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Simultaneous Surgical Repair of a Tibialis Anterior Tendon Rupture and Diabetic Charcot Neuroarthropathy of the Midfoot A Case Report
Abstract
The combination of simultaneous rupture of a tibialis anterior tendon and Charcot neuroarthropathy of the midfoot in a diabetic patient is a rare and challenging condition that can lead to major complications if not addressed appropriately. This article discusses a tibialis anterior tendon rupture that may have developed before or after the incidence of the diabetic Charcot neuroarthropathy midfoot deformity and raises awareness to potential spontaneous tendon ruptures that may be associated with the diabetic Charcot foot.
... The demographics of atraumatic or spontaneous TAT ruptures, based on 38 reported cases in 14 articles, show they most commonly occur in the elderly (age greater than 60 years) and occur in men more than women [9,11,24,32,43,48,57,63,66,67,71,[77][78][79]. The majority of articles surmised that spontaneous TAT ruptures occur through gradual weakening, overuse and degeneration of the tendon [43,57]. ...
... The surgical outcomes do not appear to differ in regard to the age and gender of the patient [76]. By considering chronicity, gap, and location of TAT rupture, several surgical techniques including direct end to end repair [13,14,27,37,42,54,60,63,65,[69][70][71]74,76,82,84,92,94,96], fixation to medial cuneiform or navicular [26,32,54,74], lengthening and rotationplasty procedures [9,24,26,30,48,64,77,80,81,89], tendon transfer [26,27,33,45,52,54,65,67,68,76,78,83], free allograft [11,19,43,66] or autograft [5,31,32,57,67,76,79,[85][86][87] interposition have been reported. ...
... The indications for tendon transfer are a large defect, a massively degenerated TAT tendon and marked fatty infiltration of TAT muscle on MRI. The Extensor Hallucis Longus (EHL) [26,27,38,41,45,52,54,65,67,78,83], Extensor Digitorum Longus (EDL) [27,52,54], Peroneus Tertius [33], and Posterior Tibialis tendon [68] have been described in the literature. ...
Abstract:
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.
... Rupture of the tibialis anterior tendon is a rare lesion and only few reports are found in the literature [1][2][3][4][5][6][7]. Most subcutaneous ruptures occur in the elderly with structural weakness of the tendons [8,9], and the diagnosis is often delayed, since patient can maintain dorsiflexion of the foot by compensatory use of extensor digitorum longus and extensor hallucis longus [10]. ...
Background: Rupture of the tibialis anterior tendon is a rare lesion and only few reports are found in the literature. Another not so rare condition is a thromboembolic event following a lower limb surgical procedure or immobilization period. Although there is general agreement that patients undergoing major hip or knee surgery benefit from prophylactic anti-thrombotic therapy, currently there are no unanimously accepted recommendations for thromboprophylaxis in patients with isolated lower limb injury or surgery.
Purpose: The aim of this study is to provide a case report and a critical review of publications on the matter. Case Report: We herein report a case of a 38-year-old man, otherwise well, who sustained a small open wound anterior to the tibiotarsal joint caused by the tip of a knife. Ultrasound confirmed a complete anterior tibialis tendon rupture. Patient underwent to acute repair and was discharged with an ankle cast, with the guidance of full-time use. There was no recommendation of any type of mechanical or pharmacological thromboprophylaxis. Five days later he presented deep venous thrombosis. Treatment was conducted with enoxaparin (20 mg daily) for 3 months.
Discussion: Rupture of the tibialis anterior tendon is decidedly rare and often neglected. Acute repair may be attempted, since delayed tendon reconstruction has had less favorable functional results. Deep venous thrombosis is a potentially life threatening condition that can occur after lower limb injury or immobilization period. We performed a literature review but we cannot draw definite conclusions, given the paucity of high quality studies. In conclusion, there is a need for further research with deeper assessment of thromboprophylaxis indications and contraindications.
Charcot neuroarthropathy (CN) of the foot/ankle is a devastating complication that can occur in neuropathic patients. It is a progressive and destructive process that is characterized by acute fractures, dislocations, and joint destruction that will lead to foot and/or ankle deformities. Early diagnosis is imperative, and early treatment may be advantageous, but the condition is not reversible. There is no cure for CN but only treatment recommendations. Ultimate goals of care should include providing a stable limb for ambulation and no ulcerations.
Objective
A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes.
Method
A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997–2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded.
Results
A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction.
Conclusion
Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.
We describe the findings on physical examination and video-assisted observational gait analysis, of two chronic cases of isolated, closed ruptures of the tibialis anterior tendon.Physical examination revealed a normal range of active dorsiflexion and an absent tibialis anterior tendon. This movement is achieved through the recruitment of the extensor hallucis longus (EHL), resulting in a maximal extension of the great toe. If recruitment of the EHL is abolished by active flexion of the hallux, then the range of active dorsiflexion is reduced. Variable degrees of pronation of the foot accompany dorsiflexion and are dependent on the recruitment of the EHL. Video analysis of gait showed minimal foot drop, but in one case an audible foot tap. Pronation of the foot was maximal in the swing phase of gait and reducing towards the end of this period as the hallux extended maximally elevating the arch and increasing the dorsiflexion of the ankle. Heelstrike was in neutral achieved by internal rotation of the tibia and foot, just prior to heelstrike. Subsequent forefoot strike was consequently in neutral or mild supination.
Unlabelled:
Spontaneous rupture of the tibialis anterior tendon is infrequently seen as a clinical entity. In this report, we describe the case of a diabetic neuropathic patient that underwent successful surgical repair of a spontaneously ruptured tibialis anterior tendon with no other factors that would render the tendon susceptible to injury or rupture.
Level of clinical evidence:
4.
Twelve patients with rupture of the anterior tibial tendon are presented. Nine patients were aware of an acute event prior to their symptom onset and three were not aware of any acute event. Complete rupture of the tendon was noted in 10 patients and incomplete rupture was seen in two patients. Treatment was individualized based on age, etiology, preinjury function, patient health, and personal considerations. Five patients were treated without surgery. Three preferred no orthotic devices, and two believed their function was improved with an ankle-foot orthosis. Seven patients were treated operatively using a variety of individualized reconstructive techniques. All operatively treated patients demonstrated increased function and strength. Based on our findings, operative reconstruction is recommended in appropriate patients.
Closed rupture of the anterior tibial tendon is uncommon, with 33 cases being reported previously. In this report we add another to these few. The literature is reviewed; late diagnosis is frequent, and the injury occurs in middle-aged and elderly patients after distorsion of the foot in plantar flexion and eversion. The treatment of the rupture in early and delayed cases is discussed.
Spontaneous rupture of the tibialis anterior tendon is uncommon. This article presents a case report in which spontaneous rupture of the tibialis anterior tendon occurred secondary to a gouty tophaceous deposit within the tendon. This report adds to the list of pathological conditions that should be considered in closed spontaneous rupture of the tibialis anterior tendon.
Daily activities, such as walking or running, put a certain degree of stress and demand on the tendons of the lower extremities. To date, there are very few reported cases in the literature concerning pathology of the anterior tibial tendon or muscle. Of those cases reported and discussed, the majority were complete ruptures as a result of an acute forced injury, with very few reports of secondary pathological conditions or laceration injuries. This article is a review of the literature, as well as conservative versus surgical treatment and the sequelae following such injuries.
We report three cases of anterior tibial tendon ruptures and the results of an anatomical study in regard to the tendon's insertion site and a literature review.
Three patients were referred to our hospital with anterior tibial tendon ruptures. In the anatomical study, 53 feet were dissected, looking in particular for variants of the bony insertion of the tendon.
Two patients had surgical treatment (one primary repair and one semimembranosus tendon graft) and one conservative treatment. After a mean followup of 14 weeks all patients had satisfactory outcomes. In the anatomical study, we noted three different insertion sites: in 36 feet the tendon inserted into the medial side of the cuneiform and the base of the first metatarsal bone and in 13 feet only into the medial side of the cuneiform bone. In the remaining four feet the tendon inserted into the cuneiform and the first metatarsal bone, but an additional tendon was noted taking its origin from the anterior tibial tendon near its insertion into the medial cuneiform and attaching to the proximal part of the first metatarsal.
According to literature, surgical repair is the treatment of choice for acute ruptures and for patients with high activity levels. For chronic ruptures and patients with low demands, conservative management may lead to an equally good outcome. Knowledge of the anatomy in this region may be helpful for diagnosis and for the interpretation of intraoperative findings and choosing the most appropriate surgical procedure.