CHAPTER 28 Rupture of the Anterior Tibial Tendon

The management of rupture of the anterior tibial tendon (ATT) depends almost entirely on the size of the gap present. Generally, ruptures occur in older persons as a consequence of degeneration and friction underneath the extensor retinaculum. The rupture is followed by a variable degree of retraction of the tendon. A small stump of tendon usually is left distally under the retinaculum, and the proximal stump retracts between 2 and 10 cm. The options for correction include an end-to-end repair, transfer of the extensor hallucis longus (EHL) tendon, a tendon graft interposition, and a V–Y lengthening advancement of the proximal ATT. The decision regarding which of these is performed depends on the strength of the limb, the presence of an equinus contracture, and the presence of any accessory claw toe deformities as a result of the rupture of the ATT or additional foot deformities. Even with early prompt diagnosis, degeneration of the tendon usually is present, with fraying of the tendon ends and retraction, and augmentation or supplementation of the tendon repair will be necessary. If the tendon exhibits minimal retraction, ideally it should be reattached to the medial cuneiform.

A very reasonable alternative is to insert the tendon into the navicular. For some years I performed a rerouting of the ATT (a modified Young procedure) for management of the adult flatfoot deformity. This was particularly useful if previous surgery for a flexible flatfoot deformity had failed. In this procedure, the ATT is not detached distally but is rerouted under the navicular to support the medial arch of the foot. What I observed is that there is no loss of dorsiflexion strength, and the transfer takes advantage of the slight inversion function of the ATT. Therefore, in the presence of a rupture of the ATT, and particularly if the foot is flat, I am inclined to insert the tendon into the navicular. This repair is very effective in cases in which retraction of the tendon is minimal but not enough length is available to reattach it distally into the cuneiform (Figure 28-1).

Figure 28-1 A and B, In this acute rupture, the anterior tibial tendon (ATT) could not reach the cuneiform. A graft was not thought to be necessary. C-F, The tendon stump was sutured, and a second incision made medially over the navicular for insertion of a suture anchor. The ATT suture was then pulled percutaneously out of the medial incision so that the appropriate tension on the repair could be generated, and the tendon was attached to the navicular.

With this technique, I make a 2-cm incision over the dorsum of the midfoot in order to retrieve the stump of the anterior tibial tendon. A puncture is then made over the navicular to insert a suture anchor, which is done under fluoroscopic guidance to ensure correct positioning of the anchor. The sutures at the tip of the stump of the tendon are then passed subcutaneously out of the puncture incision used for the anchor. The sutures from the anchor are then passed subcutaneously into the longitudinal incision, with needles attached, and through the tendon. The tension on the tendon is maximized by simultaneously pulling the sutures on the stump out distally through the puncture (see Figure 28-1).

If fixed clawing of the hallux is present as a result of accessory use of the EHL and extensor digitorum longus (EDL) tendons, then an arthrodesis of the hallux interphalangeal joint is ideal, and the EHL tendon can be used to augment the repair (Figure 28-2). A tendon graft works well in this instance, but it should be supplemented possibly with an EHL tenodesis to strengthen the repair. Positioning the foot in at least 10 degrees of dorsiflexion at the completion of the repair regardless of the technique is important.

Figure 28-2 Acute-on-chronic rupture in a 73-year-old patient with a claw hallux deformity. A, Note the hemorrhage in the tendon. B, The tendon could not be repaired without a graft, and the extensor hallucis longus (EHL) was cut distally and passed deep to the retinaculum. C, The EHL was attached to the medial cuneiform under tension with the foot supinated and then woven through the anterior tibial tendon in a double thread to reinforce the repair.

The main problem with the final repair is the potential for wound dehiscence. Bowstringing of the repair always occurs, and because the extensor retinaculum is potentially deficient at the completion of the repair, the underlying skin is subjected to increased pressure from the repaired tendon. For this reason, I make the skin incision more lateral than the underlying repair and then raise the skin flap so that with closure, no pressure from the tendon is on the actual incision (Figure 28-3

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