n tips & techniques Section Editor: Steven F. Harwin, MD Chronic Tibialis Anterior Tendon Tear Treated With an Achilles Tendon Allograft Technique Ezequiel Palmanovich, MD; Yaron S. Brin, MD; Lior Laver, MD; Dror Ben David, MD; Sabri Massrawe, MD; Meir Nyska, MD; Iftach Hetsroni, MD tus,16,17 rheumatoid arthritis,17 erative tibialis anterior tendon Abstract: Tibialis anterior tendon tear is an uncommon in- psoriasis,18 and deposition of was diagnosed clinically and jury. Nontraumatic or degenerative tears are usually seen gout tophi19,20 also have been confirmed by ultrasound. in the avascular zone of the tendon. Treatment can be con- reported to be associated with After 3 months of phys- servative or surgical. Conservative treatment is adequate tendon ruptures. In older pa- iotherapy treatment without for low-demand older patients. For active patients, surgical tients and in partial tears, non- improvement, surgical treat- treatment can be challenging for the surgeon because after operative treatment has been ment was recommended. The debridement of degenerative tissue, a gap may be formed described.8,21 patient’s American Orthopae- that can make side-to-side suture impossible. The authors Surgical techniques de- dic Foot and Ankle Society present allograft Achilles tendon insertion for reconstruc- scribed in the literature in- (AOFAS)22 score was 23 and tion of chronic degenerative tears. Using Achilles tendon al- clude direct side-to-side his Foot and Ankle Disabil- lograft has the advantage of bone-to-bone fixation, allowing repair and interposition of ity Index (FADI)23 score was rapid incorporation and earlier full weight bearing. autogenous tendon graft for 34.6 preoperatively. delayed reconstruction.2,6,9 With the patient under The current authors describe general anesthesia, a direct he etiology of tibi- zone within 5 to 30 mm from a surgical technique using anterior approach to the ankle Talis anterior tendon tear, the insertion.9,10 Predispos- fresh-frozen Achilles tendon was performed, and a degen- first described in 1905 by ing conditions to rupture are allograft for the reconstruc- erative, retracted tibialis an- Brüning,1 may be traumatic systemic lupus erythemato- tion of degenerative tears of terior tendon was discovered or nontraumatic.2 A traumatic sus,9 hyperparathyroidism,11 the tibialis anterior tendon. (Figure 1). Debridement was lesion is usually the result of a chronic acidosis that leads to performed for the proximal laceration or blunt trauma.3-5 nephropathy,12 and local or CASE REPORT and distal parts of the ten- Nontraumatic or degenera- systemic steroid therapy.13,14 A 64-year-old man pre- don, which resulted in a 5-cm tive tendon tears are usually Quinolone treatment has re- sented with a soft tissue mass gap. End-to-end suture was seen in men in their fifth to cently been recognized as in the anterior aspect of the impossible (Figure 2). It was seventh decades of life6-9 and causing tendinitis and tendon ankle. The patient reported decided to use a fresh-frozen usually occur in the avascular rupture.15 Diabetes melli- decreased ankle dorsiflexion Achilles tendon allograft with strength and difficulty per- its bony attachment for recon- The authors are from the Orthopedics Department, Meir Medical Cen- forming activities of daily liv- struction (Figure 3). A hole ter, Kfar Saba, Israel. ing. On physical examination, was drilled in the middle dor- The authors have no relevant financial relationships to disclose. the tibialis anterior tendon sal part of the navicular bone Correspondence should be addressed to: Ezequiel Palmanovich, MD, could not be palpated, and rel- for bony attachment (Figure Orthopedics Department, Meir Medical Center, Tchernichovsky St 59, Kfar- Saba 44281, Israel ([email protected]). ative weakness of ankle dor- 4). The Achilles tendon bone doi: 10.3928/01477447-20131021-04 siflexion was noted. Degen- block was implanted into the 850 ORTHOPEDICS | Healio.com/Orthopedics n tips & techniques navicular tunnel and secured to the distal part of the tibialis anterior tendon with absorb- able Vicryl (Somerville, New Jersey) suture. Once the bony attachment was performed, the tendons were sutured to each other with Vicryl using the side-to-side technique (Figure 5). The wound was 1 2 3 closed, and a nonweight-bear- Figure 1: Intraoperative photograph Figure 2: Intraoperative photograph Figure 3: Photograph showing the ing cast was applied. of a degenerative tibialis anterior ten- of a degenerative tibialis anterior fresh-frozen Achilles allograft tendon. don tear showing the proximal stump. tendon tear showing the gap before After 6 weeks, protected debridement. full weight bearing was al- lowed. Intensive physiothera- py to recover ankle movement and tibialis anterior tendon strength was prescribed. At 1-year follow-up, the patient reported no disability, and full recreational activities were resumed. His AFOAS score was 90 and his FADI score was 89.4. Full ankle movement was noted. 4 DISCUSSION Figure 4: Intraoperative photograph showing the fresh-frozen Achilles al- Tibialis anterior tendon tear lograft tendon being implanted into the drilled navicular bone. can be caused by traumatic or nontraumatic events. Nontrau- 5 matic or degenerative tears have Pain is mild, but decreased co- ankle-foot orthosis should Figure 5: Intraoperative photograph been related to several predis- ordination in walking with a be used for older patients showing side-to-side anastomosis 9,11-14,16-20 of the proximal stump and the fresh- posing illnesses. steppage or foot-slapping gait with a low functional activ- frozen allograft tendon. An avascular zone 5 to 30 and a tendency for toe dragging ity level, as well as for pa- mm from the insertion was may be evident.3 tients for whom treatment has described by Petersen et al.10 In many cases, the diagno- been delayed for more than 3 tures were identified on the Its location correlates well sis of tibialis anterior tendon months.6,8 Others have advo- basis of clinical presentation: with the most frequent site of rupture can be established by cated repair or reconstruction (1) nontraumatic ruptures spontaneous tibialis anterior physical examination alone. of the tendon to restore ankle that occurred in low-demand tendon ruptures.1 Magnetic resonance imaging dorsiflexion and inversion older patients who presented The clinical presentation is of the ankle is the diagnostic of the ankle to approximate late with minimal dysfunction described as a triad of pseu- method of choice when clini- a normal gait pattern and and (2) traumatic ruptures dotumor at the anteromedial cal history or physical exami- theoretically to avoid later that occurred in high-demand aspect of the ankle, loss of the nation are unclear.25 development of foot defor- younger patients who present- contour of the tibialis anterior Because tibialis anterior mity.6,17,26,27 ed earlier with increased dis- tendon over the ankle, and the tendon ruptures are uncom- Ouzounian and Anderson27 ability. The authors concluded use of the extensor hallucis lon- mon, no clear guidelines exist reviewed their clinical expe- that patients with traumatic gus and the extensor digitorium for their treatment.26 Advo- rience with 12 patients who ruptures, regardless of the communis tendons to achieve cates of nonoperative treat- had tibialis anterior tendon time of presentation, demon- dorsiflexion of the ankle.6,24 ment have suggested that an ruptures. Two types of rup- strate better function after op- NOVEMBER 2013 | Volume 36 • Number 11 851 n tips & techniques erative intervention and that the use of fresh Achilles ten- sung. München Med Wchschr. 14. Velan GJ, Hendel D. Degen- 1905; 52:1928-1929. erative tear of the tibialis ante- patients with nontraumatic don allograft to reconstruct 2. Scott TA, Sammarco JG, Sam- rior tendon after corticosteroid ruptures who present early adductor mechanism insuf- marco JV. Surgical repair of injection—augmentation with tibialis anterior tendon rupture. the extensor hallucis longus should be managed surgically ficiency after total hip ar- Acta Or- Tech Foot Ankle Surg. 2012; tendon, case report. whereas those with delayed throplasty. Medial collateral thop Scand 11:39-44. 1997; 68:308-309. presentation can be managed ligament reconstruction was 15. Kaleagasioglu F, Olcay E. Flu- 3. Crosby LA, Fitzgibbons TC. 27 8 with bracing. Dooley et al described using Achilles al- Unrecognized laceration of oroquinolone-induced tendi- tibialis anterior tendon: a nopathy: etiology and preven- recommended nonsurgical lograft for combined knee Tohoku J Exp case report. Foot Ankle. 1988; tive measures. 33 Med treatment for patients with ligament injury. 9:143-145. 2012; 226:251-258. a delay in diagnosis of more To the current authors’ 4. Din R, Therkilsden L. Rupture 16. Kashyap S, Prince R. Spotane- than 3 months. knowledge, the technique de- of tibialis anterior associated ous rupture of the tibialis an- terior. Clin Orthop Relat Res. Sammarco et al6 recom- scribed herein has not been with a closed midshaft tibial fracture. J Accid Emerg Med. 1987; 216:159-161. mend that tendon repair should used before. It permits full 1999; 16:459. 17. Otte S, Klinger HM, Lorenz F, be performed in all cases, re- strength recovery and pro- 5. Forst R, Forst J, Heller KD. Haerer T. Operative treatment gardless of age, when the pa- vides a secure bony distal Ipsilateral peroneus brevis ten- in case of a closed rupture of Arch don grafting in a complicated the anterior tibial tendon. tient is symptomatic with an insertion, giving the tibialis Orthop Trauma Surg case of traumatic rupture of . 2002; unsteady or slapping gait or anterior muscle an excellent tibialis anterior tendon. Foot 122:188-190. weakness and fatigability due bony anchor. This is advan- Ankle Int. 1995; 16:440-444. 18. Aydingöz U, Aydingöz O. Spontaneous rupture of the to lack of dorsiflexion strength. tageous because the long, 6. Sammarco VJ, Sammarco GJ, Henning C, Chaim S.