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

Tibialis Anterior Tendon Reconstruction Utilizing Split Tendon Turn-down: A Case Report and Technique Guide

Tibialis anterior tendon (TAT) ruptures are rare, equating to less than 1% of all musculotendinous injuries. These injuries can be acute or atraumatic, with the latter often associated with chronic degenerative tendinopathy. Surgical repair is indicated when conservative measures fail in meeting functional demands. Direct end-to-end repair is the preferred method for TAT ruptures but may not be feasible with a large tendon defect. Various surgical techniques have been described to address this pathology, including allograft tendon interposition or extensor hallucis longus (EHL) transfer. The authors present a unique technique utilizing a minimal incision TAT turn-down with dermal matrix allograft augmentation, and, in addition, a case implementing this technique in a patient with a large insertional defect. The patient's postoperative course and outcomes were favorable, with improvements in pain, satisfaction, functional scores, and strength. The surgical technique offers versatility and can be adapted to different tendon defect sizes. It also allows for minimal-incision exposure, beneficial for patients with comorbidities or compromised skin integrity. In conclusion, the authors present a case report and surgical technique for the management of large-deficit, chronic TAT ruptures using split TAT turn-down. This technique provides a potential solution for cases where direct end-to-end repair is not feasible.Level of Evidence: Level V.

Early Resection of the Tibialis Anterior Tendon for Tendon Exposure After Total Ankle Arthroplasty to Prevent Deep Infection: A Report of Three Cases in Patients With Rheumatoid Arthritis

Exposure of the tibialis anterior (TA) tendon with wound dehiscence after total ankle arthroplasty (TAA) with the anterior approach is a problematic complication, especially in rheumatoid arthritis (RA) patients. Once the TA tendon is exposed, the duration of wound healing is prolonged, and it could be a risk factor for deep infection. Thus, early resection of the TA tendon was evaluated for tendon exposure with wound dehiscence after TAA in RA patients. In this case report, three rheumatoid ankles that showed wound dehiscence with exposure of the TA tendon after TAA with the anterior approach are presented. Early resection of the TA tendon and debridement under local anesthesia were performed within two days after wound dehiscence. In all cases, wound healing was completed within two weeks after the treatment. Drop foot was not seen in any patients, and there was no difference between the pre and postoperative (1 year after TAA) range of dorsiflexion. Muscle strength for ankle dorsiflexion was also maintained. In conclusion, early resection of the TA tendon appears to be a useful option for undesirable tendon exposure with wound dehiscence to prevent deep infection and prolonged wound healing after total ankle arthroplasty in RA patients.

Reconstruction of chronic tibialis anterior tendon ruptures using a free anterior half of a peroneus longus tendon autograft: A technical note

Purpose: Chronic rupture of the tibialis anterior (TA) tendon is rare. Several reconstruction techniques have been introduced. However, to the best of our knowledge, the use of a free anterior half of a peroneus longus tendon (AHPLT) autograft has not been reported for reconstruction of TA tendon rupture. This study aimed to describe the surgical technique and present the clinical outcomes of reconstruction of the chronic TA tendon ruptures using an AHPLT autograft. Methods: Between September 2013 and April 2019, five patients with chronic TA tendon rupture were surgically treated by reconstruction using an AHPLT autograft. The AHPLT could be easily harvested percutaneously with a tendon stripper from the ipsilateral lower leg around the reconstruction site. The study included four men and one woman, with a mean age of 43.8 (range: 23-65) years. Results: At a mean follow-up period of 42.8 (range; 12-70) months, the mean Foot Function Index value significantly improved from 53.6 ± 19.8 preoperatively to 25.8 ± 20.8 postoperatively (p = .04). None of the patients had morbidities (such as nerve injury, delayed tendon ruptures, or tenosynovitis) around the AHPLT donor site. Three patients were very satisfied, two patients were satisfied, and one patient was fair with the results. Conclusions: Reconstruction of chronic TA tendon ruptures using a free AHPLT autograft could be successfully performed with satisfactory clinical outcomes and minimal donor site morbidities. Future studies with a larger population size and a comparative group are warranted to confirm these findings.

Ultrasound Examination and Navigation for Repeat/Delayed Reconstruction of the Ankle Extensor Tendons

Herein, we describe a 46-year-old woman with persistent pain and weakness in her left ankle/foot one year after surgical repair of all three ankle extensor tendons following a penetrating injury. This report presents a unique case whereby US imaging played a paramount role in the diagnosis and surgical management of a previous nonanatomic repair of the ankle extensor tendons after a penetrating injury one year prior. The above-quoted findings were subsequently corrected with end-to-end sutures. On the third postoperative month follow-up, the patient was free of any complaints or complications.

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.

Postoperative results of distal tibialis anterior tendinosis

INTRODUCTION

Although distal tibialis anterior tendinopathy is a common condition, it has rarely been described in literature. It is often a condition in overweight women around 50-70 years old with pain that worsens at night. The purpose of this retrospective study is to describe the specific clinical signs and postoperative results of distal tibialis anterior tendinopathy.

MATERIAL AND METHODS

Between 2013 and 2017 we operated 9 patients (10ft) who failed a conservative treatment of distal tibialis anterior tendinopathy. Surgery consisted of debridement of the diseased tendon and reinsertion with a bone anchor. There was a minimum follow-up of 12 months. All patients were clinically evaluated postoperative (range 14-57 months after surgery) with the use of the American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analog Scale (VAS) RESULTS: The mean AOFAS score postoperative was 99 (range 94-100). The mean VAS score postoperative was 1 (range 0-3). In all 10 cases the patient was completely satisfied with the result following surgery. There was no recurrence or rupture of tendon after debridement.

CONCLUSION

Distal tibialis anterior tendinopathy is mainly a clinical diagnosis where conservative treatment should always be the first choice. However, our results show that when conservative treatment fails, surgical treatment can lead to very good long term results with a high level of patient satisfaction.

A report of three cases which required tibialis anterior tendon resection to recover delayed wound healing after total ankle arthroplasty in patients with rheumatoid arthritis

Delayed wound healing is one of the severe complications after total ankle arthroplasty (TAA). In particular, once tibialis anterior (TA) tendon is exposed from tendon sheath of extensor retinaculum, wound healing will be critically intractable. We report three cases (mean age: 75.3 years old) of delayed wound healing after TAA cured by resection of TA tendon in patients with rheumatoid arthritis (RA). All three cases underwent TAA through an anterior approach, with careful suture of extensor retinaculum in wound closure. Ankle joint was fixed with splint and avoid weight bearing for three weeks after surgery. Delayed wound healing with TA tendon exposure was observed, and initially treated by debridement, basic fibroblast growth factor spray, and negative pressure wound therapy, which all failed to obtain wound healing. Finally, complete resection of TA tendon led to rapid wound healing. In all cases, ankle dorsal flexion was compensated by other extensors, with maintained range of motion and muscle strength (manual muscle testing 3 to 4) compared to pre-operation at 1 year after TAA operation. Resection of TA tendon may be considered as one of the salvage treatment options of severe delayed wound healing in TAA with anterior approach, especially in elderly patients.

Predictive role of ankle MRI for tendon graft choice and surgical reconstruction

PURPOSE

Tendon transfers have become a common surgical procedure around the ankle. In this study, we sought to evaluate the existence of a correlation between specific anthropometric parameters and the size of some ankle tendons measured on MRI, in particular those mostly used as graft in ankle surgery.

METHODS

We recorded gender, height, weight, and body mass index (BMI) of 113 patients (57 females; mean age: 42 ± 18) who underwent ankle MRI. MRI measurements performed by a radiologist were: axial shortest diameter of Achilles (AT), posterior tibialis (PTT), flexor digitorum longus (FDLT), flexor hallucis longus (FHLT), peroneus longus (PLT), and anterior tibialis (ATT) tendons, intermalleolar distance (ID) and talus width (TW). Mann-Whitney U test and Pearson's correlation coefficient were used. After applying the Bonferroni correction for multiple comparisons, statistical significance was set at p < 0.002.

RESULTS

The mean patient height, weight and BMI were 169 ± 9.8 cm (range: 140-193), 72.4 ± 16.4 kg (range: 44-142), and 25 ± 5.7 (range: 16-50), respectively. The mean ankle measurements were: AT = 5.3 ± 1.4 mm, PTT = 3.3 ± 0.6 mm, FDLT = 2.6 ± 0.4 mm, FHLT = 2.7 ± 0.4 mm, PLT = 2.9 ± 0.5 mm, ATT = 3±0.6 mm, ID = 62.9 ± 4.5 mm, and TW = 28.8 ± 2.5 mm. A statistical difference between male and female patients was observed regarding ID (z = -6.955, p < .001), TW (z = -6.692, p < .001), AT (z = -3.587, p < .001), PTT (z = -3.783, p < .001), and FDLT (z = -3.744, p < .001). Both PTT and FDLT showed a significant correlation with ID (p < .001) and TW (p < .001). ATT size was significantly correlated with weight, ID and TW (all with p < 0.001). PLT and AT showed a significant correlation only with ID and weight (p ≤ .001), respectively.

CONCLUSION

Our data might help orthopaedists in preoperative planning to identify the best graft for ankle surgical procedures including tendon transfers.