of the tibialis posterior tendon associated with ankle fracture is rare and difficult to diagnose. This rupture can be easily overlooked because the clinical examination is limited owing to acute pain related to a closed ankle fracture. Complete rupture of the tibialis posterior tendon can be identified by a loss of tension during ankle fracture fixation, but partial rupture is more difficult to detect because the tibialis posterior tendon can maintain its tension. A few cases of complete rupture of the tibialis posterior tendon combined with ankle fracture have been reported. It is well-known that failure to diagnose a rupture of the tibialis posterior tendon can lead to long-term disability and a planovalgus foot. However, to our knowledge, this is the first report of partial rupture of the tibialis posterior tendon in the English literature. Herein, we describe a patient with a neglected partial rupture of the tibialis posterior tendon combined with a medial malleolar fracture.

Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle Fractures

Tibialis posterior tendon rupture in the setting of pronation-type ankle fractures can lead to long-term debility as a result of chronic tendon dysfunction. This rare injury pattern presents a diagnostic challenge because thorough preoperative examination of the function of the tendon is limited by pain, swelling, and inherent instability of the fracture. As such, a high index of suspicion is necessary in ankle fractures with radiographs showing a medial malleolus fracture with an associated suprasyndesmotic fibula fracture. This report describes 3 cases of tibialis posterior tendon rupture associated with pronation-type ankle fractures treated acutely with open reduction and internal fixation and primary tendon repair. Additionally, common features of this injury pattern are discussed based on the current literature. In accordance with this report, the typical mechanism of injury is high energy and includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. Rupture most commonly occurs in a relatively hypovascular area of the tendon located at the posteromedial extent of the medial malleolus fracture. In the operative treatment of pronation-type ankle fractures, direct inspection of the tibialis posterior tendon allows for timely diagnosis and treatment of associated ruptures. [Orthopedics.2016; 39(5):e970-e975.].

Unique Case of Posterior Tibial Tendon Dysfunction After Stingray Strike

BACKGROUND

Posterior tibial tendon dysfunction is a common cause of adult acquired flatfoot deformity. The cause of posterior tibial tendon dysfunction is often multifactorial and may include repetitive microtrauma, poor blood supply to the tendon, and, rarely, traumatic rupture.

CASE DESCRIPTION

We present the case of a 69-year-old male with posterior tibial tendon dysfunction secondary to a stingray injury that occurred directly into the posterior tibial tendon. This injury led to an acquired adult flatfoot deformity that ultimately required surgical reconstruction. At the time of surgery, the posterior tibial tendon was severely degenerative at the site of skin penetration.

LITERATURE REVIEW

Previous case reports of stingray injury describe full-thickness skin penetration with a subsequent inflammatory response and large zone of necrobiosis. This is the first reported case of stingray trauma and envenomation directly into tendon with subsequent tendon dysfunction.

CLINICAL RELEVANCE

There are thousands of stingray injuries in the United States annually. Injuries vary in severity depending on the type of stingray, size of stingray, and depth and location of injury. For certain injuries, such as direct penetration into tendon, early irrigation and debridement may limit subsequent deficits caused by progressive tendon dysfunction.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case study.

Diagnostic Characteristics of Standard Radiographs and Magnetic Resonance Imaging of Ruptures of the Tibialis Posterior Tendon

The present study aimed to diagnose complete rupture (CR) and longitudinal rupture (LR) of the posterior tibial tendon (PTT) from the magnetic resonance imaging findings in patients with PTT dysfunction and to analyze and compare the radiographs from each group to identify radiographic indicators related to the progression of PTT injury that would allow the radiographic diagnosis of CR. We evaluated 32 feet in 27 patients with PTT dysfunction (mean age 66.5, range 49 to 82, years). Radiographs were used to acquire weightbearing anteroposterior images of the foot, which were used to measure the talonavicular coverage angle. Lateral images of the foot were also acquired with the patients in the standing position. These were used to measure the lateral talometatarsal angle, calcaneal pitch angle, and medial cuneiform-fifth metatarsal height. From the axial MRI findings, the patients were divided into a CR group and an LR group, and the radiographic attributes of the CR group were analyzed. Of the 32 feet in 27 patients, 12 feet (37.5%) in 11 patients displayed CR and 20 feet (62.5%) in 18 patients displayed LR. The talonavicular coverage angle was 48.3° ± 17.3° in the CR group and 33.6° ± 13.6° in the LR group (p = .012), and the talometatarsal angle was -28.8° ± 22.5° in the CR group and -25.4° ± 14.4° in the LR group (p = .596). The calcaneal pitch angle was 10.4° ± 6.7° in the CR group and 10.2° ± 8.0° in the LR group (p = .935). Finally, the medial cuneiform-fifth metatarsal height was -4.2 ± 7.1 mm in the CR group and 2.1 ± 4.7 mm in the LR group (p = .005). When a medial cuneiform-fifth metatarsal height of ≤0 mm or talonavicular coverage angle of ≥50° was used as the diagnostic criterion for CR on weightbearing radiographs, the sensitivity was 71.4%, specificity 88.9%, and diagnostic accuracy 81.3%; hence, we believe these to be satisfactory diagnostic criteria for CR.

Closed Medial Malleolar Multifragment Fracture With a Posterior Tibialis Tendon Rupture: A Case Report and Review of the Literature

Ankle fractures represent an exciting field of traumatology because of the wide variety of clinical presentations, injury mechanisms, and treatment options. Rupture of the posterior tibialis tendon (PTT) with ankle fracture can occur during trauma that involves pronation and external rotation of the foot or, less commonly, secondary to direct trauma to the ankle. This tendon injury is uncommon and probably misdiagnosed in many cases, because of the difficult clinical examination secondary to the pain and swelling. The identification and early treatment of PTT tears is essential for good functional outcomes to prevent the main mid- to long-term complication of disabling acquired flatfoot due to tendon failure. In the present report, we provide a review of the published data regarding ankle fractures associated with PTT rupture and describe our experience with a case of a multifragment medial malleolus fracture and complete rupture of the PTT diagnosed intraoperatively and surgically treated in a 34-year-old male, with 2.5 years of follow-up.

Posterior tibial tendon dysfunction: an overlooked cause of foot deformity

Posterior tibial tendon dysfunction is the most common cause of adult acquired flatfoot. Degenerative changes in this tendon, lead to pain and weakness and if not identified and treated will progress to deformity of the foot and degenerative changes in the surrounding joints. Patients will complain of medial foot pain, weakness, and a slowly progressive foot deformity. A “too many toes” sign may be present and patients will be unable to perform a single heal raise test. Investigations such X-ray, ultrasound and magnetic resonance imaging will help stage the disease and decide on management. The optimal manage may change based on the progression of deformity and stage of disease. Early identification and prompt initiation of treatment can halt progression of the disease. The purpose of this article is to examine the causes, signs, symptoms, examinations, investigations and treatment options for posterior tibial tendon dysfunction.

Posterior tibial tendon tear after 4-cortex syndesmotic screw fixation: a case report and literature review

We describe a previously unreported problem of a patient who underwent errant 4-cortex syndesmotic screw fixation with resultant posterior tibial tendon tear necessitating removal of hardware and repair of a tendon tear.

Acute tibialis posterior tendon rupture associated with a distal tibial fracture

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.

Achilles tendon rupture with open distal tibia and fibula fracture

The authors present a previously unreported case of an open fracture of the distal tibia and fibula with associated Achilles tendon rupture in a 27-year-old motorcyclist. Management followed established trauma principles of wound exploration, debridement, and stabilization of the fracture with reamed locked intramedullary nailing of the tibia. The injury to the Achilles tendon was not identified until surgical exploration for fixation of the fracture. This required a 2-stage operative approach, involving initial debridement and fracture fixation followed by Achilles tendon repair during the second-look wound review procedure. The authors believe this to be the first reported case of Achilles tendon rupture in association with an open transverse distal tibia fracture. Prior to surgical exploration of the wound, Achilles tendon rupture was not suspected, emphasizing the need for clinical suspicion, thorough examination, and adequate wound exploration at operation for fracture fixation.

Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon

This article provides a review of posterior tibial tendon pathology and the authors' preferred management. The tibialis posterior musculotendinous unit is the most powerful inverter of the foot and an important dynamic stabilizer of the arch. In the stance phase of the gait cycle, it serves as an initiator of both ankle plantar flexion and subtalar inversion. This creates a rigid midfoot by stabilizing the transverse tarsal joint, and allows for increased power generation by the gastrocsoleus complex through toe-off. Injuries to the posterior tibialis tendon include traumatic laceration and dislocation, as well as tenosynovitis and tendinopathy, which can lead to attenuation and rupture. If these injuries are not addressed, significant clinical deformity and disability can result.

Tibialis posterior tendon rupture associated with a closed medial malleolar fracture: a case report and review of the literature

We report an acute rupture of a macroscopically normal tibialis posterior tendon in the setting of an acute closed ankle fracture. This injury is considered to be rare, although it is probably frequently overlooked preoperatively because of limitations of the clinical examination secondary to pain. The tibialis posterior tendon rupture was identified at the time of operative repair of the ankle fracture, and direct suture repair of the tendon was undertaken. After primary suture and osteosynthesis, the patient's progress was favorable and a satisfactory outcome was achieved. A clear history of the mechanism of injury as well as a high index of suspicion should be maintained, because failure to repair rupture of the tibialis posterior tendon, in the presence of an ankle fracture, is likely to lead to long-term patient disability and a planovalgus foot.

Irreducible Salter Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon: a case report

Pediatric distal tibial fractures generally occur without significant long-term sequelae, and patients are commonly able to return to their preinjury activities after proper management. The literature reports excellent outcomes after anatomical reduction of distal tibial and ankle physeal fractures with closed or open treatment. Treatment options include simple immobilization of nondisplaced fractures, and closed or open reduction for restoration of anatomic alignment of displaced fractures. Soft tissue interposition within the fracture can threaten successful closed reduction, and may warrant open management if closed reduction fails to produce a satisfactory result. Despite the documented possibility of soft tissue interposition preventing closed reduction of pediatric ankle fractures, there is a paucity of literature reporting this complication. We report a unique case of an irreducible Salter-Harris type II distal tibial physeal fracture secondary to interposition of the posterior tibial tendon.

MR imaging of ankle inversion injuries

Ankle inversions are common in the general population and in athletes. Multiple concurrent injuries are a common result of an ankle-inversion injury. Syndesmosis injury, lateral ankle ligament tears, peroneal retinaculum or tendon injury, osteochondral lesion, or fracture may occur. Chronic pain or instability may result from one or more of these injuries. MR imaging provides superior soft tissue resolution, high sensitivity for occult fractures, and the ability to image the articular cartilage and ankle ligaments directly. This article discusses the MR imaging evaluation of acute and chronic ankle inversion injuries.

Calcaneal osteotomies for the treatment of adult-acquired flatfoot

Calcaneal osteotomies are useful procedures for the treatment of stage 2 adult-acquired flatfoot. Often combined with adjunctive soft-tissue procedures, the posterior calcaneal displacement osteotomy and Evans procedure provide effective realignment of pes planovalgus deformity. Preoperative evaluation, indications, contraindications, surgical considerations and techniques are discussed.

Rupture du tendon du tibial postérieur lors des fractures de la cheville

We report three cases of complete traumatic tibialis posterior tendon rupture which occurred after ankle fracture. Diagnosis was established at surgery. Repair of the non-degenerative tendon was achieved during the procedure for osteosynthesis of the malleolar fracture. Fractures healed a few months after surgery. The posterior tibialis muscle tendon functioned plantar arch was normal, except in one patient with multiple injuries who died in intensive care thirteen days after the accident. Although exceptional, injury of the tibialis posterior tendon should not be overlooked after ankle fracture. These injuries become apparent only at surgery for the malleolar fracture since pain hinders clinical examination. Primary suture best guarantees a good functional outcome. Residual pain, deficit in active inversion of the foot, modified medial longitudinal arch, or progression to planovalgus are retrospective diagnostic signs.

Fracture of the ankle associated with rupture of the Achilles tendon: case report and review of the literature

SUMMARY

A thirty-five-year-old man fell two meters from a ladder and sustained a closed fracture of the medial malleolus with an ipsilateral complete Achilles tendon rupture. The Achilles tendon rupture was diagnosed by means of the patient's complaints and physical findings. The ankle fracture was diagnosed incidentally on routine radiographs. Such a combination of injuries has been reported infrequently in the literature, and striking similarities have been described in the mechanism of injury and fracture pattern. Remarkably, in three of four reports the combined injury was initially misdiagnosed.

Posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot deformity in adults. Although this term suggests pathology involving only the posterior tibial tendon, the disorder includes a spectrum of pathologic changes involving associated tendon, ligament, and joint structures of the ankle, hindfoot, and midfoot. Early recognition and treatment is the key to prevention of the debilitating, long-term consequences of this disorder. Conservative care is possible in the earliest stages, whereas surgical reconstruction and eventually arthrodeses become necessary in the latter stages. The purpose of this article is to review the symptoms, physical examination, radiological examination, classification, and treatment of posterior tibial tendon dysfunction.

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.

Fibular nonunion and equinovarus deformity secondary to posterior tibial tendon incarceration in the syndesmosis: a case report after a bimalleolar fracture-dislocation

A 39-year-old woman sustained a grade II open bimalleolar fracture-dislocation of the left ankle. Six months after an ORIF of these fractures was performed, she presented with a nonunion of the distal fibula fracture and with a fixed hindfoot equinovarus and forefoot adduction deformity. At surgery for repair of the fibular nonunion, the posterior tibial tendon (PTT) was found to be entrapped in the posterior tibiotalar joint, with a portion of the tendon interposed between the tibia and the fibula in the area of the posterior syndesmosis. After extrication of the PTT, the hindfoot varus and forefoot adduction deformity were corrected. To our knowledge, this is the first case report in the English literature of a missed PTT syndesmotic entrapment that resulted in a fibular nonunion and in a fixed foot deformity after an open bimalleolar ankle fracture dislocation.

Posttraumatic posterior tibialis tendon insertional elongation with functional incompetency: a case report

We present a case report and literature review of distal intrasubstance rupture of the posterior tibial tendon with progressive pes planovalgus secondary to tendon incompetence. Three months after a severe ankle sprain, a 25-year-old basketball player presented with ankle weakness and pain. Treatment by advancement of the posterior tibial tendon to the navicular and medial displacement osteotomy of the calcaneal tuberosity restored alignment, strength, and full function.

Rupture of the extensor mechanism associated with a closed phalangeal fracture

A case of closed rupture of the extensor mechanism associated with a fracture of the proximal phalanx of the little finger is presented. Diagnosis was made only after surgical exposure for internal bone fixation.

Hallux flexion deformity secondary to entrapment of the flexor hallucis longus tendon after fibular fracture

This article presents a case of entrapment of the flexor hallucis longus tendon after open reduction and internal fixation of a Weber C ankle fracture resulting in interphalangeal joint contracture of the hallux. Pathology involving other tendons at the foot and ankle associated with ankle fractures is reviewed. Other scenarios of flexor hallucis longus pathology are discussed. Flexor hallucis longus anatomy, as related to distal fibular fractures, is outlined, and a recommendation is made to consider flexor hallucis longus entrapment as a cause of hallux dysfunction after open reduction and internal fixation of an ankle fracture.