Traumatic rupture of the tibialis posterior tendon after closed ankle fractures: A report of two cases

Summary We report two cases of posttraumatic complete rupture of the tibialis posterior tendon that occurred during closed fractures of the medial malleolus. A low located fracture of the medial malleolus and an intense forced pronation, external rotation and dorsiflexion of the foot have been involved in the physiopathogeny of that rupture. At each intervention, the tibialis posterior tendon had been disrupted above the upper edge of the groove of the medial retinaculum of the ankle. After tendon suture concomitant with osteosynthesis, the evolution was favourable. Failing to appreciate this tendon rupture, although rare, can be at the origin of residual pains and a functional deficit of foot reversion.     

Rupture of the tibialis posterior tendon in a closed ankle fracture: a case report

Rupture of the tibialis posterior tendon may occur during a trauma in pronation-external rotation of the foot or, less commonly, during a direct trauma of the ankle. When an isolated fracture of the medial malleolus is present, it is more likely that a direct trauma has occurred. A 36-year-old man with a non-displaced medial malleolar fracture was evaluated. Repair of the tendon and reduction of the fracture were performed. Twenty-four months after the operation, the fracture was completely healed, the patient was asymptomatic, he had a normal ankle range of motion, and the function and strength of the tibialis posterior tendon were equal to those on the contralateral side. Early surgical repair of the tibialis posterior tendon combined with malleolar fracture reduction is recommended to avoid progression to a plano-valgus foot.     

Tibialis Posterior Tendon Rupture Associated with a Closed Medial Malleolar Fracture: A Case Report and Review of the Literature

We report an acute rupture of a macroscopically normal tibialis posterior tendon in the setting of an acute closed ankle fracture. This injury is considered to be rare, although it is probably frequently overlooked preoperatively because of limitations of the clinical examination secondary to pain. The tibialis posterior tendon rupture was identified at the time of operative repair of the ankle fracture, and direct suture repair of the tendon was undertaken. After primary suture and osteosynthesis, the patient’s progress was favorable and a satisfactory outcome was achieved. A clear history of the mechanism of injury as well as a high index of suspicion should be maintained, because failure to repair rupture of the tibialis posterior tendon, in the presence of an ankle fracture, is likely to lead to long-term patient disability and a planovalgus foot.     

Traumatic rupture of the tibialis posterior tendon after ankle fracture: three cases and a review of the literature

We report three cases of complete traumatic tibialis posterior tendon rupture which occurred after ankle fracture. Diagnosis was established at surgery. Repair of the non-degenerative tendon was achieved during the procedure for osteosynthesis of the malleolar fracture. Fractures healed a few months after surgery. The posterior tibialis muscle tendon functioned plantar arch was normal, except in one patient with multiple injuries who died in intensive care thirteen days after the accident. Although exceptional, injury of the tibialis posterior tendon should not be overlooked after ankle fracture. These injuries become apparent only at surgery for the malleolar fracture since pain hinders clinical examination. Primary suture best guarantees a good functional outcome. Residual pain, deficit in active inversion of the foot, modified medial longitudinal arch, or progression to planovalgus are retrospective diagnostic signs.     

Traumatic rupture of the tibialis posterior tendon after ankle fracture: a case report

Degenerative tears of the posterior tibial tendon associated with chronic disease are well documented in the literature. Traumatic ruptures of this tendon, however, are much less common and consequently have received little attention. An association has been shown between pronation-external rotation ankle fractures and tears of the tendons that cross the medial aspect of the ankle, most commonly the posterior tibial tendon. In the present case report, we share our unique experience of an open-ankle fracture associated with the traumatic rupture of the posterior tibial tendon. This injury illustrates that soft-tissue injury must always be suspected concomitantly in the treatment of certain fractures on the basis of both mechanism of injury and fracture pattern.     

Traumatic rupture of the tibialis anterior tendon associated with chronic tibialis posterior dysfunction

Isolated rupture of the tibialis anterior and tibialis posterior tendon is uncommon with approximately 25 cases reported in the English literature. Rupture of the tibialis anterior in the presence of chronic tibialis posterior dysfunction has not been reported to date. We present a patient with a closed traumatic rupture of the tibialis anterior tendon which occurred on a background of a pre-existing tibialis posterior dysfunction which was being treated non-operatively and discuss the successful operative management that was performed to reconstruct both tendons.     

Tibialis posterior tendon synovitis and rupture

The anatomy of the tibialis posterior muscle and tendon is described. It is the main stabilizer of the hind foot. Clinical and radiographic signs of tibialis posterior tendon rupture and the various operative techniques used, are reviewed. The Cobb method, using half the tibialis anterior tendon passed through a hole drilled in the navicular into the tarsal tunnel and anastomosed to the proximal end of the tibialis posterior, seems to give results superior to other methods.     

Injury of the tibialis posterior tendon: a cause of acquired valgus foot in childhood

Accidental division of the tibialis posterior tendon near the medial malleolus is easily overlooked and can, if left untreated, cause a painful planovalgus deformity of the foot. Two such patients are described, who had small wounds near the medial malleolus and in whom the tendon's damage was not initially diagnosed. Both patients came later with a painful valgus flat foot. Diagnosis of the lesion may be difficult because the inversion and supination action of the tibialis posterior tendon can be mimicked by the long flexor tendons of the toes. A patient with an intact tibialis posterior tendon can invert and supinate the foot and then plantarflex and dorsiflex the toes with the foot held in that position. Damage to the tendon should be suspected in all penetrating wounds near the medial malleolus.     

Fractures of the fibula proximal to the distal tibiofibular syndesmosis.

Study of thirty-six cases of fracture of the fibula at levels proximal to the distal tibiofibular syndesmosis established that there are three types, distinguished by the direction of the fracture line, which are produced by different mechanisms: supination-external rotation, pronation-abduction, and pronation-external rotation. Advanced lesions that were seen were severe injuries of the ankle which included rupture of the deltoid ligament or fracture of the medial malleolus and complete diastasis of the distal tibiofibular syndesmosis in addition to the fracture of the fibula. Surgical treatment is necessary in most advanced lesions.     

A rare type of ankle fracture: Syndesmotic rupture combined with a high fibular fracture without medial injury

High fibular spiral fractures are usually caused by pronation-external rotation mechanism. The foot is in pronation and the talus externally rotates, causing a rupture of the medial ligaments or a fracture of the medial malleolus. With continued rotation the anterior and posterior tibiofibular ligament will rupture, and finally, the energy leaves the fibula by creating a spiral fracture from anterior superior to posterior inferior.In this article we demonstrate a type of ankle fracture with syndesmotic injury and high fibular spiral fractures without a medial component. This type of ankle fractures cannot be explained by the Lauge-Hansen classification, since it lacks injury on the medial side of the ankle, but it does have the fibular fracture pattern matching the pronation external rotation injury (anterior superior to posterior inferior fracture). We investigated the mechanism of this injury illustrated by 3 cases and postulate a theory explaining the biomechanics behind this type of injury.     

Posterior tibial tendon rupture in pronation-external rotation ankle fractures

We have recently treated two patients with closed pronation-external rotation bimalleolar ankle fractures. During the surgical explorations, an avulsion type rupture of the posterior tibial tendon was observed. Open reduction and internal fixation of the fracture in conjunction with primary tendon repair has produced excellent clinical results. We wish to report these two cases of this uncommon injury. More important, we wish to point out the association of the tendon rupture in conjunction with a particular type of fracture pattern.     

Cobb repair for tibialis posterior tendon rupture

The tibialis posterior is the main dynamic stabilizer of the hindfoot against a valgus deformity. Its rupture results in hindfoot valgus with a considerable biomechanical disturbance and functional loss in the affected foot. A new method of reconstruction of this tendon is described which involves the use of half the tendon of tibialis anterior.     

Acute tibialis posterior tendon rupture associated with a distal tibial fracture

Tibialis posterior tendon ruptures associated with closed medial malleolar fractures are rare. This article describes the association of tibialis posterior tendon ruptures with closed, high-energy, distal tibia fractures. Tendon ruptures are likely to be identified intraoperatively or missed if clinical evaluation at acute injury is limited. A high index of suspicion is required to diagnose this injury. The consequences of an unrecognized tibialis posterior tendon rupture include progressive, painful pes planus deformities due to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. Secondary operative intervention may be required. This article describes an intraoperative tenodesis technique between the tibialis posterior and flexor digitorum longus tendons when direct repair is not possible.A 48-year-old woman sustained a closed AO/Orthopaedic Trauma Association type 43A right lower-extremity distal tibia fracture and a traumatic left knee arthrotomy. Temporary stabilization with an external fixator was performed, followed by open reduction and internal fixation of the distal tibial fracture 6 days later. A periarticular nonlocking medial plate was applied, and the tibialis posterior tendon was shortened. We performed a direct tenodesis to the flexor digitorum longus tendon. At 1-year follow-up, the patient had made excellent progress, with no detectable muscle weakness, and was able to perform a single-leg toe raise.A review of the literature suggested which features of radiological evidence of tendon rupture should be examined, which may be useful in the current era considering most high-energy distal tibia or pilon fractures undergo examination with computed tomography.     

Posterior Tibial Tendon Rupture Associated With Anterolateral Distal Tibial and Medial Malleolar Fracture and a Novel Pattern of Tibiofibular Syndesmotic Injury: A Case Report and Review of the Literature

A posterior tibial tendon (PTT) rupture associated with ankle fractures is a very rare condition. Ankle pronation and external rotation (PER) movement are the typical traumatic mechanism. This injury is frequently overlooked preoperatively. Early diagnosis and treatment are very important to prevent the serious consequences related to functional PTT insufficiency on biomechanics of the foot. Few cases have been described in the literature that highlight the relationship between PTT rupture and PER type ankle fracture with a medial malleolar fracture. We present a case of a complete PTT rupture in a closed atypical ankle fracture in which a medial malleolar fracture was associated with a very large fragment from the anterolateral distal tibia (Tillaux-Chaput fragment) and a concomitant avulsion fracture from the anteromedial portion of the fibula (Lefort-Wagstaffe fragment), with a novel pattern never described before.     

Posterior tibial tendon dysfunction: Imperfect specificity of magnetic resonance imaging

MRI is frequently used in the evaluationand treatment of tibialis posterior tendon (PTT) dysfunction. MRI is reported to have sensitivity up to 95%, with 100% specificity, in the detection of rupture of the PTT. We present three cases where MRI demonstrated complete or partial rupture of the PTT, where subsequent surgery showed an intact PTT with tenosynovitis. In all cases, there was a source of inflammation external to the tendon. It is hypothesized that this exogenous origin of inflammation caused changes in the MRI signal in the PTT that resemble that seen in ruptures. These cases show that in the presence of inflammation near the tibialis posterior tendon, the MRI may falsely indicate a high-grade rupture of the tendon. Recommendations for treatment of suspected PTT rupture in the presence of significant other sources of inflammation are proposed.     

Posterior tibial tendon dysfunction. Diagnosis, evaluation, and treatment

Posterior tibial tendon dysfunction (PTTD) is a complex multifaceted condition that can affect the lower extremity. Rarely mentioned 20 years ago, today it is the subject of numerous articles, books, and is a topic at most scientific seminars relating to the foot and ankle. It is a muscle imbalance initiated by a rupture, avulsion, or chronic inflammation of the tibialis posterior tendon. With time, it progresses from a flexible to rigid flatfoot deformity. Left untreated, peritalar dislocation and degenerative joint disease may develop. This article discusses the diagnosis, evaluation, and treatment of PTTD.     

腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损

作者自行设计使用腓骨长肌及胫骨后肌联合修复陈旧性跟腱断裂伴缺损48例,获得完整随访资料43例。跟腱缺损长度为8～10cm,自身已无修复条件。手术方法的优点:联合转移的肌腱弥补了长距离跟腱缺损,保持了原有肌肉的动力,弥补了小腿三头肌的挛缩无力。保持了足内、外翻的肌力平衡,足外形正常。肌肉的血循环不受干扰,增加了修复跟腱后愈合的机会。手术后6周都能逐渐下地行走,肌力一般都能达到Ⅳ级～V级,功能恢复良好,未发生因愈合不良再次发生断裂。     

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report.

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.     

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.     

Tibialis posterior tendon dysfunction: a primary or secondary problem?

Seventeen patients with a mean follow-up of 64.4 months following a tibialis posterior tendon transfer to regain active foot dorsiflexion were clinically examined specifically for signs of tibialis posterior tendon dysfunction. The results show that 8 patients (47%) had Grade 4 or better power of eversion but none had a clinical flatfoot on the Harris-Beath footprints. Only 6% had forefoot abduction; 17% exhibited hindfoot valgus and 82% were able to perform the single-heel rise. Tibialis posterior tendon dysfunction therefore does not appear to be an inevitable sequel of tibialis posterior tendon transfer even in the presence of a functioning peroneal muscle. Other studies have noted that a pre-existent flatfoot was often present in patients with tibialis posterior tendon dysfunction. None of the patients in this study had pre-existent flatfoot. We suggest that a predisposition, in the form of a pre-existent tendency to flatfoot may also be a factor in the pathogenesis of tibialis posterior tendon dysfunction. This may explain the long-term failure of flexor digitorum longus and flexor hallucis longus tendon transfers in the treatment for tibialis posterior tendon dysfunction when the biomechanics of the foot has not been altered.