Anterior Tibialis Tendon Rupture: The Other Cause of Foot Drop. Alicia Rozario, DPM PGY-3 DVA Puget Sound Healthcare System

Transcription

1 Anterior Tibialis Tendon Rupture: The Other Cause of Foot Drop Alicia Rozario, DPM PGY-3 DVA Puget Sound Healthcare System

2 Disclosures Nothing to Disclose.

3 ANATOMY upture_files/shapeimage_1.png

4 78-7bf6-4e34-8c8a-4461c png AVASCULAR ZONE

5 EPIDEMIOLOGY, PATHOPHYSIOLOGY, and PMH Acute Rupture Chronic, Acute on Chronic Rupture Age Varies, Young 6 th -7 th decade Gender No difference Men, rare in women Risk Factors Active DM, RA, fluoroquinolones, local steroid use, gout MOI Powerful eccentric contraction of TA with hyper-plantarflexion Laceration, degenerative tears, sudden hyperplantarflexion and eversion forces; attritional

6 CLINICAL FEATURES Acute Rupture Chronic, Acute on Chronic Rupture Chief Complaint Pop or Snap sensation Missed a Stair or Foot Slaps Pain Associated Pain initially; Pain along course of tendon Painless or Mild Edema Anterior Ankle Swelling Minimal Other Visual Cues Ambulation Non-palpable Defect, Loss of contour Difficulty but possible via compensation, Limp Mass, Defect High Steppage Gait, Foot Drop, Toe Drag

7 Loss of contour

8 Mass in Chronic, Acute on Chronic Rupture Ouzounian T, Anderson R. Anterior tibial tendon rupture. FAI 16(7) , 1995.

9 IMAGING Radiograph possible osseous injury such as distal tibial fracture in acute setting CT not indicated Ultrasound MRI - complete versus partial tear; level of proximal retraction for surgical planning

10 DIFFERENTIAL DIAGNOSIS Neurological Deficit Lumbar radiculopathy (L4/L5) Common peroneal nerve palsy Herniated Intervertebral Disc Neoplasm

11 TO TREAT OR NOT TO TREAT What should I do?

12 CONSERVATIVE TREATMENT Nonsurgical Candidates: Older, Sedentary Individuals or >3 months delay *controversial* Ankle Foot Orthosis Double Upright Brace attached to shoe Short Leg Cast (partial ruptures) 3-6 weeks No Treatment inability to tolerate devices; quality of life

13 SURGICAL TREATMENT -Direct Repair Surgical Candidates: Young and/or Active Individuals *controversial* Within 1 month of initial injury ideal; up to 3 months -Delayed Repair (Tendon Reconstruction) > 6 weeks; chronic; acute direct repair not possible

14 DIRECT REPAIR

15 DELAYED REPAIR SURGICAL OPTIONS Sliding Tendon Graft Interpositional Graft EHL tenodesis or EHL tendon transfer

16 DELAYED REPAIR

17 POSTOPERATIVE COMPLICATIONS Failure of reconstruction/repair Weakness of dorsiflexion Adhesions Neuroma Wound dehiscence in delayed repair

18 LITERATURE REVIEW

19 Anterior Tibial Tendon Rupture Ouzounian T, Anderson R. FAI 16(7) , pts ruptured AT tendon 9 men/3 women, 18-83yo (avg age 61) 2 pts IDDM, 1 pt steroid dep RA 9 pts report acute trauma 7 pts surgery Young active and/or active elderly patients with acute trauma 4 pts conservative (bracing) Low functioning elderly pts with atraumatic pres RESULTS Surgical Group - Postop f/u avg 22 months - No postop complications - Overall improved function - Some loss of ankle motion Conservative Group - Overall improved slap foot gait - Continued limited function

20 Anterior Tibialis Tendon Ruptures: An Outcome Analysis of Operative Versus Non-operative Treatment Markarian G, et. al. FAI 19(12): , pts ruptures AT tendon 4 women/12 men, yrs Avg time from injury 71 days 8 pts surgery (~ 55yo) 6 acute, 2 acute on chronic 8 pts conservative (~ 74yo) all acute on chronic RESULTS Surgical Group Follow-up avg 6.68 years Operative care restores higher function level in young and/or active pts Direct surgical repair leads to improved AOFAS scores and improved levels of activity in young and/or active pts Conservative Group Follow-up avg 3.86 years

21 CONCLUSION Anterior tibialis tendon ruptures are a rare occurrence Misdiagnosed Surgical management recommended in the young symptomatic patient with moderate to high activity level Conservative management recommended in elderly and/or patient with low activity level

22 SOURCES 1. Goehring PT, Liakos P. Long-term outcomes following anterior tibial tendon reconstruction with hamstring autograft in a series of 3 cases. J Foot Ankle Surg 48(2): , Mao H, Xu G. Soft tissue repair for tibialis anterior tendon ruptures using plate and screw fixation technique in combination with anterolateral thigh flaps transplantation. J Orthop Surg Research 10:143, Henderson C, Parks B, Guyton G. Lateral and medial plantar pressures after split versus whole anterior tibialis tendon transfer. Foot Ankle Int. 29(10): , Fennell C, Phillips P. Redefining the anatomy of the anterior tibialis tendon. Foot Ankle Int. 15(7): , Negrine J. Tibialis anterior rupture: acute or chronic. Foot and Ankle Clinics 12(4): , Markarian G, Kelikiam A, Brage M, Trainor T. Anterior tibialis tendon ruptures: an outcome analysis of operative versus non-operative treatment. Foot Ankle Int. 19(12): , Mankey M. Anterior tibial tendon ruptures. Foot and Ankle Clinics 1(2): , Palmanovich E, et. al. Chronic tibialis anterior tendon tear treated with an Achilles tendon allograft technique. Orthopedics 36(11): , Ouzounian T, Anderson R. Anterior tibial tendon rupture. FAI 16(7) , Dooley BJ, Kudelka P, Menelaus MB. Subcutaneous rupture of the tendon of tibialis anterior. JBJS 62 (4) , Benzakein R, Wakim W, Delauro T, Marcus R. Neglected rupture of the tibialis anterior tendon. JAPMA 78(10) , 1988.