Repair of Chronic Tibialis Anterior Tendon Ruptures

n tips & techniques
Section Editor: Steven F. Harwin, MD
Repair of Chronic Tibialis Anterior Tendon
Ruptures
Shawn S. Funk, MD; Bethany Gallagher, MD; A. Brian Thomson, MD
Abstract: This article presents a novel technique for repair of
chronic tibialis anterior tendon ruptures. All chronic tibialis
anterior tendon ruptures reviewed were treated with this technique. Patients with chronic tibialis anterior tendon ruptures
presenting to the authors’ institution from 2006 to 2012 had
preoperative and postoperative Foot and Ankle Ability Measure scores. The average follow-up time was 2.1 years. The
average Foot and Ankle Ability Measure score was 66.1%
preoperatively and 87.1% postoperatively (P=.002). This
technique offers theoretical improved strength and may help
avoid the need for tendon graft often required by other techniques. [Orthopedics. 2016; 39(2):e386-e390.]
T
he tibialis anterior supplies
80% of the dorsiflexion
power of the ankle. Deficiency
results in a significant functional deficit.1,2 Tibialis anterior tendon ruptures occur traumatically and atraumatically.
Atraumatic ruptures occur after
the age of 45 years following
eccentric loading of a degenerated tibialis anterior tendon
against a plantarflexed ankle
and often present delayed. Patients with inflammatory ar-
The authors are from the Department of Orthopaedic Surgery, Vanderbilt
University, Nashville, Tennessee.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: A. Brian Thomson, MD, Elite
Sports Medicine and Orthopaedic Center, 356 24th Ave N, Ste 200, Nashville, TN 37203 (andrew.thomson@vanderbilt.edu).
Received: October 10, 2014; Accepted: February 13, 2015.
doi: 10.3928/01477447-20160307-05
e386
thropathy, gout, and diabetes
mellitus and patients receiving
corticosteroid treatment are at
risk for degeneration and atraumatic rupture of the tendon.1,3-8
Previous studies have identified
a hypovascular zone as 45 to 65
mm in total length starting approximately 5 mm proximal to
the insertion site.9-11 A significant number of ruptures are at
the most distal 5 to 30 mm of
the tendon, correlating with the
hypovascular zone.10-12
Patients present with a triad
of findings, including a pseudotumor at the anteromedial
aspect of the ankle, loss of the
contour of the tibialis anterior
tendon over the ankle, and the
use of the extensor hallucis
longus and extensor digitorum
longus to dorsiflex the ankle.1,7
Gait is typically foot slap or
steppage with a propensity for
toe dragging.1 Case studies
have described these injuries
and potential treatments, but
there is no consensus regarding treatment.4,8,12-14
Direct repair of the tendon
is ideal when possible with
adequate healthy tendon stalk
proximally and distally. Acute
tendon laceration is often amenable to direct repair. However, atraumatic ruptures often
occur at the distal end of the
tendon at the site of bony insertion, and often present late
due to the difficulty of diagnosis.7 Current repair techniques
involve suture anchor and
bone tunnel repair with the use
of a tendon graft.4,8,12-14 These
techniques frequently implement a graft, with associated
morbidity of harvesting, and
can result in a bulky repair. Repair with pull-out suture over a
button on the plantar surface
requires bone to tendon healing to afford repair strength
once the button is removed,
and the button can cause skin
complications.13
Distal biceps ruptures are
more common and have been
thoroughly studied in relation
to the biomechanics of differ-
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n tips & techniques
ent repair techniques. In comparing repairs using suture
anchors, bone tunnels, and the
EndoButton (Arthrex, Naples,
Florida), the EndoButton has
been found to be biomechanically superior.15-17 Due to the
distal nature of tibialis anterior
ruptures, the distal biceps repair system offers an excellent
solution and has lessened the
need for tendon graft. In this
article, the authors describe
use of the EndoButton.
Materials and Methods
After obtaining institutional
review board approval, the
electronic medical records of
all patients who had a tibialis
anterior tendon rupture from
2006 to 2012 were evaluated.
For each patient, demographic
data and outcome data were
de-identified and recorded in a
REDCap database.18 The clinical outcome used for this study
was the Foot and Ankle Ability
Measure (FAAM) score, which
is a validated outcome measure
for foot and ankle injury and
disease.19 Seven patients were
identified presenting 4 to 25
weeks after the injury.
Patients were contacted and
consented for inclusion in the
study. A posttreatment FAAM
tool was administered. This
postoperative outcome was
compared with preoperative
results previously recorded
in the medical record. The
activity of daily living questionnaire of the FAAM was
analyzed, excluding the sport
questionnaire due to average
patient age and activity level.
Statistical analysis was performed with univariate analysis with the Mann-Whitney U
test. Stata statistical software,
release 11 (StataCorp, College
Station, Texas), was used.
Preoperatively, each patient was assessed for equinus
contracture, which can be addressed with Strayer or Achilles lengthening.
Operative Technique
An anteromedial incision
was made overlying the tibialis
anterior tendon from the medial cuneiform to the level of
the superior retinaculum. The
proximal end of the ruptured
tendon was retracted, and in
the cases of chronic rupture,
significant pseudotendon had
usually formed. The distal
stump was identified and was
insufficient for direct repair.
The tendon insertion site
was debrided of the distal tendon remnant. The proximal
tendon stump and pseudotendon was minimally debrided
to healthy tissue that would
hold suture, and length was
assessed with traction. The
medial cuneiform was the insertion site.
Fluoroscopy was used to
confirm the starting point of
the bone tunnel and the trajectory to ensure adequate bone
stock surrounding the graft/
bone tunnel (Figure 1A).
Then, a 3.2-mm drill pin was
used to create a bicortical tunnel and was left in place (Figure 1B). A 7-mm reamer was
placed over the guide pin and a
unicortical tunnel was reamed,
ensuring adequate depth of the
tunnel and that the far cortex
was not reamed. The drill pin
and reamer were removed and
the bone tunnel was irrigated to
remove any debris.
Figure 1: Tibialis anterior rupture repair. Intraoperative anteroposterior radiograph identifying appropriate bony insertion site (A). Medial cuneiform is drilled
with a 3.2-mm guide pin (B). Previously whip stitched tendon is prepared and
EndoButton (Arthrex, Naples, Florida) is threaded (C). EndoButton is inserted
into the bone tunnel (D).
To confirm the tendon
would pass through a 7-mm
bone tunnel, the proximal
tendon stump was sized with
a 7-mm sizing block. The terminal 2.5 cm of the proximal
stump of the tibialis anterior
tendon was then whip stitched
using No. 2 FiberLoop (Arthrex) with a straight needle
in a locking fashion. The final
throw was locked proximally
prior to exiting the tendon end
(Figure 1C). In most cases,
pseudotendon was incorporated into the repair to extend
the working length of the tendon. The suture was begun
in healthy tendon, and only
pseudotendon that would hold
suture was used.
Using a 7-mm reamer is a
deviation from the technique
for the distal biceps repair kit.
The standard technique for the
kit overdrills 1 mm. However,
because the tarsal bones have
a higher proportion of cancel-
lous bone compared with the
proximal radius, the authors
have found that overdrilling
leads to an inadequately constrained tunnel.
The FiberLoop suture,
which had been previously cut
to remove the suture needle,
was then threaded on to the
BicepsButton (Arthrex), with
each limb entering the opposite hole and exiting through
the entry hole of the opposite
suture.
The EndoButton was then
placed on the insertor (Figure 1D), which was guided
through the medial cuneiform
bicortically. After passing
through the far cortex, the EndoButton was deployed and
flipped into position and the
tendon was pulled into the
bony tunnel (Figures 2A-B).
The authors’ goal was to place
15 to 20 mm of tendon into the
tunnel with good tendon tension with the ankle at maxi-
MARCH/APRIL 2016 | Volume 39 • Number 2e387
n tips & techniques
as tolerated in a walking boot
for 4 weeks and open chain
physical therapy were initiated. At 2 months, regular shoes
could be worn and physical
therapy continued with impact
activities. At 6 months, full activity could be resumed.
Results
Figure 2: Tibialis anterior tendon repair. The EndoButton (Arthrex, Naples,
Florida) is deployed and the distal tendon end is pulled into the bone tunnel (A).
EndoButton deployment is confirmed on radiograph with anteroposterior (B)
and lateral views with intraoperative fluoroscopy. A Bio-Tenodesis screw (Arthrex) is placed while holding tension to further tighten and augment repair (C).
Final repair (D). Final repair confirmed on intraoperative lateral radiograph (E).
Figure 3: Illustration of tibialis anterior tendon repair. Anterior view showing
starting point for bone tunnel on medial cuneiform (A). Anterior view of repaired tendon (B). Lateral view of the foot with small-diameter bone tunnel
through both cortices and larger reamed tunnel ending before far cortex (C).
Lateral view of tendon repair (D).
mum dorsiflexion. A BioTenodesis screw (Arthrex)
was then loaded on to the
driver and one end of the
FiberLoop suture was threaded through the driver with the
screw loaded. Tension was
maintained over both ends of
the FiberLoop while driving
the screw (Figure 2C). After
the screw was seated, the Fi-
e388
berLoop suture was tied over
the tenodesis screw (Figures
2D-E). Tendon insertion and
the final construct are illustrated in Figure 3.
Postoperative Care
Postoperatively, patients
were immobilized and nonweight bearing for 6 weeks.
After 6 weeks, weight bearing
There were 6 female patients and 1 male patient with
a tibialis anterior rupture
(Table). All tibialis anterior
ruptures were repaired using
a distal biceps repair kit with
an EndoButton and/or a BioTenodesis screw. Among the
patients with rupture, 4 had
comorbidities that could be
associated with the rupture
(Table). One rupture was traumatic, 2 ruptures were postoperative complications from a
prior surgery, and 2 ruptures
failed repair by other techniques. The Achilles lengthening procedure using either the
Hoke or the Strayer technique
was performed in all but 2
cases.
The FAAM was used preoperatively to evaluate patients’ function. The FAAM
was administered postoperatively for 1 case because of
function prior to surgery. The
average follow-up time was
2.1 years. The average FAAM
score was 66.1% preoperatively and 87.1% postoperatively
(P=.002). No comparative
analysis was performed. Further details regarding mechanism of injury and presentation are provided in the Table.
Discussion
Tibialis anterior rupture, a
rare injury that is commonly
misdiagnosed and presents
late, causes significant morbidity. This process was first
described in 1905 by Bruning, and no consensus exists
regarding treatment.7,20 Several techniques have been
proposed with reasonable
results.4,8,12-14 Techniques for
tendon repair for other tendon injuries have been evaluated thoroughly, including
strength comparisons; however, each pathologic condition
represents a unique treatment
dilemma.15-17
Tendon repair and reconstruction options for the tibialis anterior tendon include
direct repair when possible;
however, this is rarely possible for chronic tibialis anterior tendon ruptures because
of their distal nature. Reconstruction options include direct repair of tendon-tendon,
tendon-bone with or without
auto/allograft tendon, or tendon substitution with extensor
hallucis longus transfer.7
No biomechanical studies
have been performed comparing repair techniques for the
tibialis anterior; however, corollaries can be made to the distal biceps, which has had extensive biomechanical testing.
The EndoButton has shown
superior strength and a higher
load to failure than bone tunnel, suture anchor, or interference screw in isolation.15-17
This study showed significant improvement in the
FAAM.19 Limitations of the
study included small sample
size and lack of a control
group. Because tibialis anterior tendon rupture is rare, studies have had small numbers
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n tips & techniques
Table
Follow-up, y
Preop
Postop
Results of Tibialis Anterior Repair
Surgical Technique
100%
FAAM ADL
Questionnaire
Score
Comorbidities
93%
94%
Complications
Presenting Symptoms
1.99
58%
71%
Mechanism of
Injury
OA, prior foot
surgery
Repair to medial cuneiform with EndoButton
(Arthrex, Naples, Florida)
and Bio-Tenodesis screw
(Arthrex)
Strayer technique
0.66
41%
100%
Weeks to
Diagnosis
Foot drop and frequent tripping
DM
Repair to medial cuneiform with EndoButton
and Bio-Tenodesis screw
Strayer technique
4.05
88%
Patient
Age, y/
Sex
Dull pain for a month
and mass anterior
ankle
OA
1.87
80%
Unknown
4
Chronic instability and pain
No identifiable
injury
Foot drop and pain
along tibialis anterior
tendon
Repair with harvest of
hamstring tendons for
graft
Bio-Tenodesis screw (no
button)
Hoke technique
61%
77.9/F
5
Chronic rupture
No specific injury
Discomfort and mass
anterior ankle
2.77
70%
25
Postoperative pain
and hyperesthesias
anterior ankle
Trip forward
Repair to medial cuneiform with EndoButton
and Bio-Tenodesis screw
Strayer technique
61%
Injured during podiatric
surgery (1st TMT
plantarflexion
arthrodesis)
Burning over anterior
ankle and foot slap
2.63
10
Repair to medial cuneiform with EndoButton
and Bio-Tenodesis screw
0.82
4
Repair to medial cuneiform with EndoButton
and Bio-Tenodesis screw
Strayer technique
DM
95%
Burning pain
while riding a bus
No identifiable
injury
Repair failure
Revised to EndoButton and BioTenodesis screw
with allograft
augmentation
61%
Failed tendon repair 5 years prior
(suture anchor
repair)
53.0/F
71.3/F
53.2/F
35.2/F
57.4/M
46.4/F
Primary suture repair
This failed and was
revised
Broken glass
resulting in transverse laceration
across dorsum
of foot
Obvious tendon
laceration
Decreased sensation
dorsum of foot
Immediate/revised
after chronic
re-rupture at 26
weeks
Abbreviations: ADL, activity of daily living; DM, diabetes mellitus; F, female; FAAM, Foot and Ankle Ability Measure; M, male; OA, osteoarthritis; preop, preoperative; postop,
postoperative; TMT, tarsometatarsal.
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n tips & techniques
of patients. The largest study
had 19 patients and was not
restricted to chronic ruptures.7
Rare injuries motivate surgeons to use clinical corollaries to aid in the development
of treatment methods.
Conclusion
The authors have presented
a technique for tibialis anterior tendon repair using an
EndoButton. This has proved
to be an effective treatment
and is preferred at the authors’
institution. This technique
is biomechanically superior
in anatomic corollaries. The
straightforward method often
alleviates the need for tendon
graft by using robust pseudotendon. This technique would
also permit placement of the
tendon insertion in the navicular if tendon length was
inadequate. Further studies
validating this technique are
warranted.
e390
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