Tibialis Anterior Tendon Reconstructed With Plate and Screw

Tibialis Anterior T windupon theorise With Pformer(a) and cheatTraumatic Ruptures On The Insertion Of The Tibialis Anterior T baron Reconstructed With Plate And Screw Fixation Technique And Anterolateral Thigh Flap zip title musculus musculus tibialis muscle muscle muscle foregoing muscularity hypothesiseed with base and tooshie simple regression techniqueHaijun Mao M.D., Guangyue Xu M.D.InstitutionOrthopedics, The Affiliated Drum reign Hospital of Nanjing University Medical School, Nanjing, ChinaAbstractObjective Traumatic faults of the tibialis preceding muscularity ar rare but can make up substantial utilitarian deficiencies. This cultivation aimed to evaluate the effectiveness of the reconstruction of traumatic ruptures on the presentation of the tibialis anterior muscle utilize home base and screw fixation technique and anterolateral thigh (ANTEROLATERAL second joint) tiffs.Methods Eight consecutive endurings with a traumatic rupture of anterior tibi alis heftiness on the foundation were managed from February 2008 to February 2012. The founding was reconstructed with house and screw fixation technique, and the create from raw stuff faultings were affected with ANTEROLATERAL thigh big drifts.Results All flaps survived without any complications. The modal(a) operative and surgical American Orthopedic Foot and articulatio talocruralis Society articulatio talocruralis-hind foot hit of the patient roles were 51 and 94.7. adept mortise-and-tenon joint dorsiflexion strength against strong resistance was observed in eight whatsoever ankles operatively, and a substantial improvement in strength was remark compared with the preoperative examination.Conclusion Repairing a ruptured insertion of the tibialis anterior brawniness using plate and screw fixation technique and ANTEROLATERAL THIGH flaps was a reliable technique and yielded satisfactory results. aim of Evidence Level V, retrospective case series.Key words ti bialis anterior muscle plate and screw fixation techniqueruptureIntroductionRuptures of the tibialis anterior heftiness, either traumatic or atraumatic, are un universal. Traumatic ruptures are ca theatrical role by an acute trauma attended with osseous or soft- wind injuries in addition to hurting and weakness in dorsiflexion of the ankle1,2. Tibialis anterior tendon is important in ankle dorsiflexion3. Ruptures of this tendon can cause portional deficiencies.A localized pseudotumor is usually present at the anteromedial aspect of the ankle, synonymic to the forswear, ruptured tendon end. Physical examination whitethorn include loss of the manakin of the tibialis anterior tendon over the ankle and the use of the extensor muscle hallucis longus and extensor digitorum communis to dorsiflex the ankle2.Traumatic ruptures are usually accompanied with associated injuries. Traumatic ruptures of the tibialis anterior tendon that occur in the avascular lesion within 2cm to 3cm of th e insertion make an end-to-end suture impossible because machinate reattachment is necessary1,36. These ruptures are caused by accidents and result in tissue faultings. Consequently, island or free flaps may be required during the repair of the tibialis anterior tendon.Clear guidelines slightly the interposition of these injuries are currently unavailable. Reconstruction of this tendon to restore ankle dorsiflexion and inversion includes end-to-end repair, tendon transfer, or allo ingraft augmentation4,710. The present take away describes a surgical technique using plate and screw fixation with anterolateral thigh (ANTEROLATERAL THIGH) flaps to reconstruct traumatic ruptures of the tibialis anterior tendon.Patients and MethodsEightconsecutive patients with a traumatic rupture of anterior tibialis tendon on the insertion were managed from February 2008 to February 2012. These patients comprised six males and two females with an average age of 32( dictate,24-46) years. Five and three ruptures problematic the right and left legs, respectively.This study defines traumatic rupture as a rupture that occurred because of locate blunt trauma (e.g., accident) to the tendon accompanied by osseous or soft-tissue injuries. These blunt traumatic cases were accompanied by tissue defects, which were reconstructed with ANTEROLATERAL THIGH free flaps. Early repair (3weeks after the rupture or less) was performed for all the traumatic cases, and the average time from rupture to mathematical process was 1.8(range 3days to 3weeks) weeks.Rupture of tibialis anterior tendon was diagnosed based on annals and visible examination. All patients had sectional complaints, includingweakness in dorsiflexion or unsteady rate, limping, and increase fatigue with passinging. Physical examination included a pseudotumor at the anterior take apart of the ankle, loss of the normal contour of the tendon, and weak dorsiflexion of the ankle accompanied by hyperextension of all toes. Ma gnetic resonance imaging was performed to assess the abjuration of the tendon and confirm the diagnosing.All patients were available for follow-up. A retrospective check was conducted on medical records, final patient interviews, and physical examinations at an average of 2years and 3months (range 1year and 3months to 4years) postoperatively of all cases. Postoperative manual strength testing was performed using a 0 to 5 scale (0, no evidence of contractibility 1 (trace), evidence of muscle contraction with no joint motion 2 (poor), range of motion with temperance eliminated 3 (fair), range of motion against gravity 4 (good), range of motion against some resistance and 5 (normal), range of motion against strong resistance. 11 The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot hit was used for preoperative and postoperative evaluation. This 100-point standard range system is designed to compare the results of different treatment methods in patients with the l ike disorder. The anti-hindfoot AOFAS scores evaluate pain (50 points), function (including gait, range of motion, and strength) (40 points), and alignment (10 points). 12Surgical TechniqueAll surgical cases were performed under general anesthesia in the affiliated drum tower hospital of nanjing university medical school.A midget longitudinal incision was made above the superior extensor retinaculum. The extensor retinaculum was left intact if possible to avoid adhesions of the tendon.The proximal ruptured tendon end typically retracted to the inferior edge of the retinaculum or just to a lower place it. Debridement was performed for the proximal and distal parts of the tendon.If the tendon could be brought to its insertion, a direct tendon repair was carried out. If the tendon ends could not be approximated or if the tendon could not be apposed onto its insertion site, an interpositional tendon graft, which included plantaris tendon (two cases), extensor digitorum longus tendon ( one case), and peroneus tertius tendon (one case), was used to bridge the gap and reinforce repair . An anchor is usually used in most reported literature. However, this study employed plate and screw fixation technique to repair the tibialis anterior tendon to its anatomical insertion.Direct tendon repairs were performed in foursome cases. The end of the tibialis anterior tendon was placed on its anatomical insertion, and then a mini-plate was pressed on it and screwed. The harvested grafts had smaller diameter than the tibialis anterior. In most patients, this tendon could be doubled, which usually resulted in a graft with a diameter of 5mm to 6mm. The ankle and foot were held in maximum dorsiflexion and maximal supination, respectively, to determine the final length of the tendon graft. One end of the grafted tendon was fixed using plate and screw fixation technique. The tendon should surround one screw to ensure a firm insertion. When the adenoidal attachment was performed, t he tendons were sutured to each some other(a) with Vicryl using the side-to-side technique. Finally, the tissue defect was repaired with free flaps. In this study, the ANTEROLATERAL THIGH was performed in all cases.Short-leg browse immobilizing was used for the first 2weeks to maintain the ankle in 0 of dorsiflexion. fish bearing in the grade was allowed in the succeeding 2weeks. The duration of cast immobilization was determined in part by the surgeons perception of repair quality during surgery. At 6weeks postoperatively, weight bearing and rich dorsiflexion were allowed. Plantar flexion was gradually increased.ResultsAll ANTEROLATERAL THIGH flaps survived without any complications, such as necrosis and infection, except for bloated appearance. The average preoperative and postoperative AOFAS Ankle-Hind foot scores of the patients were 51 and 94.7, respectively. Active dorsiflexion was possible after 2weeks to 3weeks.Good ankle dorsiflexion strength against strong resistanc e was observed in eight ankles postoperatively, and a substantial improvement in strength was noted compared with the preoperative examination. All patients were able to walk without a visible limp. However, one patient had a diminutive residual weakness in dorsiflexion in comparability to the uninjured side. On physical examination they fluent had5/5 strength. This caused some symptoms of fatigue or pain after prolonged walking. One patient had 4/5 strength result in a little claudication and continued hyperextension of the toes when walking. Because of the small sample size, there was no valid statistical means to compare the results.Complications arose in one patient. She developed a regional pain syndrome. At the final assessment, we considered that the adhesion of the intermediate stolon of the superficial peroneal nerve may be the cause of complication. by and by the operation of releasing nerve, the patient reported no residual pain and walked with a normal gait. All pati ents were satisfied with the final result and would permit the procedure again.Case reportA 46year-old man suffered from a tissue defect and rupture on the insertion of the tibialis anterior tendon from a motor vehicle accident (Figure 1). His preoperative AOFAS Ankle-Hind foot score and ankle dorsiflexion strength were 53 and 3/5, respectively. One week later, a complete debridement was performed. We used the plate and screw technique to reconstruct the tendon insertion without tendon grafting (Figure 2). The defect was reconstructed with ANTEROLATERAL THIGH free flap. After the operation, a short-leg cast was performed. At 2weeks after the operation, the flap was persistent and the wound healed well. At a 14month follow-up, the postoperative result was 95.3 and the ankle dorsiflexion strength was 5/5 (Figures 3 and 4). He was able to walk without a visible limp.DiscussionRuptures of the tibialis anterior tendon are rare but can lead to considerable functional deficiencies. Ouzou nian and Anderson10reviewed their clinical experience with 12 patients who had tibialis anterior tendon ruptures. Two types of ruptures were place based on clinical presentation (1) atraumatic ruptures, which occurred in low-demand older patients who presented late with minimal dysfunction and (2) traumatic ruptures, which occurred in high-demand younger patients who presented earlier with more than disabilities. The authors concluded that patients with traumatic ruptures, regardless of the time of presentation, demonstrated better function after operative intervention.13 In our studies, the average age of the patients was 32(range,24-46) years. Therefore, correct diagnosis should be performed as early as possible.Delayed diagnosis is common because of intact ankle dorsiflexion that occurs as a result of secondary function of the extensor hallucis longus and extensor digitorum communis muscles14-17. The diagnosis is significantly based on physical examination, accompanying by weak ness of ankle dorsiflexion and a palpable defect of the subcutaneous portion of the tendon and a peseudotumor at the anterior part of the ankle. A pseudotumor usually corresponds with the retracted ruptured tendon end, which becomes entrapped at the distal tip of the superior extensor retinaculum. Ankle dorsiflexion is weaker than that in the contralateral extremity. A steppage gait is a characteristic but is not universally present.Conservative treatment with ankle-foot orthoses, bracing, and activity modification is a viable option in quiet patients. However, we speculated that even in cases with a considerable delay, a reconstruction should still be considered regardless of the age of the patients8.Several operative techniques have been published. many a(prenominal) reports recommend an end-to-end suture, but most publications report the use of other techniques because of the difficulties of obtaining an fitted suture repair2,3,18. In cases where tendon stumps are often retra cted and undergo degenerative changes, an end-to-end suture does not provide adequate tensile strength to transmit the forces required for function. For such cases, tendon graft is needed. In recent literature, the interpositional autografts used include plantaris tendon, extensor digitorum longus, extensor hallucis brevis, and Achilles tendon2,13,19.We used ANTEROLATERAL THIGH flaps for the soft tissue reconstruction in these patients. The advantages of ANTEROLATERAL THIGH flaps include consistent and reliable anatomy, long pedicle, being farthermost from the ablative site, allowing two-team court, the feasibility to create multiple skin paddle by recruiting additional perforators, the flexibility to reconstruct composite defect with chimeric flap by recruiting different tissue types based on a one pedicle, and low donor-site morbidity. When a muscle component is required, we preferred to elevate the flap in a chimeric fashion anterolateral thigh hough elevating the flap as a mu sculocutaneous flap is also a viable option and may decrease the operative time20.A suture anchor or a bio-tenodesis screw is often used for the reconstruction of the insertion of the tibialis anterior tendon. However, this study employed the plate and screw fixation technique to reconstruct the insertion because of its several advantages. The screw can fix the tendon to the bone as point, and the plate can fix the tendon as flat. correspond to the physics formula of press(p)=force(f)/square(s), large square results in small pressure when muscle tension is constant. The plate and screw fixation technique may increase the square and decrease the pressure, thereby improving the firmness betwixt the bone and the tendon. Two patients removed the cast a week after the operation. At the last interview, the patients had a manual strength of 5/5 and walked without a visible limp. These results indicate that the technique decreased the duration of cast immobilization compared with previou sly published reports. However, no valid statistical approach could be performed because of the small sample size. In our future research, we will use a large sample size to validate the results statistically. The applied technique was simple and easy to follow.During our operation, we tested different directions (perpendicular, parallel, or other angles) of the plate to the tendon and the direction of the muscular contraction. We considered that placing the plate perpendicular to the tendon is relatively easy. We speculated that a share force exists between the plate and tendon if the plate is parallel to the tendon. In addition, a cutting action may be produced on the tendon after a long time. Thus, we situated the plate perpendicular to the direction of muscular contraction.This study has few limitations. First, it is retrospective and lacks a control group of nonoperatively managed patients. The results are not representative of all patients with tibialis anterior rupture this study only included younger patients who were symptomatic. Second, the AOFAS Ankle-Hindfoot score was used as the clinical outcome measurement, which is not a pass instrument. Nevertheless, this study allows comparison of results because AOFAS Ankle-Hindfoot score is also used in other published studies.ConclusionWe recommend surgical reconstruction of the traumatic ruptured tibialis anterior tendon using plate and screw fixation technique and ANTEROLATERAL THIGH flaps. This technique allows early mobilization and yields satisfactory results.