Traumatic Tibialis Anterior Rupture Reconstruction Using Iliotibial Band Autograft

Introduction

Management of a degloved foot involves thoughtful repair or reconstruction. Orthoplastics is a developing field that recognizes improved patient outcomes with multidisciplinary care, fewer procedures, and earlier mobilization. ² Although rupture of both the tibialis anterior (TA) and extensor hallucis longus (EHL) tendons is a rare clinical phenomenon, it is of clinical significance. Dysfunction of TA and EHL tendons can debilitate the patient as it impairs dorsiflexion, inversion, and first toe extension, limiting the ability to ambulate safely. ⁸ The literature regarding management and outcomes of traumatic TA and EHL tendon injuries is sparse. The range of current management of dorsal foot tendon rupture includes conservative management, primary repair, use of allografts, and use of autografts.^1,7 The iliotibial (IT) band has been reportedly used in anterior cruciate ligament (ACL) reconstruction, but use of it in alternative tendinous reconstruction is limited outside of the pediatric population.^4,6

The anterolateral thigh (ALT) flap is often used in lower extremity reconstruction for soft tissue defects, as it is a versatile fasciocutaneous flap with minimal donor site morbidity.^4,5 Use of a vascularized tensor fascia lata (TFL) autograft, a tendon taken with the flap en bloc and therefore with preserved vasculature, is the most commonly employed composite flap for lower extremity tendon reconstruction when soft tissue coverage is needed. ⁹ Vascularized tendon has been shown to be beneficial to healing and infection prevention,^5,10 although unfortunately, tendinous structures are not uniformly in close proximity to the pedicle that the ALT flap is tethered to.

We report the case of a patient with traumatic degloving injury to his left foot with multiple tendinous injuries who underwent novel and successful reconstruction of the TA and EHL tendons using the IT band, which was harvested during an ALT flap for soft tissue reconstruction.

Case Report

We present the case of a healthy 41-year-old male who presented after a motorcycle accident, resulting in a 9 × 20-cm left dorsal foot degloving injury with 4 cm of segmental loss of his TA tendon and near complete laceration of his EHL tendon. He had a 6-year smoking history and worked as a carpenter. He underwent serial debridements and partial repair of the EHL tendon with negative-pressure wound therapy. At the time of definitive reconstruction, he underwent reconstruction of his TA and EHL tendons with devascularized IT band autograft and soft tissue coverage with an ALT flap.

First, the TA tendon was partially released under the extensor retinaculum with 1-2 cm of excursion, which was insufficient to allow for primary repair. At the time of ALT flap dissection, the IT band was easily accessible and a 12 × 3-cm autograft was harvested (Figure 1).

Figure 1.

Iliotibial band autograft after harvest (12 × 3 cm).

The autograft was rolled in line with the fibers in order to target a 6-mm screw hole based on the TA tendon size and was doubled (Figure 2). The tendon was then attached proximally to the TA stump using 3 Pulvertaft weaves with a FiberWire suture and was then secured distally to the medial cuneiform using a Bio-Tenodesis screw (Figure 3). The EHL injury was addressed next. A FiberWire was used to reapproximate the medial portion of the EHL, which had significant gapping after initial repair. Next, the remnant IT band autograft was affixed around the entire EHL to augment the repair and provide additional support (Figure 4). Finally, a K-wire was placed across the hallux metatarsophalangeal joint and a threaded Steinmann pin was placed on the calcaneus and into the tibia in order to protect the EHL repair.

Figure 2.

The IT band autograft rolled in line with the fibers.

Figure 3.

The autograft attached proximally to the TA stump and distally to the medial cuneiform.

Figure 4.

Illustration of use of iliotibial band autografts to repair the segmental loss of the anterior tibialis tendon (left) and augment the damaged extensor hallucis longus tendon (right). Figure created in BioRender. Gebhardt, S. (2025).

The ALT flap was then used for coverage of the large soft tissue defect. An end-to-end anastomosis was performed to the posterior tibial artery with venous anastomoses to deep and superficial systems. Flap sensory neurotization was performed using the lateral femoral cutaneous nerve branch with neurorrhaphy to traumatically divided saphenous nerve.

The patient recovered well postoperatively without complication. He remained nonweightbearing for 6 weeks. The wires were removed at 4 weeks in the clinic and the Steinmann pin was removed at 6 weeks in the OR, at which point the patient was allowed to begin weightbearing and range of motion exercises. At 7 months postoperatively, he was able to ambulate and obtained 10 degrees of dorsiflexion, 36 degrees plantarflexion, 14 degrees inversion, and 9 degrees eversion (Figure 5). His IT band function remained intact.

Figure 5.

Healed left foot dorsiflexed at a 10-month postoperative follow-up visit.

Discussion

Herein we report the novel use of the IT band to repair the TA and EHL tendons at the time of definitive soft tissue reconstruction with an ALT flap. Orthoplastics and use of free flaps have become increasingly common in lower extremity reconstruction and limb salvage as it has been shown to improve patient outcomes; limb salvage has reported success rates approaching 95% with orthoplastic management.^2,8 ALT flaps are workhorses of reconstruction; in cases of tendon injury, a vascularized tissue graft using the tensor fascia lata is the most commonly used flap.^3,9 Unfortunately, this is not a viable option in patients whose injured tendons are nonadjacent to TFL because of pedicle tethering or when multiple tendons require repair.

Although there is evidence that demonstrates improved outcomes in vascularized tendon grafts, ¹⁰ Hu et al ⁶ demonstrated that in the pediatric population, a devascularized IT band can serve as an excellent tendon repair autograft with comparable complication rates and negligible donor site morbidity. Additionally, there is a theoretical improvement in pain levels and shortened time to ambulation after muscle-sparing IT band autograft harvest compared with TFL because of less invasive muscle dissection. As described above, harvesting the graft and repairing the tendon during dissection of the flap prior to flap insert shortens flap ischemia time. This case study supports the use of the IT band as an autograft in the setting of patients with multiple tendons requiring repair and in patients whose tendons are not adjacent to ALT vascular pedicle and TFL tendon.

Conclusion

Traumatic TA and EHL tendon injuries are rare but are of functional significance, requiring thoughtful reconstructive care. We report the orthoplastic case of a patient who underwent IT autograft repair of the TA and EHL tendons with ALT flap for soft tissue coverage after traumatic degloving injury to the left foot. We suggest the use of the IT band as an autograft in patients with multiple tendons requiring repair or tendons not in close proximity to the pedicle for a vascularized tendon transfer at time of definitive reconstruction.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251337076 – Supplemental material for Traumatic Tibialis Anterior Rupture Reconstruction Using Iliotibial Band Autograft

Supplemental material, sj-pdf-1-fao-10.1177_24730114251337076 for Traumatic Tibialis Anterior Rupture Reconstruction Using Iliotibial Band Autograft by Natalie Kuhn, Susanna Gebhardt, Michelle Zhifeng Chiu, Brian Freniere and Naveen Pattisapu in Foot & Ankle Orthopaedics