I wanted to get some opinions from the group in regards to   experiences with repairs of anterior tibial tendon ruptures?

I have a gentleman who is 66yrs old, very young, and active lifestyle.  He hikes across the country and locally with his wife.  He stepped off of a tree stump 4 wks ago and had pain and burning to his ankle and up the front of his leg.  He continued on with his hiking and activity until he sustained a 2nd sprain.  After the first injury he noticed his foot slap the ground and it worsened after the 2nd injury. He does not smoke, social alcohol drinking, and owns his own lawn and landscaping business. He is a snow bird and spends his winters in Phoenix.  He is healthy, has dyslipidemia, and takes lipitor and diclofenac

I have repaired this tendon on 3 occassions in the past.  I need to look into any recent literature, but outcomes are equivocal from my past experience in regards to full return of function, though there are reports of patients who do recover. 

Would love to hear your experiences....and I will search the literature as well!

 

I will post the MRI images this evening....

 

 

  • Comments (18)
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  • ^ I tend towards that same approach, especially if I've formed a long term relationship with the patient.
  • I tend agree, that we all agree surgical repair for this rupture was the standard of care.  the patient was informed of this. 

    I discuss all pros and cons with the patient in regards to treatments and ultimately with their decisions.  He was well informed (I believe) on my end that surgery was likely what he needed.  He was aware going a non-surgical route would result in the deficit and need for bracing such as AFO long term.

    He chose to pursue the person who had done an operation on his contralateral foot.  Why that person felt surgical repair of the tendon was not necessary at the time, and took a "watch and see" approach, I am not sure.  The patient however was comfortable with this decision.  This was clearly documented by me, my discussion and his decision.

    We fear the legal ramifications for every action we take.  However, there comes a point where we have to believe that we did what we could do, educated the patient the best we could and the decision they made was THEIRS.  They are to take ownership of that decision.

    I don't know if the patient makes a decision that is not in agreement with our first recommended tx plan that it would be grounds for me to discharge them from the clinic.  Many times I have given patients an alternative treatment plan if they were not ready, or did not want a particular plan that I may have believed was the plan to go with.  It may all sound a bit idealistic, but there are situations where the alternate tx plan may indeed be the better one for the patient.

  • Yes, you could also do that.

  • Actually...

    If the patient refuses surgery, I would recommend discharging the patient and 

    have them follow up with another physician.

    You are under no obligation to treat this patient


    Dr. B


  • Agreed. Without a doubt, we need to recommend surgery. If we advise surgery and the patient refuses after having been informed of the ramifications, then the outcome is on them. I think a person can more easily live with the consequences of his or her decision if it was their choice rather than the result of someone else's actions or inactions. The patient that I mentioned above has had several surgeries in the past and at his age just really did not want to have surgery ever again. What was surprising to me was how well he is functioning with bilateral ruptures but I wouldn't expect everyone to feel or function the same way.

  • Nat's example of the patient who hikes with the foot drop demonstrates how powerful a patient's "perception" is with regards to a successful result and patient care.

    Nat's patient was "perfectly happy" with this permanent deficit, however, I think this type of patient is an exception to the rule. In this case, I think most patients would ultimately be disappointed with a permanent deficit, if a conservative treatment recommendation was given by their physician and the resultant deficit was due to lack of surgical intervention.

    The standard of care is to surgically repair the tendon if the patient is medically suitable for surgery.

    It doesn't matter that we "once had a patient who "did great" by not having an anterior tibial tendon rupture."
    Try telling that to an attorney in a malpractice suit.

    The bottom line is that unless the patient refuses treatment, transfers care, or is not cleared for surgery, then the practitioner's obligation is to practice within the community's practice of the standard of care-- or above that.

    I think most patients would likely be disappointed with a permanent loss of function -and would consider a lawsuit- when an inappropriate course of conservative care was recommended and this resulted in a permanent deficit.

    It's important to document your surgical recommendations in this case. If the patients "perception" changes and he feels he wasn't treated appropriately, let him disdain the practitioner who decided to leave it up to "fate" to heals his tendon rupture. (Which is ridiculous)

    The bottom line is this... If you recommended surgical repair of a tendon rupture, and he's not psychologically ready for a procedure, and he undergoes the procedure and there's a complication, them he'll resent it and may try to sue you.

    Whereas, if you recommend a surgical repair, and he got a second opinion, and stuck with the inappropriate conservative recommendations then in a way, you should be thankful.

    Patients are going to do what they want. And, as Dr. Shaw said, it defies all logic, science, evidence, and qualified and trained medical advice.

    Next time, tell him to obtain the medical opinion of Dr. Oz on TV, and he'll save himself a co-pay.
  • DR. MCLEOD...

     

    WELL SAID

     

    DR. B

  •  Also have had several patients that have neglected Anterior Tibial Tendon ruptures, and how well they do depends on to what extent the tendon adhered to surrounding structures distal to the ankle, tightness of their gastrocnemius, and strength of the extensor tendons which will now become the primary dorsiflexor of the foot. Extensor substitution becomes quite obvious, and in one patient he elected for surgery over a year later only because all of his toes on the affected side were becoming hammered.

  • Suhad,

    I have a patient in his mid-70's who ruptured his tibialis anterior tendon close to a decade ago and chose not to have it repaired. A few months ago he ruptured his contralateral TA tendon, I recommended surgery, and he declined. He now has bilateral muscle weakness with foot drop but amazingly he says he is functionally fine. He likes to hike several miles at a time, several days per week during summer, and although his feet slap the ground he is not bothered by it, has no pain, and is able to do everything he wants. 

    I also would advise surgery ASAP to anyone who suffers this same injury. As stated by others, any delay may make surgery no longer an option. He needs to understand the ramifications of his decision to delay care.

    Nat

  • Quote:

    Misako,

    I did document to this effect.  I also explained to him that any delay in the surgery would likely result in atrophy of the muscle and even if the tendon is reapproximated at a later date, there is little chance it will regain function given the atrophy.  I too am not sure as to exactly what they would "be waiting to see" by not repairing the tendon early rather than later?

    Suhad:

    Biomechanically, I must agree with your conclusions as well as your advice to the patient.

    A torn AT tendon such as this to repair by physiological healing in a wait and see approach defies logic, scence and the evidence.

    Dennis



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