Tibialis Anterior Tibialis Anterior RuptureRupture

Xray RoundsXray Rounds

Aug 17Aug 17thth 2010 2010

BackgroundBackground

Originally described in 1905 Originally described in 1905 (Bruning)(Bruning)

104 published cases 104 published cases (2006 data)(2006 data)

Third most common rupture LEThird most common rupture LE1)Achilles1)Achilles2)Patellar2)Patellar

Male 50-70 yrs Male 50-70 yrs Strongest extensor Strongest extensor

– 80% dorsiflexion force80% dorsiflexion force

SymptomsSymptoms

Often mildOften mild– Easily overlookedEasily overlooked

Slapping footSlapping foot Most young pts have laceration Most young pts have laceration

Ultrasound vs MRIUltrasound vs MRI– Confirm clinical dxConfirm clinical dx– Surgical planningSurgical planning

MechanismMechanism

Supination with abrupt Supination with abrupt plantarflexionplantarflexion– 4 causes:4 causes:

1)1)Open, direct traumaOpen, direct trauma2)2)Closed, indirect traumaClosed, indirect trauma3)3)Inner traumaInner trauma4)4)Spontaneous ruptureSpontaneous rupture

• Likely from previous degenerative processLikely from previous degenerative process• SLE, Hyperparathyroidism, chronic SLE, Hyperparathyroidism, chronic

acidosis of lead nephropathy, steroid acidosis of lead nephropathy, steroid therapy, DM, RA, psoriasis, gout.therapy, DM, RA, psoriasis, gout.

AnatomyAnatomy

Avascular zone Avascular zone – Middle part, anterior half (.5-3cm from Middle part, anterior half (.5-3cm from

insertion)insertion) 70% insert into medial side of med 70% insert into medial side of med

cuneiform and base of 1cuneiform and base of 1stst met base met base 25% insert only into medial side of 25% insert only into medial side of

medial cuneiformmedial cuneiform 5% extra tendon b/n m cuneiform and 5% extra tendon b/n m cuneiform and

11stst met base met base

Anagnostakos et al 2006Anagnostakos et al 2006

TreatmentTreatment

No clear guidelinesNo clear guidelines Nonsx for Nonsx for

– Low functional demand ptsLow functional demand pts– >3 months since injury >3 months since injury

1.1. If possible primary repair or sliding tendon repairIf possible primary repair or sliding tendon repair2.2. Distal avulsionsDistal avulsions

– Reattach transosseouslyReattach transosseously3.3. <4cm defects<4cm defects

– Turn down TA repair to cover deficitTurn down TA repair to cover deficit4.4. >4cm >4cm

– Tendon graft or transferTendon graft or transfer EHL, Ext to 5EHL, Ext to 5thth toe, P Brevis/Tertius, and PT toe, P Brevis/Tertius, and PT

May also need GSR to balance forcesMay also need GSR to balance forces

Sammarco 2009Sammarco 2009

Surgical OutcomesSurgical Outcomes

19 TA repairs 19 TA repairs (largest report)(largest report)

– 3 complications3 complications– Improvement in MS in 18/19Improvement in MS in 18/19

AOFAS hindfoot score 55.5AOFAS hindfoot score 55.593.693.6

CaseCase

HPIHPI– 73 yo male73 yo male– 6/10 pain6/10 pain– Twisted ankle golfingTwisted ankle golfing– Presented with MRI in hand 9 days post injuryPresented with MRI in hand 9 days post injury

PMHPMH– Bladder CancerBladder Cancer

PSHPSH– L Kidney removed, Bladder surgery, AAAL Kidney removed, Bladder surgery, AAA

Allergy: MorphineAllergy: Morphine PEPE

– Pain along TA tendon, 0/5 dorsiflexory power, edema/erythema at dorsal Pain along TA tendon, 0/5 dorsiflexory power, edema/erythema at dorsal midfootmidfoot

Xrays (-) MRI Complete TA ruptureXrays (-) MRI Complete TA rupture Impression Impression

– TA ruptureTA rupture PlanPlan

– Scheduled for surgery 10 days post injuryScheduled for surgery 10 days post injury EHL transfer with interference screw EHL transfer with interference screw

ReferencesReferences

Anagnostakos K, Bachelier F, Furst OA, Kelm J. Anagnostakos K, Bachelier F, Furst OA, Kelm J. Rupture of the Anterior Tibial Tendon: Three clinical Rupture of the Anterior Tibial Tendon: Three clinical cases, anatomical study, and literature review. FAI cases, anatomical study, and literature review. FAI 27:330-339, 2006.27:330-339, 2006.

Ellington JK, McCormick J, Marion C, Cohen BE, Ellington JK, McCormick J, Marion C, Cohen BE, Anderson RB, Davis WH, Jones CP. Surgical outcome Anderson RB, Davis WH, Jones CP. Surgical outcome following tibialis anterior tendon repair. FAI 31:412-following tibialis anterior tendon repair. FAI 31:412-417.417.

Kopp FJ, Backus S, Deland JT, O’Malley MJ. Anterior Kopp FJ, Backus S, Deland JT, O’Malley MJ. Anterior Tibial Tendon Rupture: Results of Operative Tibial Tendon Rupture: Results of Operative Treatment. FAI 28:1045-1047, 2007.Treatment. FAI 28:1045-1047, 2007.

Sammarco VJ, Sammarco GJ, Henning C, Chaim S. Sammarco VJ, Sammarco GJ, Henning C, Chaim S. Surgical repair of acute and chronic tibialis anterior Surgical repair of acute and chronic tibialis anterior tendon ruptures. JBJS 91:325-332, 2009.tendon ruptures. JBJS 91:325-332, 2009.