Tibialis Anterior Tendon Research Articles

Lateral Cuneiform Ossification and Tibialis Anterior Tendon Width in Children Ages 3 to 6: Implications for Interference Screw Fixation of Tibialis Anterior Tendon Transfers in Children.

While the transfer of the tibialis anterior tendon (TAT) to the lateral cuneiform (LC) following serial casting has been used for nearly 60 years to treat relapsed clubfoot deformity, modern methods of tendon fixation remain largely unstudied. Interference screw fixation represents an alternative strategy that obviates concerns of plantar foot skin pressure-induced necrosis and proper tendon tensioning associated with button suspensory fixation. A better understanding of LC morphology in young children is a necessary first step in assessing the viability of this fixation technique. Therefore, the purpose of this investigation is to define LC morphology and TAT width in children aged 3 to 6 years. A retrospective radiographic review of 40 healthy pediatric feet aged 3 to 6 years who had either magnetic resonance imaging or computed tomography 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. The average ossified LC width ranged from 8.5 mm in the 3-year-old cohort to 10.3 mm in 6-year-old children. Analysis of variance testing revealed no statistically significant difference in width between age groups. Average ossified LC length ranged from 13.5 mm in the 3-year-old cohort to 18.3 mm in 6-year-old children with statistically significant increases in age groups separated by 2 or more years. Significant differences in LC height, volume, and TAT diameter were demonstrated after analysis of variance testing. The TAT to ossified LC width ratio ranged from 44% to 53% across age groups. The dimensions of the LC ossification center are large enough to allow interference screw fixation in children 3 to 6 years of age. Further studies are needed to investigate interference screw fixation performance in the pediatric clubfoot population. Level IV.

Short-term effectiveness of one-stage anterior and posterior cruciate ligaments and posterolateral complex reconstruction combined with medial collateral ligament repair for KD- Ⅳ knee dislocation

To investigate the short-term effectiveness of one-stage anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and posterolateral complex (PLC) reconstruction combined with medial collateral ligament repair for KD-Ⅳ knee dislocation. Between January 2018 and June 2020, 9 patients with KD-Ⅳ knee dislocation were treated. Of 9 cases, 7 were male and 2 were female with an average age of 32.3 years (range, 23-43 years). The knee dislocation was caused by falling from height in 6 cases and traffic accident in 3 cases. The injury located at left knee in 2 cases and right knee in 7 cases. The time from injury to operation was 14-24 days, with an average of 19 days. The preoperative International Knee Joint Documentation Committee (IKDC) score was 45.6±4.2, Lysholm score was 42.4±7.0, and the knee joint active flexion range of motion was (75.2±12.3)°. The posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test were all positive. Under arthroscopy, PCL was reconstructed with the autologous tendons, ACL with allogeneic Achilles tendon, PLC with the allogeneic anterior tibial tendon by Larson enhanced reconstruction method, and MCL was repaired with anchor or simple suture. The operation time was 2-3 hours (mean, 2.5 hours). All incisions healed by first intention after operation. All patients were followed up12-25 months (mean, 16.1 months). After operation, 2 cases developed knee flexion disorder and pain, and 1 case had knee joint stiffness. At last follow-up, the IKDC score was 76.9±7.4, the Lysholm score was 81.6±6.4, and the knee active flexion range of motion was (122.9±7.2)°, all of which significantly improved when compared with preoperative ones ( P<0.05). During follow-up, there was no failure of the grafts. At last follow-up, there were significant differences in the posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test between pre- and post-operation ( P<0.05). The imaging review showed that the positions of the bone tunnels were satisfactory, the reconstructed ACL, PCL, and PLC structures were continuous, and MCL insertions were restored. One-stage ACL, PCL, and PLC reconstruction combined with MCL repair to treat KD-Ⅳ knee dislocation can effectively restore knee joint stability, improve joint laxity, and improve joint movement.

Incorporation of Whipstitch Suture in Tibial Interference Fixation Improves Pullout in Anterior Cruciate Ligament Soft Tissue Grafts.

Interference screw fixation of soft tissue grafts is commonly used in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to determine whether including suture material at the graft-screw interface affects ultimate fixation strength of soft tissue grafts using a tibialis anterior tendon allograft model. Forty fresh-frozen human tibialis anterior tendon allografts were fixed to rigid polyurethane foam simulating the tibial tunnel. Twenty grafts underwent fixation with interference screws and 20 with interference bolts. Within each group, 10 grafts had suture in contact with either the screw or bolt. A load-to-failure test was then performed at a rate of 200 mm/min. The group of allografts with sutures in the tibial tunnel had significantly higher load to failure than the group without sutures. Using interference screw fixation, failure load of the grafts without sutures in the tunnel (535.2 ± 73.40 N) was significantly lower (P = .001) than with sutures in the tunnel (696.3 ± 110.0 N). Using interference bolt fixation, failure load of the grafts without sutures in the tunnel (613.0 ± 83.46 N) was significantly lower (P <.0001) than with sutures in the tunnel (845.8 ± 87.23 N). In a biomechanical model, suture within the tibial tunnel enhances fixation strength with both interference screw and bolt fixation for soft tissue tibialis anterior allografts. Additionally, there was no difference in load to failure when comparing failure of a screw with suture in the tunnel with an interference bolt without suture. Due to improved biomechanical properties, incorporation of suture in the bone-graft interface should be considered when performing soft tissue ACL allograft reconstructions. Failure at the tibial bone-graft interface is a known complication of ACL reconstruction, and incorporation of suture within the interface should be considered for improved biomechanical properties.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon

Category:Bunion; Midfoot/ForefootIntroduction/Purpose:Plantar Plating in the Modified Lapidus Procedure (MLP) to treat severe Hallux Valgus deformities (HVD) or hypermobility of the first ray has become more popular. Due to biomechanical considerations, early weightbearing can be achieved. The surgical procedure and some plate designs make a release of the Tibialis Anterior tendon (TAT) necessary and screws have to be placed through or close to its insertion. We investigate if there are detectable changes of the tibialis anterior tendon or the function of the tibialis anterior muscle (TAM).Methods:We retrospectively reviewed 22 Feet (17 patients) after plantar plating for a modified Lapidus procedure. All patients underwent a MRI at an average of 27 months (range 12-49 months) postoperatively for evaluation of the tendon. Clinical outcome was evaluated using the EFAS score. Dorsiflexion strength was measured and compared to the healthy contralateral extremity.Complications and union rates were assessed.Results:The subjective satisfaction was rated at a mean of 8.2 (range, 5 - 10; SD +-1.5) on a scale from 0 to 10. Fourteen (82%) patients would undergo the same surgical treatment again. MRI images showed signs of tendinopathy of the TAT in 13 feet (59%). There were no ruptures, signs of thinning of the tendon or fatty infiltration detected. Complication rate was low with only on case with performed revision surgery. Regarding the Range of Motion, the force data comparing both feet of the patients is statistically close in comparison to the other side without any statistical differences.Conclusion:The MLP using a plantar-positioned locking plate leads to high patient satisfaction rates and provides significant improvement of preoperative deformity in severe HVD at midterm follow-up. Inversion strength was reduced, and MRI showed signs of tendinopathy in more than half of the cases. However, these findings did not seem to have any effect on the clinical outcome. None of the present patients had a high degree of fatty infiltration of the TAM in accordance with the Goutallier grading. Plantar-positioned locking plates do not seem to impair the TAM or the TAT.

Anterior Ankle Skin Surface Pressures in Lower Extremity Splints: Minimizing Insult after Injury

Category:Ankle; Trauma; OtherIntroduction/Purpose:Though ubiquitously utilized in orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint-related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Improper splinting techniques include inadequate molding of plaster/fiberglass splints, inadequate padding over bony prominences, excessive compressive forces from elastic bandages applied too aggressively, and/or pressure areas created by applying padding and casting material in varying joint positions. While clinicians commonly 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 study is to evaluate anterior ankle skin pressure secondary to joint position change during splinting.Methods:Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (2 limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan I- Scan system (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. 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. Percent change from initial contact pressure centered on the tibialis anterior with either Webril (Covidien/Medtronic, Dublin, Ireland), or Specialist Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with goniometer.Results:There were 2 limbs total that were analyzed for the presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantarflexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1).Conclusion:In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers in patients sustaining foot/ankle trauma. This data, though preliminary, underscores the importance in proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

Contact Pressure Reduction in the Anterior Ankle During Placement of Short Leg Splints

Category:Trauma; AnkleIntroduction/Purpose:Lower extremity splints are commonly used in orthopaedic care throughout emergency departments, operating rooms, and outpatient clinics. Although the mainstay of ankle immobilization, they have been associated with ulcers due to high contact pressures over bony prominences and the anterior ankle. High contact pressures may occur in the anterior ankle when splint padding is applied while the ankle is in a plantarflexed position and subsequently dorsiflexed as the plaster or fiberglass hardens. The purpose of this study is to measure contact pressures in the anterior ankle when cast padding is applied in a plantarflexed position and subsequently dorsiflexed. We hypothesized, that the removal of padding over the anterior ankle following dorsiflexion would result in reduced anterior ankle contact pressures.Methods:Short leg posterior U-splints were applied to the right lower extremity in two healthy volunteers with an underlying pressure transducer [Tekscan I-Scan system (Tekscan Inc, South Boston, MA, USA)] on the skin surface centered over the tibialis anterior tendon. Anterior ankle surface pressures were measured when the padding was applied in maximum plantar flexion and dorsiflexed to neutral position as measured by a goniometer. This was then repeated in the same subjects but prior to dorsiflexion, a 3cm x 3cm square of padding was removed over the pressure transducer prior to dorsiflexion. Percent change from initial contact pressure centered on the tibialis anterior with either Webril (Covidien/Medtronic, Dublin, Ireland), or Specialist Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) was calculated.Results:There were 2 limbs analyzed for presentation of this pilot data. The percent change in anterior ankle contact pressure when padding was applied in plantar flexion and then placed in neutral was an average increase of 264% with just padding and 238% with padding and plaster. [TP1] Subsequently, the removal of padding from the anterior ankle resulted in an average decrease of 126% of[TP2] the increased pressure relative to baseline measurements (Figure 1). The reduction in contact force with the removal of Webril was greater than Specialist.Conclusion:In this pilot data, we report increases in anterior ankle contact pressures when splint padding is applied in plantar flexion and re-positioned into neutral. However, removal of anterior ankle padding reduces pressure over the anterior ankle and may reduce the risk of iatrogenic splint related ulcers in this area. Additionally, this technique may elicit varying reductions in anterior ankle pressure depending on the type of cast padding utilized. This data, though preliminary, underscores the importance of avoiding excess padding over the anterior ankle during splint application.

Reconstruction of chronic tibialis anterior tendon ruptures using a free anterior half of a peroneus longus tendon autograft: A technical note.

Purpose: Chronic rupture of the tibialis anterior (TA) tendon is rare. Several reconstruction techniques have been introduced. However, to the best of our knowledge, the use of a free anterior half of a peroneus longus tendon (AHPLT) autograft has not been reported for reconstruction of TA tendon rupture. This study aimed to describe the surgical technique and present the clinical outcomes of reconstruction of the chronic TA tendon ruptures using an AHPLT autograft. Methods: Between September 2013 and April 2019, five patients with chronic TA tendon rupture were surgically treated by reconstruction using an AHPLT autograft. The AHPLT could be easily harvested percutaneously with a tendon stripper from the ipsilateral lower leg around the reconstruction site. The study included four men and one woman, with a mean age of 43.8 (range: 23-65) years. Results: At a mean follow-up period of 42.8 (range; 12-70) months, the mean Foot Function Index value significantly improved from 53.6 ± 19.8 preoperatively to 25.8 ± 20.8 postoperatively (p = .04). None of the patients had morbidities (such as nerve injury, delayed tendon ruptures, or tenosynovitis) around the AHPLT donor site. Three patients were very satisfied, two patients were satisfied, and one patient was fair with the results. Conclusions: Reconstruction of chronic TA tendon ruptures using a free AHPLT autograft could be successfully performed with satisfactory clinical outcomes and minimal donor site morbidities. Future studies with a larger population size and a comparative group are warranted to confirm these findings.

Absence of Peroneus Tertius in Split Anterior Tibialis Tendon Transfer Surgery

Split anterior tibialis tendon transfer is a common orthopedic surgical procedure for varus foot deformities. In the absence of the peroneus tertius, the peroneus brevis may be used in the transfer. Little is known about the prevalence of each transfer type. The goal of this study is to understand trends in tendon transfer for patients who undergo split anterior tibialis tendon transfer. Records of all patients who underwent tibialis anterior tendon split transfer at our institution between January 2004 and September 2020 were reviewed. After, 337 subjects who underwent tibialis anterior tendon split transfer were included. The peroneus tertius was absent in 33.2% (112/337) of subjects. Logistic regressions showed the odds of having a missing peroneus tertius were 66.9% lower for subjects with cerebral palsy and related etiologies (odds ratio [OR]: 0.331, 95% confidence interval [CI]: 0.21, 0.53), 47% lower for white subjects (OR: 0.53, 95% CI: 0.31, 0.91), and 59.1% lower for non-Hispanic subjects (OR: 0.409, 95% CI: 0.25, 0.66). The odds of a missing peroneus tertius tendon were 2.72 times higher for subjects who identified in the other racial category (95% CI: 1.65, 4.49), and 2.41 times greater for subjects who identified as Hispanic (95% CI: 1.51, 3.84). Patients who underwent the procedure who identified as Hispanic or members of other (non-White, -Black, -Asian) racial groups had an increased likelihood of having a missing peroneus tertius tendon. Patients who identified as white, having cerebral palsy or related etiologies, or non-Hispanic had a decreased risk of having a missing peroneus tertius tendon.

Three-dimensional gait analysis in children with recurrent idiopathic clubfoot undergoing complete tibialis anterior tendon transfer.

This study was aimed to evaluate the kinetics and kinematics of the foot and ankle using three-dimensional gait analysis in children with recurrent clubfoot treated with tibialis anterior tendon transfer (TATT). Three-dimensional gait analysis of 17 children with dynamic supination (24 feet; 12 males; mean age: 6.34 years) was performed pre- and post-TATT. Spatial, temporal and kinematic parameters, as well as the gait deviation index (GDI), were recorded for all patients. Moreover, to evaluate the severity of dynamic supination during walking, we also measured the angle between the plane of the foot and the X-axis during the swing phase (V-angle-S). The postoperative step length (38.95 ± 8.36 cm) and stride length (76.73 ± 15.92 cm) were significantly smaller than their preoperative values (40.68 ± 9.35 cm and 80.57 ± 17.51 cm; P = 0.0316 and P = 0.0028, respectively). The postoperative peak internal ankle rotation angle in the frontal plane (20.45° ± 14.44) was significantly lower than the preoperative value (25.93° ± 9.84; P = 0.029). The postoperative peak internal foot progression angle in the transverse plane (0.96° ± 5.83) was significantly lower than the preoperative value (4.34° ± 8.88; P = 0.026). However, both the peak ankle varus moment and GDI were not significantly different between the pre- and postoperative data. Postoperative V-angle-S values (28.55° ± 7.56) were reduced compared to their preoperative values (32.52° ± 6.53; P = 0.0094). TATT to the lateral cuneiform can correct dynamic supination in patients with a recurrent clubfoot; however, it has limited or no effects on hindfoot varus deformity. Level of evidence: Level III.

Efficacy of Ankle Arthodesis with Retrograde Sign Nail

Aim: To evaluate the efficacy of ankle arthrodesis by using Retrograde SIGN Nail. Study Design: Retrospective study. Place and Duration of the Study: Department of Orthopaedic &amp; Spine Surgery, Ghurki Trust Teaching Hospital, Lahore from 1st January 2018 to 30th June 2020. Methodology: Thirty patients were enrolled for arthrodesis by using retrograde nails. Clinical and radiological examination confirmed the severe arthritis of the subtalar joints in all cases. Surgical procedure was initiated by using lateral incision fibula segment of 1.5 cm was excised 6-8 cm proximal to the fibula tip. After adequate exposure, from proximal lateral to distal medial, approximately 5-6 cm transaction of the fibula was made obliquely. Soft tissue was the initiating point of dissection and the portion was placed on the back table for further use as an autogenous bone graft. To expose the medial gutter, approximately 2-3 cm incision was carefully made at medial to the tibialis anterior tendon without indulging saphenous nerve and vein. Results: A weak positive Pearson correlation was found between BMI and FAAM score but a significant (P=0.00001). Conclusion: Retrograde nailing techniques help to achieve the goals of the union. It also assists in the preservation of hind foot alignment. Keywords: Ankle deformity, Ankle arthrodesis, Ankle arthritis, Retrograde nailing

Reconstruction of traumatic medial malleolus loss using the bone sliding technique: A case report.

IntroductionOpen injury of the medial malleolus is relatively rare, and it can cause instability of the ankle joint and affect the walking function of the lower extremity. We describe an original plan for the reconstruction of medial malleolus defects using the bone sliding technique and report as follows.Case presentationA 48-year-old female presented with an isolated open injury to her right ankle by a traffic accident. The skin of the medial ankle was severely contaminated with mud, and the medial malleolus, part of the Talus's cartilage and soft tissue, were defective. The anterior tibial artery was cut, and the anterior and posterior tibial tendons were ruptured.ConclusionWe describe the reconstruction of the medial malleolus using a bone sliding technique. At two years follow-up, she had a good outcome with a nearly painless, stable ankle with functional plantarflexion but restricted dorsiflexion. The original method is a new choice for the reconstruction of the medial malleolus.

Reproducible and Reliable Method for Syndesmotic Screw Fixation: An MRI-Based Cross-Sectional Image Analysis

Ankle arthrosis may be an unexpected potential result in syndesmotic injuries because of instability and malreduction. For anatomical reduction and stabilization, a reliable and stable reference point is crucial to correctly place syndesmotic screw. The aim of this study was to determine a reliable reference point and to quantify the ideal angle for placement of the screw. In this prospective cohort study, 99 healthy volunteers underwent right ankle magnetic resonance (MR) imaging. On the axial sections, the ideal axis of the syndesmotic screw and other reference points were depicted with 4 lines and 2 angles which were evaluated at the level 2 cm above the tibial plafond. Values were recorded by 2 independent observers to assess for interobserver reliability. The mean value of syndesmotic screw position according to the ground line was 28° ± 6.4° like Arbeitsgemeinschaft für Osteosynthesefragen suggestion. Furthermore, it was determined that the syndesmotic screw could be placed more precisely in the position when placed at an angle of 26.2° ± 1.1° with the axis perpendicular to the line passing through the anterior tibial and Achilles tendons. Ideal syndesmotic screw positioning must be stable enough in case not to be affected by lower extremity alignment deficiencies or foot deformities. So, the anterior tibial and Achilles tendons can be used as reproducible and reliable landmarks for the placement of syndesmotic screws.

Role of the Ilizarov fixator in high tibial osteotomy

Role of the Ilizarov fixator in high tibial osteotomy

Anatomic Multiple Ligament Reconstructions of the Knee

Background: Multiple ligament injuries of the knee occur in a variety of settings, often from athletic activities. Multiple cruciate and collateral ligament injuries may be associated with hamstring tendon rupture, common peroneal nerve (CPN) injury, meniscus, bone, and cartilage damage. Indications: After evaluation for concomitant life-threatening and vascular injuries (especially of the popliteal artery), the knee is assessed through a thorough physical examination and imaging series, including varus, valgus, and posterior stress radiography, and magnetic resonance imaging (MRI). Research over the last 30 years has suggested that operative treatment in the acute setting (&lt;3 weeks) in a single-stage procedure may have improved results to delayed/staged reconstruction. Early range of motion starting on postoperative day 1 is important to prevent development of arthrofibrosis. Technique: We describe the technique used to surgically manage a patient suffering from anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and complete posterolateral corner (PLC) rupture. Neurolysis of the CPN is performed to free the irritated nerve from scar tissue, along with biceps femoris tendon and lateral capsular repairs. Anatomic-based reconstructions are performed. The ACL reconstruction is with a single bundle using a patellar tendon autograft, PCL reconstruction is a double bundle with Achilles and tibialis anterior tendon allografts, and PLC reconstruction is accomplished with a split Achilles tendon allograft. The correct orientation of tunnel placement must be planned to avoid tunnel convergence; these angles have been determined through 3D modeling. The optimal sequence for graft tensioning has been established and follows the pattern: PCL, ACL, PLC, and then medial-sided structures if necessary. Results: Successful outcomes have been reported for both medial and lateral based injuries, and follow-up studies have also shown equivalent results between acute and chronic outcomes, and for multiligament injuries involving the ACL and PCL if anatomic reconstructions with appropriate tunnel angles, passage and tensioning sequence of grafts, and rehabilitation regimens are performed. Discussion/Conclusion: Single-stage anatomic reconstruction is the gold standard for managing multiple ligament injuries in the knee. Commencement of early 0° to 90° knee range of motion and PCL-supporting bracing are critical to prevent arthrofibrosis and protect the grafts from attenuation.

Role of anisotropic invariants in numerically modeling soft biological tissues as transversely isotropic hyperelastic materials: A comparative study

Fiber-reinforced biological soft tissues are often modeled as anisotropic hyperelastic materials. Four strain invariants can be used to define a strain energy function for soft tissues reinforced with a single fiber family: two isotropic invariants I1,I2 and two anisotropic invariants I4,I5. Invariant I5 is often omitted in the strain energy functions to simplify the problem mathematically. In this study, the implications of using only I4 or the use of both anisotropic invariants I4,I5 in the numerical modeling of soft tissues were analyzed. A simple modification to the Holzapfel–Gasser–Ogden (HGO) model is proposed by adding a term that contains invariant I5. Material parameters were calculated by fitting the models with experimental data of uniaxial traction in the tibialis anterior tendon tissue of rats. General analytical solutions for the simple load scenarios were obtained. Such solutions are taken as a reference point to measure the precision of the numerical results obtained in the finite element simulations. The main differences between the models were observed in the shear behavior. The proposed model predicts three different shear responses (two responses with fiber reinforcement and one isotropic response), while the HGO model predicts two equal isotropic responses and only one with fiber reinforcement. Two sets of simple shear experimental data on a fiber-reinforced elastomer material were used to verify the shear stress prediction of the models. The experimental data show that the three shear behaviors are different; thus, the HGO model offers a limited description of the shear behavior. Furthermore, analytical solutions and experimental data suggest that invariant I5 is related to the elastic energy of the fibers when the material is subjected to shear in a direction parallel to the fibers. The models for non-homogeneous deformations were also compared. For this comparison, an irregular geometry was implemented in ABAQUS, and the traction and shear conditions were simulated by changing the fiber inclination. The most critical difference was found when the shear was parallel to the direction of the fiber and the minor difference when the fiber was at 45° to the load force.

Tibialis Posterior Transfer for Foot Drop: The Difference in Outcome for Two Different Attachment Sites.

IntroductionCommon peroneal nerve injury leading to foot drop is of multifactorial etiology. The goal is to restore a normal toe-heel gait. Various static or dynamic surgical options are being performed. Among all, tendon transfer is the most commonly performed procedure with its different dorsal attachment sites on the foot i.e. tendon to bone or tendon to tendon transfer. The objective of our study was to evaluate the outcomes of two methods of transfer in terms of attachments sites on functional outcomes.Materials and methodsIn a retrospective study conducted at Liaquat National Hospital Karachi, a total of 38 patients were included. All of them were operated upon for foot drop from June 2015 to May 2018. A total of 32 patients showed up for the follow-up, 17 patients underwent tibialis posterior transfer with attachment on the second metatarsal and 15 on the tibialis anterior tendon. Functional outcome was assessed by grading of active foot dorsiflexion at six months and at the time of the study by and categorized as excellent, good, moderate, and poor.ResultsMost of the patients in both groups were male, and the mechanism of injury was penetrating trauma. At six months post-operatively, the majority of the patients in both groups showed excellent to good category of active dorsiflexion. At the time of the study (mean 34.4 months postoperatively) patients with insertion at second metatarsal were found to have active dorsiflexion as: excellent: 6 (35.3%), good: 8 (47.1%), moderate: 3 (17.6%), and for insertion at Tibialis Anterior tendon: excellent: 1 (6.7%), good: 6 (40.0%), moderate: 6 (40.0%) and poor: 2 (6.2%). These results were compared using the chi-square test and it was found to be statistically significant (p-value: 0.016).ConclusionInsertion at second metatarsal gives more favorable results as compared to insertion at tibialis anterior with balanced dorsiflexion.

189 Anterior Ankle Surface Pressures in Lower Extremity Splints: Minimizing Insult After Injury

Though ubiquitously utilized in lower extremity orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint- related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Pressure ulcers result from perpendicular forces that compress the soft tissues between body mass, bony prominences, and the support surfaces below. Within those soft tissues are vessels that run parallel to the surface of the site of skin collapse and may collapse easily from pressure loads. As such, prolonged pressure above the threshold for capillary tolerance results in occluded blood flow, interstitial fluid flow, ischemia, pain, necrosis, and sloughing of dead tissue. While clinicians commonly pad bony prominences to minimize the skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is real but has not been well studied or described. The purpose of this biomechanical study is to identify problems with anterior ankle skin pressure secondary to joint position change during splinting and ultimately to determine the optimal position of the ankle during application of the splint as well as the padding technique required over the anterior ankle to minimize iatrogenic skin pressure ulcers. Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (two limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan® I-Scan® system, (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. 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. Percent change from initial contact pressure centered on the tibialis anterior with either Webril© (Covidien/Medtronic, Dublin, Ireland), or Specialist© Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with a goniometer. There were two limbs total that were analyzed for presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1). In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers. This data, though preliminary, underscores the importance of proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

Histological and radiographic evaluation of three common tendon transfer techniques in an un-ossified bone porcine model: implications for early anterior tibialis tendon transfers in children with clubfeet.

PurposeTo compare the histological healing and radiographic effects of tendons transferred to ossified or unossified bone using different tendon fixation techniquesMethodsNine new-born piglets underwent bilateral tendon transfers to either the ossified boney calcaneal body or unossified apophysis. The tendons were fixed using metallic suture anchors, sutures alone or a bone tunnel. At six weeks of age, calcanei were harvested, radiologically imaged and then prepared for histology. A semi-quantitative aggregated scoring system with values ranging from 0 (poor) to 15 (excellent), was used to grade healing at the surgical enthesis and the apophyseal ossification was graded by five independent reviewers in triplicate using a modified (1 to 4) validated scoring system.ResultsHistologically, the cartilaginous transfers utilizing the tunnel and suture techniques also demonstrated the best average aggregated scores of entheses healing rivalling that measured in transfers using the classic bone tunnel technique (clinical benchmark), whereas suture anchor fixation demonstrated the worst healing in both the ossified and unossified samples. All three transfer techniques caused at least minor alterations in apophyseal ossification, with the most significant changes observed in the metallic suture anchor cohort. The tunnel and suture techniques demonstrated similar and more mild abnormalities in ossification.ConclusionTendon transfers to unossified bone heal histologically as well as transfers classically performed through tunnels in bone. Suture fixation or tunnel techniques appear radiographically and histologically superior to suture anchors in our newborn porcine model.Level of evidence

Clubfoot Activity and Recurrence Exercise Study (CARES).

Approximately half of treated clubfoot patients initially corrected with the Ponseti method experience relapse that requires additional treatment. The consequences of relapse on childhood activity levels have not been well studied. Ponseti noted lower functional ratings at 18-year follow-up in clubfoot patients who had undergone tibialis anterior tendon transfer for relapse. Clubfoot Activity and Recurrence Exercise study (CARES) is an observational, prospective cohort study that compares physical activity in 30 clubfoot patients without and with relapse. Eligible participants were 5 to 10 years old, diagnosed with idiopathic clubfoot at birth, and had not received any clubfoot treatment for at least 6 months before study. Recruitment for this study occurred in-person and through Facebook clubfoot groups. Consented participants wore Fitbits secured to their wrists for at least 14 days, and completed a demographic survey, Child Health Questionnaire (CHQ), and the clubfoot disease-specific instrument (CDSI). Participants' daily activity was monitored through Fitabase. Participants without and with clubfoot relapse had similar daily step counts, distance walked, and step intensities, except for moderately active step intensity, which was higher in the clubfoot relapse group. Total steps, total distance, distances (very active, moderately active), minutes (very active, fairly active), and lightly active intensity of steps were significantly higher for participants whose families earn more than $100,000 per year. Various physical activities and sports were reported by both groups in daily activity sheets. Neither demographics nor the CDSI or the CHQ scores significantly differed between the 2 groups. Step counts of children with clubfoot with or without relapse were similar to published levels for healthy children. Children with clubfoot initially treated with the Ponseti method who undergo treatment for relapse have comparable physical activity to those who have not relapsed. They also have comparable step counts to that of the general pediatric population. These reassuring findings can guide conversations with parents when addressing concerns regarding their children's physical activity after treatment for relapse of clubfoot deformity. Level II-therapeutic studies-investigating the results of treatment.

Tendon transfer for dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy – A case report

Introduction and importanceIrreparable sciatic nerve palsy is a cause of foot drop and resulting in absent or weak most of the muscles in leg. There may be dysfunctions of all tendons in the leg excepting Achilles tendon and plantaris tendon. The treatment of this atypical neurologic injury has not been defined.Case presentationI reported a case of foot drop following irreparable sciatic nerve palsy in which there was a dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon. The medial gastrocnemius tendon and plantaris tendon were transferred into the anterior tibialis tendon, the extensor digitorum longus tendon and extensor hallucis longus tendon. The lateral gastrocnemius tendon was transferred into the peroneus brevis. Four months post-operative, he reported no pain and became capable of walking without the assistance of an orthosis or a crutch and without steppage gait.Clinical discussionAnterior transfer of the tibialis posterior tendon was the preferred procedure. If no posterior tibial tendon function was presented, then in order of preference, the extensor hallucis longus, extensor digitorum longus, peroneal, flexor hallucis longus tendon, medial gastrocnemius, lateral gastrocnemius and plantaris tendon would be used.ConclusionThe atypical dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy was presented. Tendon transfer using medial gastrocnemius tendon, lateral gastrocnemius tendon and plantaris tendon seemed to be a good choice for treatment of this injury. It allowed reconstruction of a stable, painless, plantigrade foot.Level of evidenceCase report.