The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Closed Medial Malleolar Multifragment Fracture With a Posterior Tibialis Tendon Rupture: A Case Report and Review of the Literature Matteo Formica, MD 1, Federico Santolini, MD 2, Mattia Alessio-Mazzola, MD 1, Ilaria Repetto, MD 1, Angelo Andretta, MD 1, Marco Stella, MD 2 1 2
Orthopaedic Clinic, IRCCS S. Martino IST, Genoa, Italy Ortopaedic and Traumatology Unit, IRCCS S. Martino IST, Genoa, Italy
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Ankle fractures represent an exciting field of traumatology because of the wide variety of clinical presentations, injury mechanisms, and treatment options. Rupture of the posterior tibialis tendon (PTT) with ankle fracture can occur during trauma that involves pronation and external rotation of the foot or, less commonly, secondary to direct trauma to the ankle. This tendon injury is uncommon and probably misdiagnosed in many cases, because of the difficult clinical examination secondary to the pain and swelling. The identification and early treatment of PTT tears is essential for good functional outcomes to prevent the main mid- to long-term complication of disabling acquired flatfoot due to tendon failure. In the present report, we provide a review of the published data regarding ankle fractures associated with PTT rupture and describe our experience with a case of a multifragment medial malleolus fracture and complete rupture of the PTT diagnosed intraoperatively and surgically treated in a 34-year-old male, with 2.5 years of follow-up. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle fracture diagnosis flatfoot malleolus tibialis posterior tendon rupture
Complete rupture of the posterior tibialis tendon (PTT) in the background of an acute closed ankle fracture is uncommon and has been described in only a few case reports. When an isolated fracture of the medial malleolus is present, high-energy direct trauma is the most frequent causal mechanism involved. Traumatic rupture of the PTT can rarely be attributed to forced dorsiflexion with inversion or pronation and external rotation, in which the medial compartment of the ankle is involved. Because of the pain associated with the fracture, only a limited clinical examination will be possible. As such, rupture of the PTT is often identified only intraoperatively, and rupture of the PTT could frequently be misdiagnosed. Unawareness of the possible rupture of PTT in such types of trauma and consequently the lack of treatment can lead to long-term patient disability. The consequences of an unrecognized acute PTT rupture include progressive, painful pes planus deformities owing to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. The PTT supports the medial longitudinal arch, contributing to the stabilization of the foot and supination. In selective cases of tendon failure, secondary operative
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Mattia Alessio-Mazzola, MD, Orthopaedic Clinic, University of Genoa, IRCCS IST, S. Martino, Genoa, Italy. E-mail address: [email protected] (M. Alessio-Mazzola).
intervention could be necessary to restore the proper anatomy and the correct arch stability. Case Report A healthy 34-year-old male was admitted to the emergency department with a painful, swollen left ankle. He reported a motorbike accident with involvement of the medial side of the ankle. On clinical examination, the left ankle appeared swollen, with a wide area of ecchymosis and pain, primarily over the medial aspect of the ankle. His active and passive movements were very limited and painful; no neurologic deficit was noted, and the posterior tibialis artery and dorsalis pedis were both palpable. Radiographs showed a multifragmented fracture of the medial malleolus, uncommon for the pathologic mechanism reported. Radiographic studies in the anteroposterior, lateral, and oblique projections and a computed tomography (CT) scan were performed to better identify the articular involvement (Fig. 1). Closed reduction with the patient under general anesthesia was attempted without success. A posteromedial curved incision was performed, and a multifragment fracture of the medial malleolus was identified. Complete rupture of the PTT, 1.5 cm proximal to the tip of the medial malleolus, was diagnosed intraoperatively. The tendon was healthy looking with no signs of degenerative tendinopathy (Fig. 2). The distal tendon stump was interposed between the fragments of the fracture, preventing
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.03.007
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M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 1. (A) Preoperative radiographs and (B) computed tomography scans showing an isolated multifragmented tibial malleolar fracture.
Fig. 2. Intraoperative view of the posterior tibialis tendon lesion.
satisfactory closed reduction. Anatomic reduction and osteosynthesis of the malleolus with Kirschner wires and nonabsorbable suture wire using the Zuggurtung technique was performed. The PTT was repaired using a modified Kessler technique. The tendon was replaced within its natural course, and accurate reconstruction of the medial flexor retinaculum was performed. The deltoid ligament was exposed, examined, and successfully repaired with direct suture. The ankle and foot were then immobilized in a below-the-knee closed cast, with the ankle in slight subtalar joint inversion to minimize tension on the repaired PTT. No weightbearing was permitted for 3 weeks. At 3 weeks postoperatively, the first cast was removed, and the hindfoot was brought back to the neutral position and immobilized in a cast. Weightbearing was allowed at this stage to promote proprioception and gait re-education. Radiographic healing of the fracture was assessed at 6 weeks, and the second cast was removed to allow passive and active range of movement exercises and muscular reinforcement (Fig. 3). At 7 weeks postoperatively, the patient had normal range of motion of the ankle (minimal limitation of range of motion in dorsiflexion of 5 ), and the subtalar joints had full recovery of the strength of anterior tibialis tendon and PTT (5 of 5) without any loss in his medial arch height. At 4 months postoperatively, the clinical and radiographic evaluation showed healing of the fracture, with no intolerance to the wires (which were maintained in site), maintenance of the medial arch length compared with the contralateral side, and a return to previous activities (Fig. 4). At 2.5 years postoperatively, baropodometric and podographic examinations of plantar weightbearing were performed and showed a bilateral normal rectus footprint. The only abnormal aspect seen at the baropodometric examination was a moderate overload on the left forefoot during the dynamic examination (70% versus 30% of the total body weight), likely because of occasional dorsal pain at the left ankle reported by the patient mainly after intense sports activity (Fig. 5). A normal
M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 3. (A) Anteroposterior and (B) lateral radiographs at 6 weeks of follow-up.
repartition of weightbearing was seen at the static examination (Fig. 6). Moreover, the podoscopic examination revealed a slightly reduced medial arch height. This was similar to the contralateral side. Calcaneal valgus was more evident on the right side (Fig. 7). The foot and ankle score was 80 of 100, with good subjective patient satisfaction. The patient did not report any relapse and was able to continue his previous occupation and sports activities, with no substantial limitations. Discussion The PTT is the largest and anterior-most tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. The PTT muscle originates on the tibia, interosseous membrane, and fibula. It descends within the posterior
compartment of the leg, between the flexor digitorum longus and flexor hallucis longus under the flexor retinaculum. Running superficial to the deltoid ligament and then deep to the plantar calcaneonavicular ligament in the hindfoot, it ends at the level of the ankle with a shift in direction of almost 90 around the medial malleolus. Its plantar insertion is complex. On 1 side are multiple insertions on the navicular tuberosity. On the other side, the main tendon has insertions on all the tarsal bones, with the exception of the astragalus, and on the second, third, and fourth metatarsals, with fan-shaped fascicles (1,2). Spontaneous ruptures are uncommon in a healthy tendon, although well described; however, they can occur when pre-existing chronic tendinopathy is concomitant (3–6). Traumatic events have not played a singular role in rupture of the PTT and have uncommonly led to acquired flatfoot in adults (7). Moreover, comorbidities such as
Fig. 4. (A) Anteroposterior and (B) lateral radiographs at 4 months of follow-up.
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M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 5. Dynamic baropodometric examination views at 2.5 years of follow-up showing normal gait analysis with a moderate overload on the left forefoot.
aging, diabetes, corticosteroids, connective tissue disease, rheumatoid arthritis, obesity, and hypertension can lead to microvascular damage, predisposing the tendon to spontaneous rupture and mid- to longterm insufficiency (8–10).
Our patient had no history of risk factors; thus, the only possible mechanism of the acute rupture was pronation and external rotation trauma, with direct damage from the bone fragments to the PTT. A relatively avascular zone exists in the middle portion, just as the
Fig. 6. Static baropodometric examination views at 2.5 years of follow-up showing the body weight distribution between the forefoot and hindfoot is within the range of normality.
M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 7. Posterior view of hindfeet showing slight bilateral calcaneus valgus.
tendon passes posteriorly and distally to the medial malleolus. This segment of the tendon, especially the distal portion, is the site most often reported to be traumatically ruptured secondary to forced pronation and external rotation mechanisms of injury (11–13). This “watershed” region of the tendon is also the primary area to undergo degeneration changes in the chronic tendinopathy (14). Studies on cadaveric models have demonstrated that the combination of pronation and external rotation injury with a dorsiflexed foot causes the maximal tensile forces generated within the PTT. Moreover, West et al (10) postulated that if the PTT is loaded slowly, such as would be likely in the case of a low-energy ankle fracture, it will generally fail at its midsubstance, in the relatively avascular region of the tendon lying posterior and distal to the medial malleolus. Subacute tear or chronic tendinosis at the avascular portion of the PTT has been reported to be the most common cause of tendon failure. This causes acquired flatfoot of adults because of a progressive tear, which often develops against a background of tendinopathy in overweight females >50 years of age with flat valgus feet (6,14). Therefore, ruptures can occur anywhere along the substance of the tendon and not just at the medial malleolus. Partial or complete tears can be missed at presentation and, even intraoperatively, if the injury is not suspected and a meticulous tendon examination is not undertaken. Imaging studies can sometimes be useful for diagnosing these lesions. Some case studies have reported medial bone avulsions as a possible radiographic sign that could suggest a PTT injury or, more commonly, a deltoid ligament rupture in ankle fractures. Medial bone avulsions result from direct avulsion injuries to the medial tibial metaphysis. These case reports described searching for medial bone flakes on plain radiographs. In the case of a malleolar fracture, medial osseous avulsion will more frequently represent disruption of the deep portion of the deltoid ligament as a response to a combination ligamentous and osseous injury (15). If CT is also performed preoperatively, it could be prudent to search specifically for medial bone flakes, which can be missed on plain radiographs. However, ultrasonography is the reference standard imaging examination for the study of tendon rupture, dislocation, and quality and can be performed when an associated tendon injury is suspected, even if most lesions are diagnosed intraoperatively (16). Definitively, the suspicion of a PTT lesion in such trauma is mandatory and must be excluded in the differential diagnosis. This will aid in preventing failure of closed reduction because of interposition of the tendon’s stump in the fracture, which has been described by some investigators (10–12,17–19). However, soft tissue interposition because of a deltoid ligament injury in the case of complex ankle
5
fractures will more often be the cause of failure of satisfactory closed reduction (20,21). It can also be useful postoperatively in detecting misdiagnosed ruptures associated with ankle fractures. Misdiagnosed ruptures will result in prolonged pain and weakness along the medial aspect of the ankle, with a poor response to rehabilitation. In the present case, we performed standard radiographic projections and CT to better study the lesion. An unusual, isolated, and multifragment fracture of the tibial malleolus was identified. A signal alteration around the PTT was evident but was not recognized as complete rupture of the tendon because of a concomitant fracture hematoma. The diagnosis in our case could only be assessed intraoperatively, just as has been described in most cases. The consequences of an unrecognized PTT rupture include progressive and painful pes planus deformities owing to the unopposed action of the peroneus brevis muscle and the lack of support of the medial longitudinal arch. This must be stressed, because PTT rupture concomitant with medial malleolar fractures are frequently undiagnosed, resulting in long-term disability and gait alteration. Only a few published case reports have described this association (22). Early surgical treatment of both the fracture and the PTT lesion is mandatory to regain the function of the tendon and avoid progression to a planovalgus foot (23–25). All published studies have reported a good outcome at the 6-month follow-up examination and excellent long-term results, with a return to the patients’ previous activity level after primary repair, just as was confirmed in our case report. If endto-end suturing is not possible and a loss of substance has occurred, some studies have described successful results by performing tenodesis to the flexor digitorum longus tendon (26). Mueller (27) and Kupcha and Shah (28) have reported disabling acquired flatfoot deformity secondary to untreated PTT rupture. In conclusion, PTT rupture is an uncommon lesion associated with ankle fractures and is often misdiagnosed. The diagnosis can be assessed using imaging studies (e.g., CT, ultrasound, magnetic resonance imaging). The diagnosis is more frequently made intraoperatively because of the several limitations of clinical examination. Highfrequency ultrasonography plays an important role in the investigation of disorders involving the PTT and represents the reference standard technique if a PTT tear is suspected. Untreated lesions will be associated with poor functional outcomes owing to the evolution to a disabling and painful planovalgus foot. Acute trauma does not play a singular role in rupture of the PTT, and many other factors such as aging, obesity, hypertension, diabetes, and corticosteroids can predispose the tendon to damage. Early identification of tendon rupture is necessary, and repair of a PTT rupture must always be performed together with malleolus osteosynthesis to restore good function and a normal gait. Direct tenodesis between the PTT and flexor digitorum longus tendon is a viable option but will rarely be necessary if an acute PTT tear has been accurately recognized and properly repaired. Moreover, a flexor digitorum longus transfer into the navicular bone is more likely to necessary in the presence of chronic PTT or longstanding tendinosis with a concomitant pes planovalgus deformity.
References 1. Canepa G, Franchin F, Stella M, Formica M. Le alterazioni dell’arco plantare nelle malattie costituzionali dello scheletro. Chir Piede 32:5–10, 2008. del piede nelle 2. Canepa G, Franchin F, Stella M, Formica M, Bedeschi F. Le deformita malattie costituzionali dello scheletro. Chir Piede 36:7–35, 2012. 3. Mittal RL, Jain NC. Traumatic dislocation of the tibialis posterior tendon. Int Orthop 12:259–260, 1988. 4. Martinelli N, Bonifacini C, Bianchi A, Moneghini L, Scotto G, Sartorelli E. Acute rupture of the tibialis posterior tendon without fracture: a case report. J Am Podiatr Med Assoc 104:298–301, 2014. 5. Mann RA. Surgery of the Foot, ed 5, CV Mosby, St Louis, 1986, pp. 476–480. 6. Lhoste-Trouilloud A. The tibialis posterior tendon. J Ultrasound 15:2–6, 2012.
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7. Holmes GB, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 13:70–79, 1992. 8. Akra GA, Saeed K, Limaye RV. An unusual etiology for adult-acquired flatfoot. J Foot Ankle Surg 49:488.e11–488.e14, 2010. 9. Funk DA, Cass JA, Johnson KA. Acquired flat-foot secondary to posterior tibial tendon pathology. J Bone Joint Surg Am 68-A:95–102, 1986. 10. West MA, Sangani C, Toh E. Tibialis posterior tendon rupture associated with a closed medial malleolar fracture: a case report and review of the literature. J Foot Ankle Surg 49:565.e9–565.e12, 2010. 11. Frey C, Shereff M. Tendon injuries about the ankle in athletes. Clin Sports Med 7:103–118, 1988. 12. Jahss MH. Disorders of the Foot and Ankle, ed 2, WB Saunders, Philadelphia, 1991. 13. Johnson KA. Tibialis posterior tendon rupture. Clin Orthop 177:140–147, 1983. 14. Gluck GS, Heckman DS, Parekh SG. Tendon disorders of the foot and ankle, part 3: the posterior tibial tendon. Am J Sports Med 38:2133–2144, 2010. 15. Tornetta P III. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am 82:843–848, 2000. 16. Prato N, Abello E, Martinoli C, Derchi S, Bianchi S. Sonography of posterior tibialis tendon dislocation. J Ultrasound Med 23:701–705, 2004. 17. S balle K, Kjaersgaard-Andersen P. Ruptured tibialis posterior tendon in a closed ankle fracture. Clin Orthop Relat Res (231):140–143, 1988. 18. Giblin MM. Ruptured tibialis posterior tendon associated with a closed medial malleolar fracture. Aust N Z J Surg 50:59–60, 1980. 19. Monto RR, Moorman CT III, Mallon WJ, Nunley JA III. Rupture of the posterior tibial tendon associated with closed ankle fracture. Foot Ankle 11:400–403, 1991.
20. Stufkens SA, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strateg Trauma Limb Reconstr 7:73–85, 2012. 21. Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg 43:20–29, 2004. 22. Uzel AP, Massicot R, Delattre O, Augouard S. Traumatic rupture of the tibialis posterior tendon after ankle fracture: three cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot 92:283–289, 2006. 23. Penney KE, Wiener BD, Magill RM. Traumatic rupture of the tibialis posterior tendon after ankle fracture: a case report. Am J Orthop 29:41–43, 2000. 24. Ceccarelli F, Faldini C, Pagkrati S, Giannini S. Rupture of the tibialis posterior tendon in a closed ankle fracture: a case report. Chir Organi Mov 91:167–170, 2008. 25. Jarvis HC, Cannada LK. Acute tibialis posterior tendon rupture associated with a distal tibial fracture. Orthopedics 35:e595–e597, 2012. 26. Walker RH, Farris C. Irreducible fracture-dislocations of the ankle associated with interposition of the tibialis posterior tendon: case report and review of the literature of a specific ankle fracture syndrome. Clin Orthop (160): 212–216, 1981. 27. Mueller TJ. Ruptures and laceration of tibialis posterior tendon. J Am Podiatry Assoc 74:109–119, 1984. 28. Kupcha PC, Shah SA. Posterior tibialis dysfunction as a cause of acquired flatfoot in adults. Del Med 69:255–257, 1997.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Closed Medial Malleolar Multifragment Fracture With a Posterior Tibialis Tendon Rupture: A Case Report and Review of the Literature Matteo Formica, MD 1, Federico Santolini, MD 2, Mattia Alessio-Mazzola, MD 1, Ilaria Repetto, MD 1, Angelo Andretta, MD 1, Marco Stella, MD 2 1 2
Orthopaedic Clinic, IRCCS S. Martino IST, Genoa, Italy Ortopaedic and Traumatology Unit, IRCCS S. Martino IST, Genoa, Italy
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Ankle fractures represent an exciting field of traumatology because of the wide variety of clinical presentations, injury mechanisms, and treatment options. Rupture of the posterior tibialis tendon (PTT) with ankle fracture can occur during trauma that involves pronation and external rotation of the foot or, less commonly, secondary to direct trauma to the ankle. This tendon injury is uncommon and probably misdiagnosed in many cases, because of the difficult clinical examination secondary to the pain and swelling. The identification and early treatment of PTT tears is essential for good functional outcomes to prevent the main mid- to long-term complication of disabling acquired flatfoot due to tendon failure. In the present report, we provide a review of the published data regarding ankle fractures associated with PTT rupture and describe our experience with a case of a multifragment medial malleolus fracture and complete rupture of the PTT diagnosed intraoperatively and surgically treated in a 34-year-old male, with 2.5 years of follow-up. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: ankle fracture diagnosis flatfoot malleolus tibialis posterior tendon rupture
Complete rupture of the posterior tibialis tendon (PTT) in the background of an acute closed ankle fracture is uncommon and has been described in only a few case reports. When an isolated fracture of the medial malleolus is present, high-energy direct trauma is the most frequent causal mechanism involved. Traumatic rupture of the PTT can rarely be attributed to forced dorsiflexion with inversion or pronation and external rotation, in which the medial compartment of the ankle is involved. Because of the pain associated with the fracture, only a limited clinical examination will be possible. As such, rupture of the PTT is often identified only intraoperatively, and rupture of the PTT could frequently be misdiagnosed. Unawareness of the possible rupture of PTT in such types of trauma and consequently the lack of treatment can lead to long-term patient disability. The consequences of an unrecognized acute PTT rupture include progressive, painful pes planus deformities owing to the unopposed action of the peroneus brevis muscle and lack of support of the medial longitudinal arch. The PTT supports the medial longitudinal arch, contributing to the stabilization of the foot and supination. In selective cases of tendon failure, secondary operative
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Mattia Alessio-Mazzola, MD, Orthopaedic Clinic, University of Genoa, IRCCS IST, S. Martino, Genoa, Italy. E-mail address: [email protected] (M. Alessio-Mazzola).
intervention could be necessary to restore the proper anatomy and the correct arch stability. Case Report A healthy 34-year-old male was admitted to the emergency department with a painful, swollen left ankle. He reported a motorbike accident with involvement of the medial side of the ankle. On clinical examination, the left ankle appeared swollen, with a wide area of ecchymosis and pain, primarily over the medial aspect of the ankle. His active and passive movements were very limited and painful; no neurologic deficit was noted, and the posterior tibialis artery and dorsalis pedis were both palpable. Radiographs showed a multifragmented fracture of the medial malleolus, uncommon for the pathologic mechanism reported. Radiographic studies in the anteroposterior, lateral, and oblique projections and a computed tomography (CT) scan were performed to better identify the articular involvement (Fig. 1). Closed reduction with the patient under general anesthesia was attempted without success. A posteromedial curved incision was performed, and a multifragment fracture of the medial malleolus was identified. Complete rupture of the PTT, 1.5 cm proximal to the tip of the medial malleolus, was diagnosed intraoperatively. The tendon was healthy looking with no signs of degenerative tendinopathy (Fig. 2). The distal tendon stump was interposed between the fragments of the fracture, preventing
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.03.007
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M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 1. (A) Preoperative radiographs and (B) computed tomography scans showing an isolated multifragmented tibial malleolar fracture.
Fig. 2. Intraoperative view of the posterior tibialis tendon lesion.
satisfactory closed reduction. Anatomic reduction and osteosynthesis of the malleolus with Kirschner wires and nonabsorbable suture wire using the Zuggurtung technique was performed. The PTT was repaired using a modified Kessler technique. The tendon was replaced within its natural course, and accurate reconstruction of the medial flexor retinaculum was performed. The deltoid ligament was exposed, examined, and successfully repaired with direct suture. The ankle and foot were then immobilized in a below-the-knee closed cast, with the ankle in slight subtalar joint inversion to minimize tension on the repaired PTT. No weightbearing was permitted for 3 weeks. At 3 weeks postoperatively, the first cast was removed, and the hindfoot was brought back to the neutral position and immobilized in a cast. Weightbearing was allowed at this stage to promote proprioception and gait re-education. Radiographic healing of the fracture was assessed at 6 weeks, and the second cast was removed to allow passive and active range of movement exercises and muscular reinforcement (Fig. 3). At 7 weeks postoperatively, the patient had normal range of motion of the ankle (minimal limitation of range of motion in dorsiflexion of 5 ), and the subtalar joints had full recovery of the strength of anterior tibialis tendon and PTT (5 of 5) without any loss in his medial arch height. At 4 months postoperatively, the clinical and radiographic evaluation showed healing of the fracture, with no intolerance to the wires (which were maintained in site), maintenance of the medial arch length compared with the contralateral side, and a return to previous activities (Fig. 4). At 2.5 years postoperatively, baropodometric and podographic examinations of plantar weightbearing were performed and showed a bilateral normal rectus footprint. The only abnormal aspect seen at the baropodometric examination was a moderate overload on the left forefoot during the dynamic examination (70% versus 30% of the total body weight), likely because of occasional dorsal pain at the left ankle reported by the patient mainly after intense sports activity (Fig. 5). A normal
M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 3. (A) Anteroposterior and (B) lateral radiographs at 6 weeks of follow-up.
repartition of weightbearing was seen at the static examination (Fig. 6). Moreover, the podoscopic examination revealed a slightly reduced medial arch height. This was similar to the contralateral side. Calcaneal valgus was more evident on the right side (Fig. 7). The foot and ankle score was 80 of 100, with good subjective patient satisfaction. The patient did not report any relapse and was able to continue his previous occupation and sports activities, with no substantial limitations. Discussion The PTT is the largest and anterior-most tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. The PTT muscle originates on the tibia, interosseous membrane, and fibula. It descends within the posterior
compartment of the leg, between the flexor digitorum longus and flexor hallucis longus under the flexor retinaculum. Running superficial to the deltoid ligament and then deep to the plantar calcaneonavicular ligament in the hindfoot, it ends at the level of the ankle with a shift in direction of almost 90 around the medial malleolus. Its plantar insertion is complex. On 1 side are multiple insertions on the navicular tuberosity. On the other side, the main tendon has insertions on all the tarsal bones, with the exception of the astragalus, and on the second, third, and fourth metatarsals, with fan-shaped fascicles (1,2). Spontaneous ruptures are uncommon in a healthy tendon, although well described; however, they can occur when pre-existing chronic tendinopathy is concomitant (3–6). Traumatic events have not played a singular role in rupture of the PTT and have uncommonly led to acquired flatfoot in adults (7). Moreover, comorbidities such as
Fig. 4. (A) Anteroposterior and (B) lateral radiographs at 4 months of follow-up.
4
M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 5. Dynamic baropodometric examination views at 2.5 years of follow-up showing normal gait analysis with a moderate overload on the left forefoot.
aging, diabetes, corticosteroids, connective tissue disease, rheumatoid arthritis, obesity, and hypertension can lead to microvascular damage, predisposing the tendon to spontaneous rupture and mid- to longterm insufficiency (8–10).
Our patient had no history of risk factors; thus, the only possible mechanism of the acute rupture was pronation and external rotation trauma, with direct damage from the bone fragments to the PTT. A relatively avascular zone exists in the middle portion, just as the
Fig. 6. Static baropodometric examination views at 2.5 years of follow-up showing the body weight distribution between the forefoot and hindfoot is within the range of normality.
M. Formica et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 7. Posterior view of hindfeet showing slight bilateral calcaneus valgus.
tendon passes posteriorly and distally to the medial malleolus. This segment of the tendon, especially the distal portion, is the site most often reported to be traumatically ruptured secondary to forced pronation and external rotation mechanisms of injury (11–13). This “watershed” region of the tendon is also the primary area to undergo degeneration changes in the chronic tendinopathy (14). Studies on cadaveric models have demonstrated that the combination of pronation and external rotation injury with a dorsiflexed foot causes the maximal tensile forces generated within the PTT. Moreover, West et al (10) postulated that if the PTT is loaded slowly, such as would be likely in the case of a low-energy ankle fracture, it will generally fail at its midsubstance, in the relatively avascular region of the tendon lying posterior and distal to the medial malleolus. Subacute tear or chronic tendinosis at the avascular portion of the PTT has been reported to be the most common cause of tendon failure. This causes acquired flatfoot of adults because of a progressive tear, which often develops against a background of tendinopathy in overweight females >50 years of age with flat valgus feet (6,14). Therefore, ruptures can occur anywhere along the substance of the tendon and not just at the medial malleolus. Partial or complete tears can be missed at presentation and, even intraoperatively, if the injury is not suspected and a meticulous tendon examination is not undertaken. Imaging studies can sometimes be useful for diagnosing these lesions. Some case studies have reported medial bone avulsions as a possible radiographic sign that could suggest a PTT injury or, more commonly, a deltoid ligament rupture in ankle fractures. Medial bone avulsions result from direct avulsion injuries to the medial tibial metaphysis. These case reports described searching for medial bone flakes on plain radiographs. In the case of a malleolar fracture, medial osseous avulsion will more frequently represent disruption of the deep portion of the deltoid ligament as a response to a combination ligamentous and osseous injury (15). If CT is also performed preoperatively, it could be prudent to search specifically for medial bone flakes, which can be missed on plain radiographs. However, ultrasonography is the reference standard imaging examination for the study of tendon rupture, dislocation, and quality and can be performed when an associated tendon injury is suspected, even if most lesions are diagnosed intraoperatively (16). Definitively, the suspicion of a PTT lesion in such trauma is mandatory and must be excluded in the differential diagnosis. This will aid in preventing failure of closed reduction because of interposition of the tendon’s stump in the fracture, which has been described by some investigators (10–12,17–19). However, soft tissue interposition because of a deltoid ligament injury in the case of complex ankle
5
fractures will more often be the cause of failure of satisfactory closed reduction (20,21). It can also be useful postoperatively in detecting misdiagnosed ruptures associated with ankle fractures. Misdiagnosed ruptures will result in prolonged pain and weakness along the medial aspect of the ankle, with a poor response to rehabilitation. In the present case, we performed standard radiographic projections and CT to better study the lesion. An unusual, isolated, and multifragment fracture of the tibial malleolus was identified. A signal alteration around the PTT was evident but was not recognized as complete rupture of the tendon because of a concomitant fracture hematoma. The diagnosis in our case could only be assessed intraoperatively, just as has been described in most cases. The consequences of an unrecognized PTT rupture include progressive and painful pes planus deformities owing to the unopposed action of the peroneus brevis muscle and the lack of support of the medial longitudinal arch. This must be stressed, because PTT rupture concomitant with medial malleolar fractures are frequently undiagnosed, resulting in long-term disability and gait alteration. Only a few published case reports have described this association (22). Early surgical treatment of both the fracture and the PTT lesion is mandatory to regain the function of the tendon and avoid progression to a planovalgus foot (23–25). All published studies have reported a good outcome at the 6-month follow-up examination and excellent long-term results, with a return to the patients’ previous activity level after primary repair, just as was confirmed in our case report. If endto-end suturing is not possible and a loss of substance has occurred, some studies have described successful results by performing tenodesis to the flexor digitorum longus tendon (26). Mueller (27) and Kupcha and Shah (28) have reported disabling acquired flatfoot deformity secondary to untreated PTT rupture. In conclusion, PTT rupture is an uncommon lesion associated with ankle fractures and is often misdiagnosed. The diagnosis can be assessed using imaging studies (e.g., CT, ultrasound, magnetic resonance imaging). The diagnosis is more frequently made intraoperatively because of the several limitations of clinical examination. Highfrequency ultrasonography plays an important role in the investigation of disorders involving the PTT and represents the reference standard technique if a PTT tear is suspected. Untreated lesions will be associated with poor functional outcomes owing to the evolution to a disabling and painful planovalgus foot. Acute trauma does not play a singular role in rupture of the PTT, and many other factors such as aging, obesity, hypertension, diabetes, and corticosteroids can predispose the tendon to damage. Early identification of tendon rupture is necessary, and repair of a PTT rupture must always be performed together with malleolus osteosynthesis to restore good function and a normal gait. Direct tenodesis between the PTT and flexor digitorum longus tendon is a viable option but will rarely be necessary if an acute PTT tear has been accurately recognized and properly repaired. Moreover, a flexor digitorum longus transfer into the navicular bone is more likely to necessary in the presence of chronic PTT or longstanding tendinosis with a concomitant pes planovalgus deformity.
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