0198-0211/91/1106-0400$03.00/0 FOOT& ANKLE Copyright 0 1991 by the American Orthopaedic Foot and Ankle Society, Inc
Rupture of the Posterior Tibia1 Tendon Associated with Closed Ankle Fracture R a y m o n d Rocco M o n t o , M.D., C l a u d e T . M o o r m a n , 111, M.D., William J. Mallon, M.D., a n d J a m e s A. Nunley, II, M.D.’ Durham, North Carolina
ABSTRACT Rupture of the posterior tibial tendon has rarely been associated with closed ankle fractures. All previous cases have been in association with pronation-external rotation type fractures in which the medial malleolus has been fractured. This case represents the first such report of a severed posterior tibial tendon in the absence of a medial malleolar fracture and reemphasizes the importance of critically evaluating intraoperative radiographs following the open reduction and internal fixation of closed ankle fractures to assess the possibility of soft tissue interposition. In the event of an acute rupture of the posterior tibial tendon, the authors recommend primary tendon repair.
INTRODUCTION
Rupture of the posterior tibial tendon is an unusual complication of closed ankle fractures and only nine cases have previously been reported in the English sustained their l i t e r a t ~ r e . ~ *All ~ *of~ these ~ * ~ ~patients ~’~ tendon rupture in pronation-external rotation type fractures involving the medial malleolus. We report the first case documented in the absence of a medial malleolar fracture and present a review of the literature on all posterior tibial tendon ruptures associated with ankle fractures. CASE REPORT
The patient was a 25-year-old male who sustained a severe twisting injury to his left ankle while playing soccer. He noted the immediate onset of pain and swelling of the ankle and radiographs showed a LaugeHansen Stage IV pronation-external rotation fracture of the left ankle (Fig. 1). From the Divisionof OrthopaedicSurgery, Duke University Medical Center, Durham, North Carolina 27710. ‘Address requests for reprints to James A. Nunley, M.D., Box 2919, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710.
Preoperative radiographof the left ankle. Note the preseince of a pronation-externalrotation type fracture of the fibula without an associated medial malleolar fracture.
Fig. 1.
400
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Foot & Ankle/Vol. 1 1, No. 6/June 1991
Moderate swelling of the left ankle and marked tenderness over the fibula approximately 10 cm above the level of the tibial plafond was present. The sensation of the involved foot and ankle was intact to both light touch and pinprick. At surgery the fibula was reduced and a six-hole onethird tubular plate applied with a syndesmotic screw. lntraoperative radiographs revealed a persistently enlarged medial joint space lucency (Fig. 2). This finding was presumed to represent the interposition of a deltoid ligament tear in the tibiotalar joint, and a medial incision
401
was made and the joint exposed. The deltoid ligament had indeed been torn and its distal portion was noted in the joint space and the distal portion of a severed posterior tibial tendon immediately distal to the medial malleolus was found lodged in the tibiotalar joint (Fig. 3). A modified-Kessler repair of the posterior tibial tendon was then performed (Fig. 4). The tendon sheath
Fig. 3. lntraoperative photograph demonstrating a full thickness rupture of the posterior tibial tendon.
Fig. 2. Intraoperativeradiograph immediately following open reduction and internal fixation. The medial joint space lucency is asymmetrically enlarged.
Fig. 4. Intraoperative photograph following repair of the posterior tibial tendon using a modified-Kessler repair.
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Fig. 5. Intraoperative radiograph following repair of the posterior tibial tendon. Note the restoration of ankle joint symmetry.
was reapproximated and the joint capsule and deltoid ligament repaired (Fig. 5). DISCUSSION
Primary rupture of the posterior tibial tendon is an uncommon entity with only three cases in a review of 1014 muscle and tendon disruptions at the Mayo Clinic.’ Two of the three were secondary to direct laceration of the tendon and the third was classified as a stress rupture. More commonly, tendon and muscle ruptures are seen in association with rheumatoid ar-
thritis, nonspecific tendonitis, or neurogenic disease ~tates.~.’ Giblin4reported the first case of a torn posterior tibial tendon in a closed ankle fracture while at St. Vincent’s Hospital, Sydney, Australia, in 1980. The patient had sustained a pronation-type fibular fracture with an associated medial malleolar fracture. The tendon rupture was noted at the time of surgery because of the irreducibility of the ankle secondary to the interposition of tendon tissue medially. The second case was reported by Kelbel and Jardon‘ in 1982 and added that the mechanism of injury most likely included forced dorsiflexion as well as pronation and external rotation. Acute primary repair of the posterior tibial tendon was emphasized in the management of this injury in addition to open reduction and internal fixation of the fracture. DeZwart and Davison3added two cases in 1983 from their experience in the Netherlands. They cited retraction of the proximal portion of the ruptured tendon as a difficulty in one case. Also stressed was the ease with which a ruptured posterior tibial tendon could be missed even at the time of surgery if the fracture site and joint space were not carefully explored. In 1985 Stein” reported the cases of two additional patients who each demonstrated the presence of small bony avulsion flakes from the medial metaphysis on radiographs at the time of injury. He reviewed 30 consecutive cases of medial malleolar fractures without associated posterior tibial tendon injury and noted the absence of medial metaphyseal bone flakes in this group. Stein” reasoned that the metaphyseal flakes were avulsed from the medial tibia just proximal to the fracture site and should raise the possibility of posterior tibial tendon rupture when seen. Soballe and Kjaersgaard-Anderson,” in reporting an additional case in 1987, concurred with the previously described mechanism of injury and the importance of primary repair. They accentuated the relationship of the tendon in the medial malleolar sulcus bound tightly by the flexor retinaculum as a factor increasing the risk of its entrapment in medial malleolar fractures. The tendency towards pes planus if the posterior tibial tendon is left unrepaired was also emphasized. The most recent report was that of Schaffer et al.,’ in 1987, in which two cases were documented. Neither case had evidence of Stein’s metaphyseal bone flakes. As has been noted in all reported cases, the mechanism of injury described by Schaffer et al.’ was one of pronation and forced external rotation. The tendon was believed to rupture as it stretched around the medial malleolus during external rotation about an extremely pronated foot. They reviewed their results with primary repair of the tendon and found it yielded excellent clinical outcomes.
Downloaded from fai.sagepub.com at City University Library on March 20, 2016
Foot & Ankle/Vol. 11, No. 6/June 1991
RUPTURE OF THE TlBlAL TENDON
403
CONCLUSIONS
REFERENCES
This case documents the occurrence of a complete rupture of the posterior tibial tendon in association with a closed ankle fracture. It appears from a review of this case and the additional reports in the literature that, to date, this entity has been encountered only in pronation-external rotation type closed ankle fractures. While the medial malleolus was not fractured in this case, the rupture of the deltoid ligament noted at surgery is evidence of significant medial ankle stresses sustained at the time of injury. We agree with the concept that violent external rotation of the ankle with the foot planted in pronation can stretch the posterior tibial tendon to the point of rupture in a closed ankle fracture. We further conclude that this can occur without accompanying medial malleolar fracture. We would like to stress the importance of intraoperative radiographs to assess the symmetry of the joint space, and the possibility of persistent interposed tissues preventing symmetrical reduction of the joint following open (or closed) reduction of fibular fractures.' In such cases, it is essential to explore the medial joint space and malleolar region in order not to miss a ruptured deltoid ligament or posterior tibial tendon. As in the case of other acutely ruptured tendons, the authors recommend primary repair of the posterior tibial tendon be attempted when possible.
1. Anzel, S.H., Covey, K.W., Weiner, A.D., and Lipscomb, P.R.: Disruptionof muscles and tendons. Surgery, 45:406-414,1959. 2. Coonrad, R.W., and Bugg, E.I.: Trapping of the posterior tibial tendon and interposition of soft tissue in severe fractures of the ankle. J. Bone Joint Surg., 36A 744-750, 1954. 3. DeZwart, D.F., and Davidson, J.S.A.: Rupture of the posterior tibial tendon associated with fractures of the ankle. J. Bone Joint Surg., 65A 260-262.1983. 4. Giblin, M.M.: Ruptured tibialis posterior tendon associated with a closed medial malleolar fracture. Austr N 2 J. Surg., 5 0 5960; 1980. 5. Goldner, J.L., Keats, P.K., Bassett, F.H., and Clippinger, F.W.: Progressive talipes equinovalgus due to trauma or degeneration of the posterior tibial tendon and medial plantar ligaments. Orthop. Clin. North Am., 539-51, 1974. 6. Kelbel, M., and Jardon, O.M.: Rupture of the tibialis posterior tendon in a closed ankle fracture. J. Trauma, 22:1026-1027, 1982. 7. Kettlekamp, D.B., and Alexander, H.H.: Spontaneous rupture of the posterior tibial tendon. J. Bone Joint Surg., 51A 759764,1969. 8. Lauge-Hansen, N.: Fractures of the ankle. II. Combined experimental surgical and experimental roentgenographic investigations. Arch. Surg., 60:957-985, 1950. 9. Schaffer, J.J., Lock, T.R., and Salciccioli, G.G.: Posterior tibial tendon rupture in pronation-externalrotation ankle fractures. J. Trauma, 27:795-796, 1987. 10. Soballe, K., and Kjaersgaard-Anderson,P.: Ruptured tibialis posterior tendon in a closed ankle fracture. Clin. Orthop., 231~140-143,1988. 11. Stein, R.E.: Rupture of the posterior tibial tendon in closed ankle fractures. J. Bone Joint Surg., 67A 493-494, 1985.
Downloaded from fai.sagepub.com at City University Library on March 20, 2016
Rupture of the Posterior Tibia1 Tendon Associated with Closed Ankle Fracture R a y m o n d Rocco M o n t o , M.D., C l a u d e T . M o o r m a n , 111, M.D., William J. Mallon, M.D., a n d J a m e s A. Nunley, II, M.D.’ Durham, North Carolina
ABSTRACT Rupture of the posterior tibial tendon has rarely been associated with closed ankle fractures. All previous cases have been in association with pronation-external rotation type fractures in which the medial malleolus has been fractured. This case represents the first such report of a severed posterior tibial tendon in the absence of a medial malleolar fracture and reemphasizes the importance of critically evaluating intraoperative radiographs following the open reduction and internal fixation of closed ankle fractures to assess the possibility of soft tissue interposition. In the event of an acute rupture of the posterior tibial tendon, the authors recommend primary tendon repair.
INTRODUCTION
Rupture of the posterior tibial tendon is an unusual complication of closed ankle fractures and only nine cases have previously been reported in the English sustained their l i t e r a t ~ r e . ~ *All ~ *of~ these ~ * ~ ~patients ~’~ tendon rupture in pronation-external rotation type fractures involving the medial malleolus. We report the first case documented in the absence of a medial malleolar fracture and present a review of the literature on all posterior tibial tendon ruptures associated with ankle fractures. CASE REPORT
The patient was a 25-year-old male who sustained a severe twisting injury to his left ankle while playing soccer. He noted the immediate onset of pain and swelling of the ankle and radiographs showed a LaugeHansen Stage IV pronation-external rotation fracture of the left ankle (Fig. 1). From the Divisionof OrthopaedicSurgery, Duke University Medical Center, Durham, North Carolina 27710. ‘Address requests for reprints to James A. Nunley, M.D., Box 2919, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710.
Preoperative radiographof the left ankle. Note the preseince of a pronation-externalrotation type fracture of the fibula without an associated medial malleolar fracture.
Fig. 1.
400
Downloaded from fai.sagepub.com at City University Library on March 20, 2016
RUPTURE OF THE TlBlAL TENDON
Foot & Ankle/Vol. 1 1, No. 6/June 1991
Moderate swelling of the left ankle and marked tenderness over the fibula approximately 10 cm above the level of the tibial plafond was present. The sensation of the involved foot and ankle was intact to both light touch and pinprick. At surgery the fibula was reduced and a six-hole onethird tubular plate applied with a syndesmotic screw. lntraoperative radiographs revealed a persistently enlarged medial joint space lucency (Fig. 2). This finding was presumed to represent the interposition of a deltoid ligament tear in the tibiotalar joint, and a medial incision
401
was made and the joint exposed. The deltoid ligament had indeed been torn and its distal portion was noted in the joint space and the distal portion of a severed posterior tibial tendon immediately distal to the medial malleolus was found lodged in the tibiotalar joint (Fig. 3). A modified-Kessler repair of the posterior tibial tendon was then performed (Fig. 4). The tendon sheath
Fig. 3. lntraoperative photograph demonstrating a full thickness rupture of the posterior tibial tendon.
Fig. 2. Intraoperativeradiograph immediately following open reduction and internal fixation. The medial joint space lucency is asymmetrically enlarged.
Fig. 4. Intraoperative photograph following repair of the posterior tibial tendon using a modified-Kessler repair.
Downloaded from fai.sagepub.com at City University Library on March 20, 2016
402
Foot & Ankle/Vol. 1 1, No. 6/June 1991
MONTO ET AL.
Fig. 5. Intraoperative radiograph following repair of the posterior tibial tendon. Note the restoration of ankle joint symmetry.
was reapproximated and the joint capsule and deltoid ligament repaired (Fig. 5). DISCUSSION
Primary rupture of the posterior tibial tendon is an uncommon entity with only three cases in a review of 1014 muscle and tendon disruptions at the Mayo Clinic.’ Two of the three were secondary to direct laceration of the tendon and the third was classified as a stress rupture. More commonly, tendon and muscle ruptures are seen in association with rheumatoid ar-
thritis, nonspecific tendonitis, or neurogenic disease ~tates.~.’ Giblin4reported the first case of a torn posterior tibial tendon in a closed ankle fracture while at St. Vincent’s Hospital, Sydney, Australia, in 1980. The patient had sustained a pronation-type fibular fracture with an associated medial malleolar fracture. The tendon rupture was noted at the time of surgery because of the irreducibility of the ankle secondary to the interposition of tendon tissue medially. The second case was reported by Kelbel and Jardon‘ in 1982 and added that the mechanism of injury most likely included forced dorsiflexion as well as pronation and external rotation. Acute primary repair of the posterior tibial tendon was emphasized in the management of this injury in addition to open reduction and internal fixation of the fracture. DeZwart and Davison3added two cases in 1983 from their experience in the Netherlands. They cited retraction of the proximal portion of the ruptured tendon as a difficulty in one case. Also stressed was the ease with which a ruptured posterior tibial tendon could be missed even at the time of surgery if the fracture site and joint space were not carefully explored. In 1985 Stein” reported the cases of two additional patients who each demonstrated the presence of small bony avulsion flakes from the medial metaphysis on radiographs at the time of injury. He reviewed 30 consecutive cases of medial malleolar fractures without associated posterior tibial tendon injury and noted the absence of medial metaphyseal bone flakes in this group. Stein” reasoned that the metaphyseal flakes were avulsed from the medial tibia just proximal to the fracture site and should raise the possibility of posterior tibial tendon rupture when seen. Soballe and Kjaersgaard-Anderson,” in reporting an additional case in 1987, concurred with the previously described mechanism of injury and the importance of primary repair. They accentuated the relationship of the tendon in the medial malleolar sulcus bound tightly by the flexor retinaculum as a factor increasing the risk of its entrapment in medial malleolar fractures. The tendency towards pes planus if the posterior tibial tendon is left unrepaired was also emphasized. The most recent report was that of Schaffer et al.,’ in 1987, in which two cases were documented. Neither case had evidence of Stein’s metaphyseal bone flakes. As has been noted in all reported cases, the mechanism of injury described by Schaffer et al.’ was one of pronation and forced external rotation. The tendon was believed to rupture as it stretched around the medial malleolus during external rotation about an extremely pronated foot. They reviewed their results with primary repair of the tendon and found it yielded excellent clinical outcomes.
Downloaded from fai.sagepub.com at City University Library on March 20, 2016
Foot & Ankle/Vol. 11, No. 6/June 1991
RUPTURE OF THE TlBlAL TENDON
403
CONCLUSIONS
REFERENCES
This case documents the occurrence of a complete rupture of the posterior tibial tendon in association with a closed ankle fracture. It appears from a review of this case and the additional reports in the literature that, to date, this entity has been encountered only in pronation-external rotation type closed ankle fractures. While the medial malleolus was not fractured in this case, the rupture of the deltoid ligament noted at surgery is evidence of significant medial ankle stresses sustained at the time of injury. We agree with the concept that violent external rotation of the ankle with the foot planted in pronation can stretch the posterior tibial tendon to the point of rupture in a closed ankle fracture. We further conclude that this can occur without accompanying medial malleolar fracture. We would like to stress the importance of intraoperative radiographs to assess the symmetry of the joint space, and the possibility of persistent interposed tissues preventing symmetrical reduction of the joint following open (or closed) reduction of fibular fractures.' In such cases, it is essential to explore the medial joint space and malleolar region in order not to miss a ruptured deltoid ligament or posterior tibial tendon. As in the case of other acutely ruptured tendons, the authors recommend primary repair of the posterior tibial tendon be attempted when possible.
1. Anzel, S.H., Covey, K.W., Weiner, A.D., and Lipscomb, P.R.: Disruptionof muscles and tendons. Surgery, 45:406-414,1959. 2. Coonrad, R.W., and Bugg, E.I.: Trapping of the posterior tibial tendon and interposition of soft tissue in severe fractures of the ankle. J. Bone Joint Surg., 36A 744-750, 1954. 3. DeZwart, D.F., and Davidson, J.S.A.: Rupture of the posterior tibial tendon associated with fractures of the ankle. J. Bone Joint Surg., 65A 260-262.1983. 4. Giblin, M.M.: Ruptured tibialis posterior tendon associated with a closed medial malleolar fracture. Austr N 2 J. Surg., 5 0 5960; 1980. 5. Goldner, J.L., Keats, P.K., Bassett, F.H., and Clippinger, F.W.: Progressive talipes equinovalgus due to trauma or degeneration of the posterior tibial tendon and medial plantar ligaments. Orthop. Clin. North Am., 539-51, 1974. 6. Kelbel, M., and Jardon, O.M.: Rupture of the tibialis posterior tendon in a closed ankle fracture. J. Trauma, 22:1026-1027, 1982. 7. Kettlekamp, D.B., and Alexander, H.H.: Spontaneous rupture of the posterior tibial tendon. J. Bone Joint Surg., 51A 759764,1969. 8. Lauge-Hansen, N.: Fractures of the ankle. II. Combined experimental surgical and experimental roentgenographic investigations. Arch. Surg., 60:957-985, 1950. 9. Schaffer, J.J., Lock, T.R., and Salciccioli, G.G.: Posterior tibial tendon rupture in pronation-externalrotation ankle fractures. J. Trauma, 27:795-796, 1987. 10. Soballe, K., and Kjaersgaard-Anderson,P.: Ruptured tibialis posterior tendon in a closed ankle fracture. Clin. Orthop., 231~140-143,1988. 11. Stein, R.E.: Rupture of the posterior tibial tendon in closed ankle fractures. J. Bone Joint Surg., 67A 493-494, 1985.
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