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A 45-year-old male presents with complaints that his left foot "slaps" on the floor when he tries to ambulate. He reports a remote history of playing rugby 7 months ago when an opposing player fell on his plantarflexed left ankle. He denies constitutional symptoms. On physical examination he has weak dorsiflexion and increased fatigue with walking. He is able to achieve 15 degrees of passive dorsiflexion with the knee in full extension and 20 degrees of dorsiflexion with his knee in 90 degrees of flexion. A sagittal T2 MRI is shown in Figure A and axial MRI images are shown in Figures B and C. Which of the following is the MOST appropriate next step in management?
Surgical reconstruction with posterior tibial tendon transfer and gastrocnemius recession
MRI of the proximal tibiofibular joint for evaluation of ganglion cyst and EMG of the peroneal nerve
Primary surgical repair with gastrocnemius recession
Chest CT, skeletal survey, hematology profile, and referral to an orthopaedic oncologist for biopsy of the mass
Surgical reconstruction with plantaris tendon interposition augmentation
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This patient's history, examination, and images are consistent with chronic anterior tibialis rupture. This injury most often occurs in middle-aged patients following an eccentric loading of a degenerated tibialis anterior tendon against a plantar flexed foot. The classic triad for anterior tibialis ruptures include: (1) a pseudotumor at the anterior part of the ankle that corresponded with the ruptured tendon end, (2) loss of the normal contour of the tendon, and (3) weak dorsiflexion of the ankle accompanied by hyperextension of all of the toes can help to make the diagnosis.
Sammarco et al present a Level 4 review of 19 patients with traumatic or atraumatic ruptures that were surgically treated in an early (<6 weeks) or late (>7 weeks) manner. Patients who were managed surgically both early and late had improvements in dorsiflexion strength and gait pattern and had a significant improvement in the AOFAS hindfoot score as compared with the preoperative value. The authors advocate repair or reconstruction of the tendon to restore dorsiflexion and inversion of the ankle in order to approximate a normal gait pattern and theoretically to avoid the late development of foot deformity
Ouzounian et al present a Level 4 review of 12 patients with chronic anterior tibialis ruptures. Two types of ruptures were identified on the basis of clinical presentation: (1) atraumatic ruptures, which occurred in low-demand older patients who presented late with minimal dysfunction and (2) traumatic ruptures, which occurred in higher-demand younger patients who presented earlier with more disability. The authors concluded (1) that patients with traumatic ruptures, regardless of the time of presentation, demonstrated better function after operative intervention and (2) that patients with atraumatic ruptures who present early should be managed surgically, whereas those with delayed presentation could be managed with bracing.
Illustration A demonstrates a loss of normal contour of the anterior tibialis tendon of the right ankle associated with a rupture of the anterior tibialis tendon.
Sammarco VJ, Sammarco GJ, Henning C, Chaim S.
J Bone Joint Surg Am. 2009 Feb;91(2):325-32. PMID: 19181976 (Link to Abstract)
Sammarco, JBJS 2009
Ouzounian TJ, Anderson R.
Foot Ankle Int. 1995 Jul;16(7):406-10. PMID: 7550953 (Link to Abstract)
Ouzounian, FAI 1995
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Tibialis anterior reconstruction with free tendon graft