Tibialis Anterior Tendon Research Articles

BRACING COMPLICATIONS IN IDIOPATHIC CONGENITAL TALIPES EQUINOVARUS

Specific brace-fitting complications in idiopathic congenital talipes equinovarus (CTEV) have been rarely described in published series, and usually focus on non-compliance. Our primary aim was to compare the rate of persistent pressure sores in patients fitted with Markell boots and Mitchell boots. Our additional aims were to describe the frequency of other brace fitting complications and identify age trends in these complications. A retrospective analysis of medical files of 247 idiopathic CTEV patients born between 01/01/2010 - 01/01/2021 was performed. Data was collected using a REDCap database.Pressure sores of sufficient severity for clinician to recommend time out of brace occurred in 22.9% of Mitchell boot and 12.6% of Markell boot patients (X2 =6.9, p=0.009). The overall rate of bracing complications was 51.4%. 33.2% of parents admitted to bracing non-compliance and 31.2% of patients required re-casting during the bracing period for relapse. For patients with a minimum follow-up of age 6 years, 44.2% required tibialis anterior tendon transfer. Parents admitting to non-compliance were significantly more likely to have a child who required tibialis anterior tendon transfer (X2=5.71, p=0.017). Overall rate of capsular release (posteromedial release or posterior release) was 2.0%.Neither medium nor longterm results of Ponseti treatment in the Australian and New Zealand clubfoot have been published. Globally, few publications describe specific bracing complications in clubfoot, despite this being a notable challenge for clinicians and families. Recurrent pressure sores is a persistent complication with the Mitchell boots for patients in our center. In our population of Australian clubfoot patients, tibialis anterior tendon transfer for relapse is common, consistent with the upper limit of tibialis anterior tendon transfer rates reported globally.

Tenosynovitis of the Anterior Tibialis Tendon: Typical Clinical Radiological Correlation: A Case Report

The Anterior Tibialis Tendon (ATT) is usually the site of minor injuries due to its straight course, however, overuse injuries still possible due to repetitive foot dorsiflexion. This tendon crosses the anteromedial aspect of the ankle running toward the medial border of the foot under the inferior and superior extensor retinacula and inserts at the level of the medial cuneiform and the base of the first metatarsal bone. It can be prone to tendinosis, tenosynovitis, partial or complete tear. In the first cases, the patient experiences a pain and a swelling along the distal part of the ATT worsening while dorsiflexion. The diagnosis may be easily suspected clinically, particularly in significant lesions such a complete tear, but the compensation by the extensor hallucis longus and extensor digitorum longus muscles may delay the diagnosis [1].

Chopart amputation with tendon balancing.

When foot necrosis occurs due to lower limb blood flow disorder caused by diabetes or peripheral arterial occlusion, many patients require lower limb amputation. The functional prognosis after lower limb amputation largely depends on whether the heel can be preserved. However, there are many reports that Chopart amputation causes varus and equinus deformity, and is functionally unfavorable. We herein report a case of Chopart amputation performed with muscle balancing. Postoperatively, the foot was not deformed and the patient was able to walk independently with a foot prosthesis. A 78-year-old man presented with ischemic necrosis of his right forefoot. The range of necrosis extended to the central part of the sole, so Chopart amputation was performed. In the operation, to prevent varus and equinus deformity, the Achilles tendon was lengthened, the tibialis anterior tendon was transferred through a tunnel created in the neck of talus, and the peroneus brevis tendon was transferred through a tunnel created in the anterior part of the calcaneus. At the final follow-up 7 years after the operation, no varus or equinus deformity was observed. The patient became able to stand up and walk on his heel without a prosthesis. In addition, step motion was possible by wearing a foot prosthesis.

Identification and Analysis of the Ankle Microbiome Using Next-Generation DNA Sequencing

Category: Ankle; Basic Sciences/Biologics Introduction/ Purpose: Next-generation DNA sequencing (NGS) technologies have made it possible to detect microbial genome sequences within human tissues with a sensitivity that has not been reached before, allowing research to better characterize “normal” host flora. Researchers have utilized NGS to identify the shoulder microbiome, but there are no reports yet on the ankle microbiome. Using NGS, this study aims to determine whether (1) a unique microbiome exists in human ankle tissues, (2) components of the ankle microbiome impact patient outcomes, and (3) microbes found on the skin make up a normal part of the ankle microbiome within the tissue. Methods: A prospective study recruited 33 patients undergoing total ankle arthroplasty (TAA, n=24) or ankle arthrodesis via an anterior approach (n=9) between November 2020 and October 2021 with one of two fellowship-trained foot and ankle surgeons at an academic medical center. During the operation, the surgeon would swab five layers of the ankle: skin (n=33), retinaculum (n=32), tibialis anterior tendon (n=32), joint capsule (n=32), and distal tibia (n=33). These swabs (N=162) were then sent to MicroGen Diagnostics [Lubbock, TX, USA] for NGS. Retrospective data was also collected from patient records to include demographics, medical comorbidities, surgical indication, postoperative complications, readmission and reoperation rates, and pre- and postoperative patient-reported outcome measures. The majority of subjects underwent surgery for ankle arthritis (97.0%). Most subjects were female (51.5%) and white (93.9%), and mean age at surgery was 60.73 (range, 19-85) years. Mean follow-up duration was 0.75 (range, 0.11-1.29) years. Results: Of the 162 swabs sent for NGS, 19 (11.7%) indicated 27 bacteria were present (positive), while the remaining 143 (88.3%) had no bacteria present (negative). The most common organisms were Cutibacterium acnes (40.7%) and Staphylococcus epidermidis (11.1%). The most bacteria were found in the retinaculum (29.6%), followed by the distal tibia (25.9%) and capsule (22.2%). No PROM nor follow-up duration was associated with the presence of bacteria, or the number of bacteria or affected layers. Similarly, complication (positive=18.2%, negative=22.7%; p=1.000), nonunion (positive=0.0%, negative=28.6%; p=1.000), infection (positive=0.0%, negative=4.5%; p=1.000), 90-day readmission (positive=0.0%, negative=4.5%; p=1.000), and reoperation (positive=0.0%, negative=4.5%; p=1.000) rates did not differ if a subject’s NGS profile was positive or negative. Conclusion: This study found that C. acnes and S. epidermidis were most commonly found in the ankle microbiome, though at a relatively low rate. While there is some evidence to suggest both S. epidermidis and Staphylococcus aureus biofilm formation are identified on explanted ankle prosthetics, no study to date has investigated whether or not these bacteria were present in the ankle joint prior to surgery. Furthermore, there is no evidence that patients presenting with these bacteria at the time of surgery are at a higher risk of failure following TAA or ankle arthrodesis.

Surface Pressures in Lower Extremity Splints: A Biomechanical Study.

Though ubiquitously used in orthopaedic trauma, lower extremity splints may have associated iatrogenic risk of morbidity. Although clinicians pad bony prominences to minimize skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is understudied. The purpose of this biomechanical study is to determine the effect of various short-leg splint application techniques on anterior ankle surface pressure in the development of iatrogenic skin pressure ulcers. Various constructs of lower extremity, short-leg splints were applied to 3 healthy subjects (6 limbs total) with an underlying pressure transducer (Tekscan I-Scan system) on the skin surface centered on the tibialis anterior tendon at the level of the ankle. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short-leg splints application in clinically relevant patient scenarios. Percentage change from initial contact pressure centered on the tibialis anterior with cast padding were calculated. The percentage change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then definitively placed in neutral was increased at least 2-fold without the addition of plaster in lower extremity short-leg splints. Removing anterior ankle padding following final splint application in neutral reduced contact forces at the anterior ankle 46% and 59% in splints applied in maximum PF and neutral ankle position, respectively. The present study is the first of its kind to underscore and quantify clinically relevant technical pearls that can be useful in reducing risk of iatrogenic risk of skin breakdown at the anterior ankle when placing short-leg splints, mainly, that it is imperative to apply padding in the intended final splint position and to remove anterior ankle padding following splint application when able. Level IV, biomechanical study with clear hypothesis.

Taping-induced cutaneous stimulation to the ankle tendons reduces minimum toe clearance variability

Large variability of minimum toe clearance (MTC) leads to a higher risk of tripping. Visual feedback-based gait training systems have been used to regulate MTC distribution, but these systems are expensive and bulky. Furthermore, the effect of such training lasts only for a short period of time. Considering the efficacy of elastic adhesive tape-induced cutaneous stimulation to the ankle tendons in improving proprioception and movement detection, we hypothesize that application of tapes to the ankle tendons as a practical method for modifying MTC distribution. To test this hypothesis, we recruited 13 young and healthy adults and instructed them to walk on a treadmill under four conditions: no taping, taping the tibialis anterior tendon, taping the Achilles tendon, and taping both tendons. We measured MTC distribution, lower limb joint angles and muscle activations of the tibialis anterior and gastrocnemius medialis, and compared these outcomes under the four conditions. The application of elastic adhesive tape to the ankle tendons had no significant effect on the average MTC height, but tapes applied to the Achilles tendon and both tendons significantly reduced MTC variability. Taping decreased the variability of some lower limb joint angles, but taping did not induce significant changes in the activation levels of the shank muscles. These results demonstrate that elastic adhesive tape applied to the shank can reduce MTC variability with minimal resistance, inertia and cumbersomeness.

Minimally invasive dual-incision approach: An alternative technique to repair tibialis anterior tendon rupture surgical technique and case report

The authors present a minimally invasive surgical technique to repair tibialis anterior tendon rupture which can be used in mild and moderate retraction. Operative technique is illustrated with its different steps. Advantages and indications are specified according to the data reported in the literature.

Allogreft ve Otogreft Kullanılarak Ön Çapraz Bağ Rekonstrüksiyonu Yapılan Hastaların Klinik Karşılaştırması

Aim: The purpose of this study was to examine the clinical results of individuals who underwent an autograft or allograft repair of the anterior cruciate ligament (ACL). Material and Methods: Retrospective analysis was done on the patient files of patients who underwent ACL reconstruction between 2014 and 2020 using semitendinosus-gracilis tendon autografts (SGT-A) and tibialis anterior tendon allografts (TAT-A). In this study, the data of 30 patients in each group were included. Knee laxity tests, the Lysholm knee grading system, the Tegner activity score, and the International Knee Documentation Committee (IKDC) score were used to compare patient results. Results: While there was no significant difference in the Tegner activity score between the preoperative and the final measurement (p=0.241), the IKDC scores and the Lysholm knee ratings changed statistically significantly between the preoperative measurement and the last control visit (p=0.020, and p=0.038, respectively) for both groups in this study. The SGT-A group’s Lysholm knee score had a preoperative value of 60.97% and a final control value of 90.48%. The preoperative Lysholm knee score for the TAT-A group was 61.31%, and the final control value was 95.03%. The anterior drawer and Lachman test findings showed statistically significant intergroup (autograft and allograft) alterations in both the autograft and allograft groups (both p<0.001). Conclusion: In terms of knee function and laxity, this study achieved a better clinical outcome in the allograft group compared to the autograft group.

Macrophage-Regulating Drug Treatment Promotes Tissue Proliferation in a Diabetic Foot Ulcer Patient with Exposed Anterior Tibialis Tendon - A Case Report

Macrophage-Regulating Drug Treatment Promotes Tissue Proliferation in a Diabetic Foot Ulcer Patient with Exposed Anterior Tibialis Tendon - A Case Report

Tenodesis after Tendon Lengthening for Irreparable Tibialis Anterior Tendon Avulsion Injury: A Case Report

Tenodesis after Tendon Lengthening for Irreparable Tibialis Anterior Tendon Avulsion Injury: A Case Report

TIBIALIS ANTERIOR TENDON RUPTURE – EVALUATION AND FOLLOW-UP BY ULTRASONOGRAPHY

Objective: The purpose of this study was to demonstrate the sonographic appearance of acute spontaneous anterior tibialis tendon (ATT) rupture, to describe the later sonographic appearance of ATT after 4–6–8 weeks of conservative treatment, and to describe the clinical outcome of these patients. Methods: This was a retrospective study of seven patients, physically active men, aged 40–75, who presented with clinical symptoms suggesting ATT rupture. All patients were treated conservatively by case immobilization and went through a follow-up ultrasound examination 4–6–8 weeks afterwards, until clinical recovery. Two patients had ultrasound examination one year after the injury. Results: All seven patients had a complete tear of the ATT with a visible gap between the torn tendon ends seen on sonography. The mean gap size at the time of initial examination was 2 cm. There was a disruption of the normal fibrillar pattern of the tendon, with non-clear fluid accumulated in the gap between the torn tendon ends. Using real-time dynamic ultrasound revealed paradoxical movement with retraction of the torn tendon ends and increasing the distance between the torn ends. All patients were treated conservatively. Sonographic follow-up examinations after 4, 6, 8 weeks revealed restoration of the tendon continuity with good active and passive movements. All seven patients demonstrated irregular and thickened tendon with echogenic scar. Clinically, at 6–8 weeks they had good range of motion (ROM) of the ankle enabling them to resume their normal daily activity.

Chemical Markers of Human Tendon Health Identified Using Raman Spectroscopy: Potential for In Vivo Assessment

The purpose of this study is to determine whether age-related changes to tendon matrix molecules can be detected using Raman spectroscopy. Raman spectra were collected from human Achilles (n = 8) and tibialis anterior (n = 8) tendon tissue excised from young (17 ± 3 years) and old (72 ± 7 years) age groups. Normalised Raman spectra underwent principal component analysis (PCA), to objectively identify differences between age groups and tendon types. Certain Raman band intensities were correlated with levels of advanced glycation end-product (AGE) collagen crosslinks, quantified using conventional destructive biochemistry techniques. Achilles and tibialis anterior tendons in the old age group demonstrated significantly higher overall Raman intensities and fluorescence levels compared to young tendons. PCA was able to distinguish young and old age groups and different tendon types. Raman intensities differed significantly for several bands, including those previously associated with AGE crosslinks, where a significant positive correlation with biochemical measures was demonstrated. Differences in Raman spectra between old and young tendon tissue and correlation with AGE crosslinks provides the basis for quantifying age-related chemical modifications to tendon matrix molecules in intact tissue. Our results suggest that Raman spectroscopy may provide a powerful tool to assess tendon health and vitality in the future.

MRI signal intensity ratio reflects the quality of the anterior talofibular and calcaneofibular ligaments in patients with chronic lateral ankle instability

BackgroundLigament quality can affect clinical outcomes of ligament repair in chronic lateral ankle instability (CLAI). Magnetic resonance imaging (MRI) is used to assess the morphological changes of ligaments, but the measurement of signal intensity enables quantitative evaluation, which can evaluate the degree of the ligament quality. This study aimed to evaluate the qualitative diagnostic capacity for anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) injuries of the signal intensity on MRI. MethodsThirty-eight and 20 ankles with and without CLAI, respectively, were included. The regions of interest (ROIs) were set in the ATFL, CFL, and tibialis anterior tendon (TAT) on MRI, and the signal intensities were measured. The signal intensities of the ATFL and CFL were corrected using TAT as the signal intensity ratio (SIR). The SIRs of the ATFL and CFL in the control and CLAI groups were compared. The relationship between the SIR of the ATFL and the arthroscopic findings was analyzed. Finally, the SIRs of the CFL in CLAI with and without CFL repair were compared. ResultsThe mean SIR of the ATFL in the CLAI group (6.1 ± 2.4) was significantly higher than that in the control (2.1 ± 0.4) (P < 0.01). The SIR of the ATFL was associated with the arthroscopic grading. The mean SIR of the CFL in the CLAI groups (4.1 ± 2.5) was significantly higher than that in the control (1.7 ± 0.4) (P < 0.01). The SIR of the CFL in patients with the requirement of the CFL repair (6.2 ± 1.9) was significantly higher than that without the CFL repair (2.1 ± 0.5) (P < 0.05). ConclusionsThe SIR is useful for evaluating the quality of the ATFL and CFL, which enables the decision of the treatment strategy of the CLAI.

Allogeneic Tendon Transplantation for the Treatment of Pathological Patellar Ligament Defect in Children: Technical Note and 4-Year Follow-Up.

The absence of patellar ligament will bring about a severe negative impact on daily life. Many reconstruction techniques have been described in adults. However, there is a lack of technical introduction regarding the reconstruction of the patellar ligament in children. The purpose of this study was to report a surgical technique for reconstructing the patellar ligament in children. A retrospective analysis of the clinical data on a patellar ligament (tendon sheath fibroma) patient with allogeneic tendon reconstruction. An 8-year-old child with postoperative recurrence of left patellar ligament tumor was enrolled in our study. Anterior tibialis tendon allograft was used to reconstruct the patellar ligament after complete resection of the patellar ligament for the tumor. The tunnels were constructed on the deep surface of the tibial tubercle and the root of the quadriceps tendon (to decrease the harmful impact on patella development), respectively. The allogeneic tendon was passed through the tunnels above in the shape of "8," and the two ends of the tendon were attached to the bleeding bone bed at the inferior edge of the patella with suture anchors to achieve better bone-tendon healing. During the follow-up, the knee's range of motion and imaging manifestations were recorded. Postoperative pathology suggests chondromesenchymal hamartoma, a rare benign soft tissue tumor different from the previous operation (tendon sheath fibroma). During the 4-year follow-up, the patient's active range of motion of the knee achieved 0° to 120°; and the patient could walk normally without any external help. Physical examinations (the apprehension sign and J sign) showed no ligamentous instability or patellar ligament tenderness. Imaging analysis showed that the ratio length of the patellar ligament to the patella was almost normal. The integrity, continuity, and shape of the allogeneic ligament showed excellent results in MRI. Combined with clinical and imaging findings, allogeneic tendon patellar ligament reconstruction was deemed successful. Allogeneic ligament reconstruction technique can provide a treatment option by reconstructing the extensor mechanism, minimizing the impact on patellar development, and augmenting biological healing for children with the absence of the patellar ligament.

Primary tendon repair in a case of acute traumatic tibialis anterior with extensor hallucis longus tendon rupture in a young male-a case report

&lt;p&gt;Tibialis anterior tendon rupture is a rare entity which can be either traumatic and non-traumatic. It often presents late due to mild clinical symptoms and signs. Acute ruptures are traumatic occurring in young individuals while chronic ruptures are due to degenerative processes occurring in elderly individuals, commonly after 45 years of age. Tibia anterior along with extensor hallucis tendon is an even rarer entity, operative management of which becomes mandatory, more so in a young active individual for better outcome. We have a 31-year-old male patient, who presented to us with an acute post traumatic tibialis anterior tendon rupture of 3 days duration which was diagnosed following an initial clinical examination, an unremarkable X-ray picture, and Ultrasonography confirming the diagnosis. The patient was managed with primary repair of the tibialis anterior tendon along with Extensor hallucis tendon (which was found intra-operatively) with 2-0 ethibond sutures using a cross-linked Bunnell technique. The patient regained full ankle range of motion at 8 weeks post operative period with ankle dorsiflexion and great toe extension back to pre-injury state.As we have seen with this case, early primary repair in a case of acute rupture at tibialis anterior and extensor hallucis longus rupture with non-absorbable suture has significant improved post operative outcome in terms of return of the affected range of motion and can be practice safely in new hands with limited resources as material of suture and technique has not significant effect in post operative outcome. Acute tibialis anterior and extensor hallucis tendon rupture, non absorbable suture, ethibond, cross linked Bunnell technique.&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Septic Tenosynovitis of the Lower Extremity: A Case Report

Category: Other Introduction/Purpose: Tibialis anterior rupture is an exceptionally rare complication of septic tenosynovitis. One case of septic tenosynovitis of TA has been previously documented by Lowell et al. 2020 It is worth noting in this case, that TA was unruptured. In this abstract, we present a case of TA rupture secondary to septic tenosynovitis. Methods: A 46-year-old female with a past medical history of depression, HIV, HCV, Diabetes Mellitus, medication noncompliance and current heroin abuse presented with 2 days of right ankle pain. She also reported fever, chills, diaphoresis, nausea and vomiting. She was diagnosed with right foot cellulitis based on clinical findings of erythema, induration and tenderness. She underwent computed tomography (CT) with contrast of her right lower extremity which showed a peripherally enhancing fluid collection surrounding the tibialis anterior tendon consistent with tenosynovitis. There appeared to be medial extension beyond the tendon sheath (Figure 1). A sagittal view is provided in Figure 2, which further demonstrates the fluid collection. Results: She had an I&amp;D of the fluid collection and started on IV vancomycin. After admission to the medical floor, blood cultures were drawn. The patient failed to improve after 2 days of vancomycin therapy. The blood cultures were negative. She subsequently had MRI of her right lower extremity that showed a persistent peripherally enhancing fluid collection anterior to the tibialis anterior tendon and high-grade partial tear of the tibialis anterior tendon (Figure 3). She was then taken to the operating room for a repeat incision and drainage where the tendon sheath of the tibialis anterior was incised and the tendon was exposed with washout. Wound cultures were drawn, and afterward, her antibiotic regimen was broadened with Piperacillin-Tazobactam. She was taken back to the operating room a third time for primary closure of the wound. Wound cultures grew methicillin- sensitive Staphylococcus Aureus resistant to clindamycin and she was discharged on Bactrim. Conclusion: Septic or suppurative tenosynovitis is the infection and inflammation of the closed synovial sheath of a tendon. These infections typically involve the tendons and tendon sheaths of the flexor muscles in the hand. The potential spaces of tendon sheaths create a walled-off environment ideal for pathogens to grow in isolation from host defenses. he pathogenesis of septic tenosynovitis typically involves trauma from a laceration, puncture or bite but other cases of disseminated hematogenous spread have been reported (Newman et al., 1989). Both medical and surgical management is recommended for the best possible outcome.

Interference Screw vs Suture Button Fixation for Tibialis Anterior Tendon Transfer to Lateral Cuneiform: A Biomechanical Analysis with Implications for Clubfoot Treatment

Category: Other Introduction/Purpose: While transfer of the tibialis anterior tendon (TAT) to the lateral cuneiform (LC) following serial casting has been used for over 60 years to treat relapsed clubfoot deformity, modern methods of tendon fixation remain largely unstudied. Though interference screw fixation has the potential of obviate concerns of pressure necrosis and proper tendon tensioning associated with plantar button suspensory stabilization, a better understanding of LC morphology in young children is a necessary first step in assessing the viability of this fixation technique. The purpose of this investigation is therefore to define LC morphology in children aged 3-6 years. Methods: A retrospective radiographic review of 40 healthy pediatric feet aged 3-6 years who had either MRI or CT scans was performed at a single pediatric hospital. The length, width, and height of only the ossified portion of the LC were measured digitally using sagittal, coronal, and axial imaging. In addition, the maximal cross-sectional diameter of the TAT was measured at the level of the tibiotalar joint. Results: Average ossified LC width ranged from 8.5mm in the 3-year-old cohort to 10.3mm in 6-year-old children. While the average width increased with each year of age, ANOVA testing revealed no statistically significant difference in width between age groups (p=0.091). Average ossified LC length ranged from 13.5mm in the 3-year-old cohort to 18.3mm in 6-year-old children with statistically significant increases in all age groups separated by two or more years (p=0.017). the TAT to ossified LC width ratio ranged from 44% to 53% across age groups. (table 1). Conclusion: The dimensions of the LC ossification center are large enough to allow interference screw fixation in children 3 to 6 years of age.

Surgical Management of Tibialis Anterior Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm

Category: Sports; Other Introduction/Purpose: Although rare, Tibialis Anterior Tendon (TAT) tears or ruptures can have a detrimental effect on patients' quality of life. There is no current consensus as to the most appropriate surgical treatment for TAT rupture, in part because of the paucity of data surrounding this condition. Therefore, this study attempts to address this deficiency by performing a systematic review of the literature of the different surgical interventions for TAT rupture, analyzing the level of evidence (LoE) and quality of evidence (QoE) of the included studies, and recommending an algorithm approach to the surgical treatment of TAT injury. Methods: In September 2021, the MEDLINE and EMBASE databases were systematically reviewed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following search terms were used: (anterior) AND (tibialis OR tibial) AND (tendon) AND (tear OR rupture) NOT (acl OR cruciate OR meniscal OR patellar). ??Full-length peer-reviewed studies in English with a sample size of 5 participants that reported functional outcome scores were included. We excluded systematic reviews, meta-analyses, review articles, and case series/reports with less than five participants. The LoE and QoE of the included studies were evaluated using the Journal of Bone and Joint Surgery Criteria and the Modified Coleman Methodology Score, respectively. In some cases, tabulated data from studies were analyzed to obtain relevant statistics for our analysis, including deriving descriptive statistics such as mean and standard deviation values, as well calculating p-values with two- sample t-tests assuming either equal or unequal variance. Results: Twelve studies with 171 patients were included in this review, 11 with Level IV evidence and one with Level II evidence. Additionally, there were 17 different types of repair techniques used, where direct repair (including end-to-end repair and bone fixation) was performed on 33.5% of tendons, tendon transfers were performed on 20.8% of tendons, and grafts were performed on 45.7% of tendons. For the mean postoperative AOFAS Ankle-Hindfoot (AOFAS-AH) scores, both the direct repair and autograft cohorts had significantly higher mean scores than the allograft cohort (p=0.008 and p=0.002 respectively). The autograft cohort was also found to have significantly higher post-operative means AOFAS-AH than the tendon transfer cohort (p=0.047). We also found statistically significant improvements in dorsiflexion strength after surgical intervention in early intervention (&lt;=6 weeks from injury to surgery) and delayed intervention cohorts. Conclusion: Surgical management of TAT ruptures produces good clinical outcomes in the intermediate follow-up. As there is no current consensus on the most appropriate surgical treatment, we have designed a treatment algorithm based upon the current literature citing statistical evidence determined in this systematic review.

Acute Deep Deltoid Ligament Reconstruction using a Novel, Arthroscopically-Assisted Technique: Case Report

Category: Arthroscopy; Ankle; Sports; Trauma Introduction/Purpose: The deltoid ligament complex is the main stabilizing structure of the ankle mortise and is often disrupted in rotational ankle injuries. Current treatment involves open techniques for the acute repair of the superficial deltoid layer, however, repair or reconstruction of the deep deltoid ligament (DDL) has proven to be challenging using open techniques. Our described arthroscopically-assisted technique allows for better intra-articular visualization and durable reconstruction of the ruptured DDL with suture and knotless bone anchors. The goal of this new, minimally invasive approach is to facilitate a faster and more reliable recovery and prevent long-term dysfunction and degeneration from medial and rotational ankle instability. We believe it has the potential to provide improved immediate ankle stability and decrease overall surgical morbidity compared to open treatments. Methods: Case of a 48-year-old male with ligamentous-equivalent Massioneuve fracture with medial clear space (MCS) measuring 11 millimeters. Arthroscopy revealed unstable syndesmosis and rupture of the DDL. After syndesmotic fixation, there was persistent MCS widening on stress exam. Arthroscopically-assisted DDL reconstruction was performed using an accessory anteromedial (AAM) portal between the tibialis anterior tendon and posterior tibial tendon. Needle localization identified the sagittal midpoint of the medial wall of the talus, inferior to articular cartilage. Anchor sites at both the medial talar wall and midportion of the distal medial malleolus (insertion and origin of the DDL, respectively) were then drilled via the AAM portal under arthroscopic and fluoroscopic guidance respectively at the isometric point. A suture anchor was placed into the talus and tails were loaded and secured to the medial malleolus with a bioabsorbable anchor. Ankle mortise was stable to stress exam and there were no restraints to physiologic motion. Results: The patient was kept non-weight bearing on his right lower extremity for a total of 6 weeks postoperatively and was seen in the clinic for routine follow-up visits at 2 weeks, 6 weeks, and 3 months post-procedure. Sutures were removed at 2 weeks, without any wound complications, and he was transitioned from splint to a short leg cast. He required only three days of oral narcotic analgesia. Weight-bearing in a controlled ankle motion (CAM) boot and physical therapy were both initiated at 6 weeks post-op. Radiographs at each follow-up visit were without abnormalities. At 3 months post-op, he was graduated from the CAM boot into a lace-up ankle brace, without any complaints of ankle pain or instability. The patient progressed well with full weight-bearing and physical therapy and was seen for a final visit at 5 months post-op with stable MCS. No complications were encountered. Conclusion: Acute DDL rupture is a common occurrence in ankle fractures and can be diagnosed radiographically and by arthroscopy. Known sequelae of untreated DDL disruption include medial instability and late valgus collapse. This case report demonstrates a novel, minimally invasive technique to successfully reconstruct the DDL, which may minimize the surgical morbidity compared to open dissection methods and allow for decreased recovery time postoperatively. This approach may also be utilized for cases of chronic instability. Future work includes larger case series with long-term follow-up and refinement of the technique as instrumentation advances.

Split anterior tibial tendon transfer (Splatt) to the peroneus brevis/tertius for the correction of varus foot deformity in children: A case series

Objective: The purpose of the study was to determine the safety/efficacy of a split anterior tibialis tendon transfer (SPLATT) to the peroneus brevis/tertius in children with varus feet.Methods: This is a case series of 5children with varus foot who had undergone split anterior tibialis tendon transfer (SPLATT) to the peroneus brevis/tertius. The principal outcome measures were changes in pain (measured by likert scale), difficulty with shoe wear (measured by mean difference in pre and post op scores) and radiological parameters obtained from anteroposterior and lateral radiographs of the affected foot before and after surgery. Each case was followed up for 1 year. Results: After surgery foot pain and problems with shoe wear improved. The radiological criteria also showed a clinically and statistically significant (p