Management of Isolated Anterior Tibial Tendon Rupture: A Systematic Review and Meta-Analysis.

Rupture of the tibialis anterior tendon is a rare condition reported to occur most often spontaneously in patients >45 years of age. Diagnosis is often delayed due to transient pain at the time of rupture and the ability of the long extensors to compensate for the lost action of the tibialis anterior. Treatment has been proposed to be based on the activity level of the individual; however, no consensus has been reached on the optimal treatment modality for this rare condition. A systematic review and meta-analysis were performed to determine outcomes obtained with conservative and surgical management. Twenty-four references (155 cases) were identified. Conservative management (21 cases, 13.55%) was associated with poorer outcomes (odds ratio [OR] 0.68; I2  = 61%) because of pain and functional limitations related to ankle dorsiflexory weakness. Surgical intervention (134 cases, 86.45%) had a better chance for good outcome (OR 8.40; I2  = 63%). Use of an ipsilateral split/turn-down ipsilateral tibialis anterior tendon graft (OR 32.15; I2  = 0%) semitendinous autograft (OR 15.25; I2  = 44%), or direct repair (OR 12.57; I2  = 0%) provided the best postoperative outcomes, whereas extensor hallucis longus autograft was associated with the worst (OR 0.27, I2  = 34%). The most common postoperative finding was objective mild dorsiflexory weakness (4/5 muscle strength), which did not translate to subjective functional limitation. Good functional results were found to occur regardless of patient age at the time of intervention. Results of this systematic review and meta-analysis suggests that surgical intervention provides better functional outcomes than conservative management. Use of an extensor hallucis longus autograft is not recommended if surgical intervention is performed.