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Introduction
  • Partial or complete discontinuity of the tibialis anterior tendon
  • Epidemiology
    • demographics
      • attritional rupture more common in older patients
      • strong eccentric contraction more common in younger patients
    • body location
      • at the level of the ankle joint with varying degrees of retraction of the proximal stump
    • risk factors
      • older age
      • diabetes
      • fluoroquinolone use
      • local steroid injection
      • inflammatory arthritis
  • Pathophysiology
    • mechanism of injury
      • result of either laceration of the tendon or closed rupture
      • may also result from strong eccentric contraction in young individual
  • Medical conditions & comorbidities
    • diabetes
    • inflammatory arthritis
  • Prognosis
    • Good with treatment
Anatomy
  • Ankle dorsiflexion
    • primary ankle dorsiflexor (80%)
      •  tibialis anterior
    • secondary ankle dorsiflexors
      •  extensor hallucis longus
      •  extensor digitorum longus
Presentation
  • History
    • acute
      • patient reports a 'pop' followed by anterior ankle swelling
    • chronic
      • patient reports difficulty clearing foot during gait
  • Symtpoms:
    • acute
      • pain
    • chronic
      • may be painless
  • Physical exam
    • acute injury
      • pain swelling anterior to ankle
      • weakness in dorsiflexion of the ankle
        • delay in diagnosis is common because of intact ankle dorsiflexion that occurs as a result of secondary function of the extensor hallucis longus and extensor digitorum longus muscles
    • chronic injury
      • inspection and palpation
        • swelling may be minimal
        • painless mass at the anteromedial aspect of the ankle
        • loss of the contour of the tibialis anterior tendon over the ankle (tendon not palpable during resisted dorsiflexion)
      • weakness
        • use of the extensor hallucis longus and extensor digitorum communis to dorsiflex the ankle
      • gait
        • steppage gait (hip flexed more than normal in swing phase to prevent toes from catching)
        • foot slaps down after heel strike
Imaging
  • Radiographs
    • three views of foot and ankle helpful to exclude any associated osseous injury
  • CT
    • not indicated
  • MRI
    • helpful to diagnose complete versus partial tear but not to determine if interposition graft is necessary
Differential
  • Lumbar radiculopathy (L4)
    • can be differentiated from TA rupture by
      • intact tendon palpable
      • no ankle mass
      • may have dermatomal sensory abnormality
      • positive lumbar spine MRI
  • Common peroneal nerve compression neuropathy
    • EDL, EHL also affected
    • sensory abormalities
    • history of compression to common peroneal nerve
Treatment
  • Nonoperative
    • ankle-foot orthosis
      • indications
        • low demand patient
    • casting
      • indications
        • partial ruptures
  • Operative 
    • direct repair
      • indications
        • acute injury (<6 week) injuries
        • should be attempted up to 3 months out
      • outcomes 
        • surgical repair leads to improved AOFAS scores and improved levels of activity
        • some residual weakness of dorsiflexion is expected
    • reconstruction 
      • indications
        • most often required in chronic (>6 week)  old injuries
Technique
  • Direct repair
    • approach
      • open laceration: incorporate laceration
      • closed rupture: longitudinal incision centered over palpable defect
    • repair technique
      • distal end usually accessible through laceration, proximal end may retract ~3cm
      • place hemostat in wound under extensor retinaculum and pull tendon into wound
      • primary end-to-end non-absorbable suture with Krackow, Bunnell or Kessler technique
      • ends oversewn with small monofilament if frayed to create smoother gliding surface
      • in cases of avulsion, suture anchors or bone tunnels may be used for reattachment
  • Tendon reconstruction
    • approach 
      • curvilinear incision over course of tibialis tendon, may need to be extensile depending needs of reconstruction
      • EHL can be divided through separate small incision and tunneled proximally
    • sliding tendon graft
      • harvest one half width of tibialis anterior tendon proximally and turn down to span gap
      • repair can be strengthened by securing tibialis anterior tendon to medial cuneiform or dorsal navicular distal to extensor retinaculum
    • free tendon graft
      • interposition of autograft (hamstring, plantaris) or allograft  
    • EHL tenodesis or EHL transfer
      • distal EHL stump tenodesed to EHB
      • proximal EHL stump used as tendon graft to repair tibialis anterior insertion
      • proximal tibialis anterior placed under tension prior to suturing to proximal EHL stump
Complications
  • Failure of reconstruction/repair
  • Weakness of dorsiflexion
  • Adhesion formation
  • Neuroma formation
 

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