Postoperative results of distal tibialis anterior tendinosis

IntroductionAlthough distal tibialis anterior tendinopathy is a common condition, it has rarely been described in literature. It is often a condition in overweight women around 50–70 years old with pain that worsens at night. The purpose of this retrospective study is to describe the specific clinical signs and postoperative results of distal tibialis anterior tendinopathy.Material and methodsBetween 2013 and 2017 we operated 9 patients (10 ft) who failed a conservative treatment of distal tibialis anterior tendinopathy. Surgery consisted of debridement of the diseased tendon and reinsertion with a bone anchor. There was a minimum follow-up of 12 months. All patients were clinically evaluated postoperative (range 14–57 months after surgery) with the use of the American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analog Scale (VAS)ResultsThe mean AOFAS score postoperative was 99 (range 94–100). The mean VAS score postoperative was 1 (range 0–3). In all 10 cases the patient was completely satisfied with the result following surgery. There was no recurrence or rupture of tendon after debridement.ConclusionDistal tibialis anterior tendinopathy is mainly a clinical diagnosis where conservative treatment should always be the first choice. However, our results show that when conservative treatment fails, surgical treatment can lead to very good long term results with a high level of patient satisfaction.     

Abnormal presentation of tibialis anterior herniation

Herniation of muscle tissue through a defect in the fascial sheath is rare; it is extremely uncommon for a patient to present in a clinic with a symptomatic muscle hernia. The usual presentation of a tibialis anterior muscle herniation is a bulge seen at the level of a fascial defect which decreases in size or disappears when the muscle contracts. We report an abnormal presentation of a tibialis anterior herniation in which the herniation swelling became more prominent on muscle contraction instead of diminishing. It is hypothesized that an increased pressure in leg compartment leads to a partially avascular and less responsive posterior portion of tibialis anterior muscle. This fixed volume of non-contracting muscle is then pushed out through the fascial defect during active muscle contraction. The herniation in this particular case was treated by enlarging the fascial defect. No recurrence was noted in a 12 months follow-up.     

Type III fracture of the tibial tubercle with avulsion of the tibialis anterior muscle in the adolescent male athlete

INTRODUCTION: Type III fracture of the tibial tubercle by Watson-Jones, or type IIIa injury according to John Ogden's classification has been well described and its management is now well codified in standard orthopaedic textbooks. MATERIALS AND METHODS: The authors present a case of type III fracture of the tibial tubercle associated with an avulsion of the tibialis anterior muscle. RESULTS: We demonstrated the effectiveness of bioabsorbable material for fixing the fracture preventing the need for removal of metalware, and that the anterior tibialis muscle had been stripped by the injury. CONCLUSION: A displaced type III fracture of the tibial tubercle may have an associated with avulsion of the tibialis anterior muscle, particularly in adolescent athletes. Prompt recognition and appropriate surgical treatment can give an excellent outcome.     

Management of tibialis anterior tendon rupture: Recommendations based on the literature review

Tibialis anterior tendon (TAT) rupture is a rare injury that commonly diagnosed late due to mild clinical signs and symptoms. Management of TAT rupture is a topic without a clear consensus in the literature. This current concept review tries to shed some light on the data and treatment. Our extensive literature review identified 81 case reports and case series from 1905 to 2018. Several reported management techniques with their advantages and disadvantages were analyzed and our treatment recommendations are given based on current available evidences.Levels of evidenceIV.     

Laceration of tibialis anterior tendon complicating a closed tibial fracture: A case report

Traumatic laceration of the tibialis anterior tendon complicating a closed tibial shaft fracture is a rare injury pattern. Only 3 such cases have been reported to date in the English literature and all were missed on initial examination. A case of a 17-year-old motorcyclist with an acute laceration of the tibialis anterior tendon resulting from a closed oblique tibial shaft fracture is presented. The tendon laceration was suspected preoperatively because of the patient's inability to actively dorsiflex his ankle joint and the existence of a palpable gap in the soft tissues over the anterolateral aspect of his tibia. Tibialis anterior tendon repair was performed simultaneously with fracture fixation. The role of careful physical examination is stressed so that this rare injury combination will not be missed.     

Anatomical repair of distal biceps brachii tendon rupture through a limited anterior approach

To avoid the extended anterior or the two-incision approach to the radius, we present a limited anterior approach for anatomical reattachment at the radial tuberosity of the distal biceps brachii tendon complete rupture using suture anchors. Our clinical experience in nine patients showed that secure fixation obtained with the suture anchors, limited surgical approach and anatomical reconstruction allow for early mobilization and rapid return of function, and provide excellent long-term results with acceptable complications. We suggest using the limited anterior approach in patients with early (less than 6 weeks) distal biceps brachii tendon rupture.     

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.     

胫骨去后倾化截骨在合并后倾角异常增大患者前交叉韧带翻修术中的临床应用北大核心CSCD

目的探讨胫骨去后倾化截骨加前交叉韧带(anterior cruciate ligament,ACL)翻修术治疗ACL初次重建术后失效合并胫骨平台后倾角(posterior tibial slope,PTS)异常增大患者的临床疗效。方法回顾分析2018年1月—2020年1月收治且符合选择标准的9例ACL初次重建术后失效合并PTS异常增大(≥17°)患者的临床资料。男8例,女1例;年龄21~42岁,中位年龄30岁。9例患者Lachman试验均为阳性;轴移试验阴性6例,Ⅰ度阳性2例,Ⅱ度阳性1例。PTS为(17.78±1.09)°、胫骨平台前移距离(anterior tibial translation,ATT)为(11.58±1.47)mm。国际膝关节文献委员会(IKDC)评分为(51.0±3.8)分,Lysholm评分为(49.7±4.6)分、Tegner评分为(3.7±0.7)分。初次重建至翻修时间为12~33个月,平均19.6个月。采用胫骨去后倾化截骨加ACL翻修术治疗。术后采用IKDC评分、Lysholm评分及Tegner评分评价膝关节功能改善情况,行Lachman试验、轴移试验评价膝关节稳定性,测量PTS及ATT观察膝关节形态学变化。结果术后切口均Ⅰ期愈合,未出现切口感染、脂肪液化、坏死以及下肢深静脉血栓形成、神经血管损伤等并发症。9例患者均获随访,随访时间12~36个月,平均25.8个月。末次随访时Lachman试验和轴移试验均为阴性。IKDC评分为(85.0±4.0)分、Lysholm评分为(87.7±2.8)分、Tegner评分为(6.8±0.7)分,PTS减小至(9.89±0.60)°,ATT缩短至(0.91±0.29)mm,与术前比较差异均有统计学意义(P<0.05)。结论胫骨去后倾化截骨加ACL翻修术治疗ACL初次重建术后失效合并PTS异常增大患者早期临床疗效明确,在改善膝关节稳定性同时可较好地维持正常膝关节形态。     

Closed rupture of the anterior tibial tendon

Summary Closed rupture of the anterior tibial tendon is rare. Fewer than 50 cases have been reported in the literature, perhaps because the symptoms are often neglected by the patient as well as by the doctor. Most often the rupture occurs as a consequence of a sudden plantar flexion of the ankle and pre-existing degenerative changes of the tendon tissue due to systemic disease or iatrogenic local corticoid injections. Clinically, the tendon rupture presents as acute weakness of the ankle extensors without reddening, swelling or neurological signs. Differential diagnoses such as anterior tibial syndrome and peroneal nerve palsy can thus be excluded. During the clinical examination the distal stump and the discontinuity of the anterior tibial tendon are often palpable. The clinical diagnosis can be confirmed by an ultrasound examination. An operation may be undertaken up to 3 months after the injury. Preferred procedures are end-to-end anastomosis and transosseous refixation of the tendon, followed by a plaster cast for 6 weeks postoperatively. High-risk patients can be treated conservatively, but the functional results are less satisfactory. We describe a case of an acute closed rupture of the anterior tibial tendon. A yet unpublished method of osseous reinsertion of the tendon is presented.      

后内侧入路治疗胫骨远端骨折伴前方软组织损伤

目的:探讨后内侧入路治疗胫骨远端骨折伴前方软组织损伤的疗效。方法:2008年8月至2010年8月,采用小腿后内侧入路对31例胫骨远端粉碎性骨折患者进行切开复位内固定,其中男21例,女10例;年龄24～68岁,平均46岁。14例为开放性骨折,按照Gustilo-Anderson分型:Ⅰ型5例,Ⅱ型5例,ⅢA型2例,ⅢB型2例;17例为闭合性骨折,按照Tcherne-Oestern分型:Ⅰ型3例,Ⅱ型12例,Ⅲ型2例。根据AO分型,属于43A型(26例)及43C1型(5例)。观察项目包括手术时间、术中出血量、骨折愈合时间、AOFAS(AmericanOrthopaedicFootandAnkleSociety)踝关节评分及术后并发症。结果:31例患者均获随访,时间12～36个月,平均21个月。平均手术时间70min(40～110min)。平均出血量为100ml(50～200ml)。术后闭合性骨折平均愈合时间为13周(10～18周),开放性骨折平均愈合时间为19周(15～29周)。末次随访时X线片示:1例出现4°足内翻,1例出现3°足外翻。末次随访AOFAS评分为69～100分,平均(88.4±9.7)分。其中优10例,良17例,中4例。结论:对伴有局部内外侧软组织损伤或皮肤条件较差的胫骨远端骨折患者,后内侧入路固定疗效满意。     

Subkutane Ruptur der Sehne des Muskulus tibialis anterior und ihre Therapie

Zusammenfassung Die subkutane Ruptur der Tibialis anterior Sehne stellt eine seltene Entität dar. In der Literatur finden sich bis zum Jahr 2003 54 Falldarstellungen. Obwohl es durch die Ruptur zu erheblichen Funktionsausfällen kommen kann, wird die Diagnose häufig verspätet gestellt. Eine genaue Unfallanamnese mit sorgfältiger klinischer Untersuchung sollte zur korrekten Diagnose führen, welche sich sonographisch oder kernspinntomographisch sichern lässt. Frühzeitige Sehnennaht oder Refixation kann zur Restitutio ad integrum mit normaler Funktion und physiologischem Gangbild führen. Bei verzögerter Diagnose oder in Fällen mit hochgradig degenerativer Sehnenveränderung ist häufig eine motorische Ersatzplastik oder eine Sehnentransplantation erforderlich. Wir präsentieren den Fall einer 79-jährigen aktiven Patientin, die sich 3 Wochen nach Distorsionstrauma des rechten Sprunggelenkes mit einer subkutanen Ruptur der Tibialis anterior Sehne vorstellte. Auf Grund der ausgeprägten Schwierigkeiten beim Gehen entschieden wir uns zur operativen Therapie. Intraoperativ fand sich eine fortgeschrittene degenerative Alteration der Sehne, sodass wir eine motorische Ersatzplastik mit der langen Peroneussehne durchführten. Nach sechs wöchiger Ruhigstellung im Unterschenkelgips erfolgte die Mobilisation unter Physiotherapie. Der Verlauf gestaltete sich unkompliziert und die Nachuntersuchungen nach 1 und 2 Jahren demonstrieren eine gute Funktion. Diese bisher nicht beschriebene Operationstechnik wird dargestellt und mit der vorhandenen Literatur diskutiert.     

Tendoscopy of the posterior tibial tendon

An anatomic cadaver study was performed and subsequently, in a prospective study, diagnostic and therapeutic tendoscopy (tendon sheath endoscopy) was performed in 16 consecutive patients with a history of persistent posteromedial ankle pain for at least 6 months. All patients had pain on palpation over the posterior tibial tendon, a positive tibial tendon resistance test, and local swelling. The indications were diagnostic procedure after surgery in 5 patients, diagnostic procedure after fracture in 5, diagnostic after trauma in 1, chronic tenosynovitis in 2, screw removal in 1, and posterior ankle arthrotomy in 2 patients. Inspection and surgery of the complete tendon and its tendon sheath can be performed by a standard two-portal technique. A new finding is the vincula that was consistently present in all our autopsy specimens as well as all our patients. At 1-year follow-up, 3 of the 4 patients in whom resection of a pathological thickened vincula, and 2 patients in whom tenosynovectomy and tendon sheath release were performed, were free of symptoms. Other procedures such as removal of adhesions and screw removal could well be performed. In 2 patients with a posteromedially located loose body, successful removal took place by means of a posterior tibial tendoscopic approach. There were no complications.     

Aneurysm of distal anterior cerebral artery associated with azygos anterior cerebral artery

Summary An aneurysm arising from the distal anterior cerebral artery distal to the bifurcation of the azygos anterior cerebral artery is reported. A review of the literature emphasizes the rarity of this lesion.     

Different recovery of the train-of-four ratio from rocuronium-induced neuromuscular blockade in the diaphragm and the tibialis anterior muscle in rat

PURPOSE: To clarify differences between the diaphragm and the limb muscles in terms of the effects of neuromuscular blockers concerning train-of-four (TOF) ratios, we compared the recovery of twitch tensions and TOF ratios in the diaphragm and in the tibialis anterior muscle in rats in vivo. METHODS: We conducted a dose-response study in 16 rats and a recovery study in 8 rats. In the recovery study, we made phrenic nerve-diaphragm and sciatic nerve-tibialis anterior preparations simultaneously in each of 8 rats that were anesthetized intraperitoneally with pentobarbitone (30 mg x kg(-1)) and urethane (500 mg x kg(-1)). After supramaximal stimuli were applied simultaneously in a TOF pattern to both the phrenic and sciatic nerves, rocuronium was injected intravenously, at 10 mg x kg(-1). In the diaphragm and the tibialis anterior muscle, we monitored the first-twitch response to TOF stimuli (T1) and also the TOF ratios. The following variables were determined for each muscle: (1) the times at which T1 recovered to 25%, 50%, and 75% of control T1, and the times at which the TOF ratio recovered to 25%, 50%, and 75%; and (2) the values of the TOF ratio at 25%, 50%, and 75% recovery of T1. RESULTS: At 25%, 50%, and 75% recovery of T1 in the diaphragm, TOF ratios were 8.9 +/- 5.0 %, 26.7 +/- 7.7 %, and 55.9 +/- 5.4%, respectively, while in the tibialis anterior, the TOF ratios were 18.0 +/- 5.9%, 32.5 +/- 7.4%, and 54.4 +/- 7.5%, respectively (diaphragm vs tibialis anterior; P < 0.01 for comparisons at both 25% and 50% recovery of T1). CONCLUSION: Our method of simultaneous in vivo evaluation of TOF ratios in both the diaphragm and the tibialis anterior confirmed significant differences between the two muscles in relationships between first-twitch tension and the TOF ratio.     

应用胫前肌瓣修复胫骨骨髓炎合并软组织缺损

自1999年1月-2005年3月,应用胫前肌瓣修复胫骨骨髓炎合并软组织缺损13例,同时辅以中药治疗,获得较满意的效果,现报告如下。1临床资料本组13例,男9例,女4例;年龄18⁶7岁,平均32岁。致伤原因:车祸伤6例,挤压伤4例,烧伤1例,坠落伤2例。胫骨上1/3段1例,中1/3段2例,下1/3段5例,中下2/3段5例。病程12d³0个月,外露骨有干燥、硬化、发白、变黑,周围有肉芽、瘢痕组织、脓性分泌物等。外露骨纵形长0·6⁸·0cm,皮肤缺损面积最大为4cm×10cm。2治疗方法2·1手术方法在硬膜外麻醉下,股部上止血带,术区常规消毒。首先切除溃疡及外露胫骨周围瘢痕,清除髓腔内分泌物及     

应用胫前肌瓣修复胫骨骨髓炎合并软组织缺损

自1999年1月-2005年3月,应用胫前肌瓣修复胫骨骨髓炎合并软组织缺损13例,同时辅以中药治疗,获得较满意的效果,现报告如下。1临床资料本组13例,男9例,女4例;年龄18~67岁,平均32岁。致伤原因:车祸伤6例,挤压伤4例,烧伤1例,坠落伤2例。胫骨上1/3段1例,中1/3段2例,下1/3段5例,中下2     

关节镜下肌腱切断固定于滑车远端治疗肱二头肌长头肌腱病损合并肩袖损伤

目的:探讨通过肩关节镜将肌腱切断固定于滑车远端治疗长头腱病损合并肩袖损伤的手术方法及临床疗效。方法:自2015年6月至2016年11月,对23例患有肱二头肌长头肌腱病损合并有肩袖损伤的患者,行关节镜下肌腱切断固定于滑车远端及肩袖修补术,其中男9例,女14例;年龄44～71(56.38±5.74)岁;左肩3例,右肩20例。分别于术前及术后3、6和12个月随访时采用Constant-Murley肩关节评分、VAS评分对肩关节功能进行评价,并比较肩关节活动度改善情况。结果:23例患者获得随访,时间12～18(15.37±4.82)个月。患侧肩关节无明显疼痛,肱二头肌肉外形轮廓和肌力与术前比较无明显的变化,肩关节活动度及肌力基本恢复到健侧水平。Constant-Murley评分术后3、6、12个月分别为67.47±12.19、74.82±13.26、93.47±10.19,与术前39.62±12.39比较均显著提高。根据Constant-Murley评分,优18例,良4例,差1例。术前VAS评分(6.85±2.14)与术后12个月(0.36±0.54)比较差异有统计学意义。术后12个月肩关节前屈(163.55±15.24)°、外展(164.37±14.46)°较术前肩关节前屈(75.52±6.31)°、外展(84.36±13.36)°显著提高(P0.001)。结论:肩关节镜下将肌腱切断固定于滑车远端治疗长头腱病损合并肩袖损伤的临床治疗效果满意,能缓解肩关节疼痛,恢复肩关节功能,不损伤肱二头肌的外形及肌力。     

胫骨远端骨折治疗的思考

胫骨远端指皮质松质骨交界的远侧中段骨干区和位于踝关节周围的松质骨。胫骨远端骨折包括两大部分,即不经过踝关节的骨折和经踝关节的Pilon骨折。因胫骨远端涉及踝关节及骨质本身的解剖学特点,胫骨远端骨折治疗一直是临床研究的热     

胫后肌腱功能障碍的手术治疗

目的探讨胫后肌腱功能障碍的手术治疗方法。方法2002年12月至2005年6月,手术治疗8例单侧胫后肌腱功能不良患者,男2例,女6例;年龄36～56岁,平均47岁。左足6例,右足2例;胫后肌腱功能不良Ⅱ期2例,Ⅲ期6例。根据Maryland足部评分标准,术前足踝功能为可2例、差6例。对每例患者设计个体化手术方案,联合应用足外侧柱延长术、关节融合术、胫后肌腱修复术、弹簧韧带紧缩术及趾长屈肌腱转移术等术式。骨性手术一般辅以一种以上相关的软组织手术,其中4例行胫后肌腱前移加强术,2例行弹簧韧带紧缩术,4例行趾长屈肌腱转移术。术后以短腿管型石膏将患足固定于内翻跖屈位,4～6周后改用短腿后托石膏将患足于中立位继续固定4周,拆除外固定后,根据骨愈合情况逐渐开始负重训练。结果全部病例均获得随访,随访时间12～40个月,平均28个月。根据Maryland足部评分标准,术后优4例、良3例、可1例,优良率为87.5%。所有患者术后足外形均恢复良好,能穿普通鞋。术后X线片测量的足弓高度及提示前足外展、后足外翻畸形矫正程度的特异性角度明显改善(P<0.01),其中弓高平均增加8mm,侧位距跟角平均减少14°,前后位距跟角平均减少12°,侧位第一跖距角平均减少17°,跟骨倾斜角平均增加11°,距舟覆盖角平均减少6°。结论骨性手术结合软组织手术组成的个体化联合术式治疗胫后肌腱功能不良可获得较理想的疗效。     

Arthroscopically assisted anterior decompression for femoroacetabular impingement: technique and early clinical results

Introduction  In patients with symptomatic femoroacetabular impingement resection osteochondroplasty of the femoral head–neck junction may improve hip pain and range of motion. We evaluated the short-term treatment results of an arthroscopically assisted mini-open anterior approach to compare it with the results after surgical dislocation for FAI. Methods  The clinical and radiographic results of 33 patients were reviewed retrospectively 15 months after the surgery. Harris hip scores and plain radiographs were obtained preoperatively and at follow-up. Patient satisfaction with the treatment result was quantified with a Visual Analogous scale (VAS) ranging from 0 (very dissatisfied) to 10 (very satisfied). Results  The mean Harris hip score improved from 64 points preoperatively to 85 points at the time of follow-up (P < 0.001). Mean patient satisfaction on the VAS was seven points (range: 2–10 points). In two of our first patients we observed a transient femoral nerve palsy (completely resolved at follow-up) and 15 patients reported numbness in the area of the lateral cutaneous femoral nerve. Conclusions  Treatment of anterior femoroacetabular impingement through an arthroscopically assisted mini-open anterior approach can reduce pain and improve function in a short-term observation period. Femoral osteochondroplasty as well as surgical treatment of acetabular cartilage and labrum lesions are possible, but the access is limited to the anterior and anterolateral part of the hip joint.