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Recognition of tibialis posterior tendon ruptures in the setting of ankle fractures presents a diagnos-

tic challenge. This rare injury may easily be overlooked in the acute setting because pain and swelling related to the fracture itself may limit clinical examination, and most reported ruptures are discovered in-traoperatively.1-18 Lauge-Hansen pronation

and external rotation ankle fractures with a forced dorsiflexion moment are the most commonly reported mechanisms of injury because this position places maximal stress on the tibialis posterior tendon.18 How-ever, a direct medial blow also has been described.2,17 A high index of suspicion is needed to diagnose these injuries. Unrec-ognized and untreated ruptures may lead to

long-term impairment and loss of function as a result of progressive, painful pes pla-novalgus deformity.10 This report describes 3 cases of ankle fractures associated with complete tibialis posterior tendon rupture recognized at the time of surgery.

Case RepoRtPatient 1

An otherwise healthy 29-year-old man had an isolated closed Lauge-Hansen pronation-abduction bimalleolar ankle fracture and tibiotalar dislocation as the result of a motorcycle collision. He underwent urgent closed reduction and splint immobilization at an outside hos-pital (Figure 1). Four days after the in-

Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle FracturesDerek T. BernsTein, MD; Joshua D. harris, MD; PeDro e. CosCulluela, MD; kevin e. varner, MD

The authors are from Houston Methodist Hos-pital, Houston, Texas.

Dr Harris is a previous Blue Ribbon Article Award recipient (Orthopedics, January/February 2016).

Dr Bernstein has no relevant financial rela-tionships to disclose. Dr Harris receives research support from Smith & Nephew. Dr Cosculluela is a paid consultant for Biomet. Dr Varner is a paid consultant for and receives royalties from Solana and holds stock in Wright Medical Technology, Inc.

Correspondence should be addressed to: Kevin E. Varner, MD, Houston Methodist Hospi-tal, 6550 Fannin St, Ste 2500, Houston, TX 77030 (kevarner@houstonmethodist.org).

Received: August 10, 2015; Accepted: Novem-ber 25, 2015.

doi: 10.3928/01477447-20160526-04

abstract

Tibialis posterior tendon rupture in the setting of pronation-type ankle frac-tures can lead to long-term debility as a result of chronic tendon dysfunction. This rare injury pattern presents a diagnostic challenge because thorough preoperative examination of the function of the tendon is limited by pain, swelling, and inherent instability of the fracture. As such, a high index of suspicion is necessary in ankle fractures with radiographs showing a me-dial malleolus fracture with an associated suprasyndesmotic fibula fracture. This report describes 3 cases of tibialis posterior tendon rupture associated with pronation-type ankle fractures treated acutely with open reduction and internal fixation and primary tendon repair. Additionally, common features of this injury pattern are discussed based on the current literature. In accor-dance with this report, the typical mechanism of injury is high energy and includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. Rupture most commonly occurs in a relatively hypovascular area of the tendon located at the posteromedial extent of the medial malleolus fracture. In the operative treatment of pronation-type ankle fractures, direct inspection of the tibialis posterior tendon allows for timely diagnosis and treatment of associated rup-tures. [Orthopedics. 2016; 39(5):e970-e975.]

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jury, he presented to the authors’ institu-tion for evaluation. On examination, the patient’s skin was intact, with a positive wrinkle sign, indicating that the soft tis-sues were amenable to operative treat-ment. The patient had intact flexion and extension of the toes. The foot was warm to the touch, and brisk capillary refill was present, with intact sensation to light touch in all toes.

Surgery was performed 6 days after the injury. The patient underwent open re-duction and internal fixation of the fibula with a 6-hole, 3.5-mm plate and 5 corti-cal screws measuring 3.5 mm (VariAx; Stryker, Kalamazoo, Michigan). The most distal hole was left open for potential syn-desmotic fixation. The medial malleolus was then approached through a posterome-dial incision. During dissection, disruption of the flexor retinaculum was appreciated. Further inspection showed a complete rup-ture of the tibialis posterior tendon at the level of the fracture, with proximal re-traction of 5 cm. Inspection of the tendon edges showed a clean cut without fraying, indicating a sharp transection as the most probable mechanism of disruption. After reduction and fixation of the medial mal-leolus with 2 cannulated screws measuring 4.0 mm, the tibialis posterior tendon was repaired primarily with 2-0 Fiberwire su-ture (Arthrex, Naples, Florida) with the Krackow technique. Because of the ten-sion on the repair, this was reinforced with a running Bunnell suture with an ad-ditional 2-0 Fiberwire suture, to make a 4-stranded repair (Figure 2A). A Chaput fragment was discovered intraoperatively and was reduced. Fixation was performed with a single 4.0-mm cannulated screw. Syndesmotic stability was assessed fluoro-scopically with external rotation and lateral translation stress testing with the ankle in a mortise view. Instability was document-ed, and the syndesmosis was reduced and fixed with a 4.0-mm cannulated screw. Fluoroscopic evaluation confirmed proper reduction and fixation of the ankle (Figure 2B). A well-padded trilaminar splint was

applied in plantar flexion and inversion to protect the tibialis posterior tendon repair.

At the most recent 10-month follow-up, the patient had returned to full activity and

Figure 1: Preoperative anteroposterior (A) and lateral (B) radiographs of the left ankle showing a Lauge-Hansen pronation and abduction bimalleolar ankle fracture.

BA

Figure 2: Intraoperative photographs of the left ankle showing identification and repair of a transversely oriented tibialis posterior tendon rupture with 2-0 Fiberwire suture (Arthrex, Naples, Florida) and the Krackow technique reinforced with a running Bunnell stitch (A). Postoperative anteroposterior (left), mor-tise (middle), and lateral (right) radiographs of the left ankle showing open reduction and internal fixation with a plate-and-screw construct (B). Abbreviations: D, distal; P, proximal.

A

B

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showed excellent strength in plantar flex-ion and ankle inversion.

Patient 2A 65-year-old man with poorly con-

trolled type II diabetes mellitus, peripheral neuropathy, peripheral vascular disease, and hepatitis C with cirrhosis fell off of a 6-ft-tall ladder and had an open Lauge-Hansen pronation and abduction ankle fracture with tibiotalar dislocation (Figure 3). Examination showed a 10-cm antero-

medially based transverse open wound with contamination. Dorsiflexion and plantar flexion of the toes remained intact, sensation was globally diminished distal to the ankle, and posterior tibial and dorsalis pedis artery pulses were palpable and equal bilaterally. The patient underwent urgent reduction and splinting. After initial stabi-lization, irrigation and debridement were performed on the day of injury.

After debridement and irrigation of the medial wound with 6 L of normal sa-

line mixed with bacitracin, given the lack of contamination within the wound, the decision was made to proceed with de-finitive fixation. The medial malleolus was approached through the traumatic wound, and during reduction of the medial malleolus, complete rupture of the tibi-alis posterior tendon was identified, with sharp, transversely lacerated edges at the level of the fracture. After fixation of the fracture with 2 cannulated screws measur-ing 4.0 mm (Synthes, West Chester, Penn-sylvania), the tendon edges were coapted with 2-0 Fiberwire suture with the Krack-ow technique and reinforced with a 2-0 Vicryl running epitendinous suture (Ethi-con, Somerville, New Jersey) (Figure 4A). The fibula was approached via a postero-lateral incision to maintain a safe distance from the traumatic wound. Significant comminution was appreciated, with mul-tiple bony fragments completely devoid of soft tissue attachment. These pieces were used temporarily to template the reduction and were subsequently discarded. Fixation was achieved with a bridge plating tech-nique with a 2.7-mm distal fibula locking plate (Synthes). Syndesmotic stability was assessed fluoroscopically with manual ex-ternal rotation and lateral translation stress testing with the ankle in a mortise view, and it was documented to be unstable. The pa-tient underwent manual reduction and fixa-tion with a fully threaded 3.5-mm cortical screw through the plate. Proper alignment was confirmed fluoroscopically (Figure 4B), and all wounds were closed primar-ily without tension. A trilaminar splint was applied with plantar flexion and inversion to protect the tendon repair and the medial skin. Necrotizing fasciitis developed ap-proximately 2 weeks postoperatively and ultimately necessitated below-the-knee amputation. The wound subsequently healed, and the patient was ambulating with a prosthesis at 6 months.

Patient 3An otherwise healthy 15-year-old boy

who was near skeletal maturity was tackled

Figure 3: Preoperative anteroposterior (A) and lateral (B) radiographs of the left ankle showing a com-minuted Lauge-Hansen pronation and abduction bimalleolar ankle fracture.

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Figure 4: Intraoperative photograph of the left ankle showing identification and repair of a transversely ori-ented tibialis posterior tendon rupture with 2-0 Fiberwire suture (Arthrex, Naples, Florida) and the Krackow technique reinforced with a 2-0 Vicryl running epitendinous suture (Ethicon, Somerville, New Jersey) (A). Fluoroscopic mortise (left) and lateral (right) views of the left ankle showing open reduction and internal fixation with a plate-and-screw construct (B). Abbreviations: D, distal; P, proximal.

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while playing high school football. By the patient’s description, the ankle was forced into pronation, external rotation, and dor-siflexion, at which point he felt a pop and immediate onset of severe pain and inabil-ity to bear weight. He was evaluated at the authors’ institution the next day. Physical examination showed ankle tenderness me-dially and laterally. The skin was intact, with a positive wrinkle sign. The patient had limited ankle dorsiflexion and plantar flexion as a result of discomfort, with good range of motion of the toes. Sensation to light touch was diminished along the dor-sum of the foot but otherwise was normal. Strong pulses were palpated at the dorsalis pedis and tibial arteries, with brisk capil-lary refill in all toes. Radiographs showed a closed Lauge-Hansen pronation and exter-nal rotation bimalleolar ankle fracture that was subsequently immobilized in a well- padded trilaminar splint (Figure 5).

Operative fixation was performed 5 days after injury. The patient underwent open reduction and internal fixation of the fibula with a 4-hole, 3.5-mm semitubular plate and cortical screws (Biomet, Warsaw, Indiana). During the approach to the me-dial malleolus, the tibialis posterior tendon was completely ruptured at the level of the medial malleolus fracture, with longi-tudinal intratendinous tearing proximally. After fracture fixation, the tendon edges were coapted with a 2-0 Fiberwire Kessler-type core suture augmented by a gift-box stitch (Figure 6A). Syndesmotic stability was assessed fluoroscopically with manu-al external rotation and lateral translation stress testing with the ankle in a mortise view, and it was found to be unstable. The patient underwent manual reduction and internal fixation with a suture-button im-plant (TightRope; Arthrex) (Figure 6B). A trilaminar splint was applied in plantar flexion and inversion to protect the tendon repair. At 8 months postoperatively, the patient had excellent strength in plantar flexion and ankle inversion. He returned to football without limitations at the begin-ning of the next football season.

DisCussionThis report describes 3 patients who

had ankle fractures with acute traumatic rupture of the tibialis posterior tendon.

Each patient had a pronation-type injury that resulted in a typical medial mal-leolus fracture with a suprasyndesmotic fibula fracture and associated syndes-

Figure 5: Preoperative anteroposterior (A), oblique (B), and lateral (C) radiographs of the left ankle show-ing a closed Lauge-Hansen pronation and external rotation bimalleolar ankle fracture.

CBA

Figure 6: Intraoperative photographs of the left ankle showing identification of a complete tibialis pos-terior tendon rupture with vertically oriented, intratendinous tearing and repair using 2-0 Fiberwire Kessler-type core suture (Arthrex, Naples, Florida) reinforced with a gift-box type suture (A). Postopera-tive anteroposterior (left), mortise (middle), and lateral (right) radiographs of the left ankle showing open reduction and internal fixation using a plate, screw, and suture-button construct (TightRope; Arthrex) (B). Abbreviations: D, distal; P, proximal.

A

B

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motic widening. All patients underwent acute open reduction and internal fixa-tion. Intraoperatively, complete disrup-tion of the tibialis posterior tendon was encountered at the level of the fracture site. The 2 patients who had a high-en-ergy mechanism of injury had sharp lac-erations, with fresh tendon edges. This finding was most consistent with a sharp laceration, most likely against the frac-ture edge, with the tendon already maxi-mally tensioned. The patient who had a lower-energy athletic mechanism of in-jury had additional longitudinal tearing of the tendon, consistent with shredding of the tendon against the fracture edge, with progressive elongation of the tendon to ultimate failure. In all cases, primary repair was performed.

Each patient’s immediate postopera-tive management plan included 4 weeks of non-weight bearing on the operative extremity. For the first 2 weeks, the pa-tient was kept in the splint that was placed in the operating room. At the initial post-operative visit, this splint was replaced with a cast that was worn for an additional 2 weeks. Four weeks after surgery, the patient was allowed to progress to weight bearing as tolerated in a boot, and outpa-tient physical therapy was prescribed. No orthotics were used.

This type of injury is rare, with only 23 previously reported cases over the last 35 years.1,3-9,11-18 In concert with the cur-rent findings, the most common mecha-nism of injury includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. However, direct trauma to the tendon medially also may occur.2,17 Most cases involve a high-energy mechanism of injury, such as a motor vehicle collision or a fall from height.1-10,13-18 However, lower-en-ergy athletic injuries also have been de-scribed.11,12 Rupture frequently occurs in a relatively hypovascular segment of the tendon, corresponding approximately to the level of the fracture site posteromedi-

ally, which may indicate that the tendon lacerates against it.18

These injuries present a diagnostic challenge because physical examination is often limited by patient discomfort and swelling. An irreducible ankle mortise may signal potential tendon interposi-tion and injury, even without medial mal-leolus fracture11; however, this may not be present and was not the case in this series. Compared with the remainder of the injury, tibialis posterior tendon rup-ture may have a more subtle presentation and thus may be overlooked. A high index of suspicion is required to ensure prompt diagnosis and treatment, particularly in pronation-variant ankle fractures. Failure to appreciate tibialis posterior tendon in-jury may lead to progressive, painful pes planovalgus deformity that ultimately may necessitate reconstruction. Thus, di-rect examination of the tibialis posterior tendon at the level of the fracture site is advisable in these injuries when a medial approach is made. When the radiographic pattern of the injury does not prompt a me-dial incision, the diagnosis is more chal-lenging. Persistent pain, inability to invert the foot, and rapidly progressive flat foot after injury19 may alert an astute clinician to a potential tibialis posterior injury. Al-though the authors do not advocate rou-tine use of these modalities, ultrasound or magnetic resonance imaging can be used to evaluate the integrity of the tibialis pos-terior tendon in highly suspicious cases.

Once the diagnosis has been made, primary repair should be performed when possible. However, if the tendon quality is not adequate, patients should be advised that progressive flat foot with associated pain may develop over time and may re-quire reconstruction. In either case, long-term follow-up is needed to determine whether the tendon becomes progressive-ly dysfunctional.

ConClusionAcute tibialis posterior tendon rupture

in the setting of ankle fracture poses a di-

agnostic challenge because the bony in-jury distracts from thorough evaluation of tendon integrity preoperatively. Although this concomitant injury appears to be rare, the true incidence is unknown, and expedi-tious diagnosis and treatment is essential. Most reported cases have been diagnosed intraoperatively by direct inspection. Fail-ure to appreciate these injuries in the acute setting may result in progressive, painful pes planovalgus deformity, associated impairment, and the need for additional reconstructive procedures. The authors recommend a high level of suspicion and direct intraoperative inspection of the tibi-alis posterior tendon in all pronation-type injuries.

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11. Monto RR, Moorman CT III, Mallon WJ, Nunley JA III. Rupture of the posterior tibial tendon associated with closed ankle fracture. Foot Ankle. 1991; 11(6):400-403.

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