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CASE REPORT

Spontaneous Dislocation of the Posterior Tibial Tendon

 In-tak Chu, Jin-Wha Chung


 

Address for Correspondence:

In-tak Chu, M.D.
505, Banpodong, Seougu
Seoul, Korea
Phone number : 822-590-1464
Fax number : 822-535-9834
E-mail : itchu@freechal.com

 

Abstract:

Tendon dislocations around the ankle joint are usually occurred during the sports injuries. The traumatic posterior tibial tendon dislocation is rarely reported, however spontaneous dislocation is never reported in the English literature. Authors reports a case of non-traumatic dislocation of posterior tibial tendon and clinical result
Keywords: posterior tibial tendon; dislocation; non-traumatic

J.Orthopaedics 2007;4(4)e15
 index.htm

Introduction:

Dislocation of the posterior tibial tendon is a rarely reported injury in the English literature.  Most of the previous reports had been neglected chronic dislocation of the posterior tibial tendon. The cause is commonly related to trauma with an inversion and dorsiflexion of the ankle and disruption of the retinaculum.

In this report, we address a case of acute, non-traumatic dislocation of the posterior tibial tendon in a 48-years-old plumber.

Case Report :

A 48-years-old, male plumber was referred for pain and swelling over the medial side of the ankle. He denied any previous episode of ankle injury or instability. He had no history of diabetes or neruomuscular disorders.

On the day the patient was referred to our facility, he woke up and walked several steps. He felt sudden muscle clamping pain on his right calf, and in attempts to relieve this, he stamped his foot on the floor and twisted his ankle manually. He then experienced swelling on the medial side of the ankle with pain.

Physical examination demonstrated edema and tenderness around the medial malleolus. The patient was able to walk but was unable to push up into a  tip toe position. The patient felt pain while resisted invert his plantarflexed foot and was apprehensive when the posterior tibial tendon was forced to push anteriorly.

A plain radiograph of the ankle joint revealed no abnormality. Magnetic resonance(MR) imaging of the ankle in a neutral position showed  anterior subluxation of posterior tibial tendon and surrounding effusion in the transverse plane.

The posterior tibial tendon was found to be properly intact with continuity and showed no evidence of tendon degeneration(Fig.1).

Fig. 1 .MR image shows tenosynovitis of posterior tibial tendon and surrounding structures.

 

The patient underwent exploratory surgery. Under the general anesthesia, the toruniquet was applied with the patient  in the supine position. The posterior tibial tendon was easily dislocated manually over the medial malleolus by pushing it anteromedially.

A 5cm long longitudinal skin incision was made along the course of posterior tibial tendon at the posterior border of tibia.

There was evidence of acute tenosynovitis of the posterior tibial tendon with increased synovial fluid.

The retinaculum was normal in thickness and minimally stretched but had no pseudocapsule on the surface of the tibia.

The retinaculum was incised longitudinally and focal ecchymosis of inner surface of retinaculum was noticed(fig.2). The inflamed synovium was excised. The posterior tibial tendon appeared to be normal in shape. The periosteum was elevated and posterior tibial cortex was exposed.

Fig.2.  Posterior tibial tendon is normal in thickness and inner surface of retinaculum had focal ecchymosis.

 

A 2cm long and 1cm wide trapdoor was made using a micro-oscillating saw and the fragment was transpositioned 5mm posteriorly to deepen the groove. The fragment was fixed with 2 screws and the retinaculum was sutured using absorbable suture material.

The posterior tibial tendon was noted to glide smoothly with no dislocation or 5mm subluxation for the full range of ankle motion.

Postoperatively the ankle was placed in a fiber-glass cast for 4 weeks with slight plantarflexion and inversion. Partial weight bearing ambulation was allowed by walking with the aid of crutches on the day of surgery and during the patient return home.

A gentle active range of motion was initiated and full weight bearing walking ambulation was permitted at 6 weeks postoperatively.

The patient returned to full physical activity at 12 weeks postoperatively.

At the most recent follow-up of 18 months, the patient had no symptom related to the ankle with normal range of motion and returned to pre-injury level of activity without recurrence of dislocation.

Dsicussion:

Compared to dislocation of the peroneal tendon, posterior tibial tendon dislocation is a rare injury. The most common injury is a trauma injury during the sports activities or dancing and the proposed causative mechanism is a forced dorsiflexion with inversion and a sudden tensioning of the posterior tibial tendon(1).

In the case of our patient, he had no ankle injury history. The patient had a sudden muscle cramp and swelling around the medial malleolus in the morning.

In the operative field, the retinaculum appeared to be over-stretched and focal ecchymosis was found on the inner layer of the retinaculum and the posterior tibial tendon sheath. The posterior tibial tendon was appeared to be nomal in thickness and had a slight focal color change which may have resulted from trauma during dislocation. The groove for the posterior tibial tendon was normal in depth, however, the tendon was easily dislocated anteriorly with finger pressure.

Reported operative treatments have been similar to dislocation of the peroneal tendon which include  reconstuction of the retinaculum or deepening of the groove.

Reconstruction of the retinaculum consists of reattaching the periosteal-retinacular sleeve to the anatomical margin of the groove and most reports of this procedure were satisfactory for the traumatic dislocation of the posterior tibial tendon(2,3)

In our patient, the dislocation was non-traumatic and the retinaculum did not appear over-stretched, but the posterior tibial tendon was easily dislocatable. Authors performed a deepening of the groove which was an effective treatment for this patient.

Conclusion:

The posterior tibial tendon may have been dislocated spontaneously by muscle clamping especially when the ankle was twisted manually. Deepening of the groove is a reliable and effective procedure to treat this condition.

Reference :

1) Nava BE. Traumatic dislocation of the tibialis posterior tendon at the ankle: report a case. J Bone Joint Surg 1968; 50:150-151

2) Loncarich DP and Clapper M. Dislocation of posterior tibial tendon. Foot Ankle Int 1998; 19:821-824

3) Wong YS. Recurrent dislocation of the posterior tibial tendon secondary to detachment of a retinacular-periosteal sleeve: a cast report . Foot Ankle Int 2004;25:602-604


 

This is a peer reviewed paper 

Please cite as : In-tak Chu: Spontaneous Dislocation of the Posterior Tibial Tendon

J.Orthopaedics 2007;4(4)e15

URL: http://www.jortho.org/2007/4/4/e15

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