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Updated: Jun 7 2021

Anterior Tibialis Tendon Rupture

Images ant rupture.jpg
    • Anterior Tibialis Tendon Ruptures are traumatic anterior ankle injuries that can present with foot drop and impaired gait. 
    • Diagnosis is made clinically with presence of a painless mass at the anteromedial aspect of the ankle associated with weakness of dorsiflexion.
    • Treatment is generally direct surgical repair of the tendon to achieve optimal functional outcomes. 
  • Etiology
    • 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
  • 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
  • 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 in an active, high demand patient
          • 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
        • if less then 5 degrees of ankle dorsiflexion with the knee extended perform gastrocnemius recession prior to tensioning repair
        • 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
  • Prognosis
    • Good with treatment
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