Tibialis Posterior Transfer for Foot Drop: The Difference in Outcome for Two Different Attachment Sites

Abstract

IntroductionCommon peroneal nerve injury leading to foot drop is of multifactorial etiology. The goal is to restore a normal toe-heel gait. Various static or dynamic surgical options are being performed. Among all, tendon transfer is the most commonly performed procedure with its different dorsal attachment sites on the foot i.e. tendon to bone or tendon to tendon transfer. The objective of our study was to evaluate the outcomes of two methods of transfer in terms of attachments sites on functional outcomes. Materials and methodsIn a retrospective study conducted at Liaquat National Hospital Karachi, a total of 38 patients were included. All of them were operated upon for foot drop from June 2015 to May 2018. A total of 32 patients showed up for the follow-up, 17 patients underwent tibialis posterior transfer with attachment on the second metatarsal and 15 on the tibialis anterior tendon. Functional outcome was assessed by grading of active foot dorsiflexion at six months and at the time of the study by and categorized as excellent, good, moderate, and poor. ResultsMost of the patients in both groups were male, and the mechanism of injury was penetrating trauma. At six months post-operatively, the majority of the patients in both groups showed excellent to good category of active dorsiflexion. At the time of the study (mean 34.4 months postoperatively) patients with insertion at second metatarsal were found to have active dorsiflexion as: excellent: 6 (35.3%), good: 8 (47.1%), moderate: 3 (17.6%), and for insertion at Tibialis Anterior tendon: excellent: 1 (6.7%), good: 6 (40.0%), moderate: 6 (40.0%) and poor: 2 (6.2%). These results were compared using the chi-square test and it was found to be statistically significant (p-value: 0.016). ConclusionInsertion at second metatarsal gives more favorable results as compared to insertion at tibialis anterior with balanced dorsiflexion.

Techniques for the treatment and reversion of tendon injuries in the ankle complex literature review

“…The patients were divided into two groups according to the type of surgical technique for fixing the posterior tibial tendon to the dorsum of the foot (tibial posterior to the 2nd metatarsal, n=17), in group 1, and group 2 (n=15), in the posterior tibial tendon for transferring the anterior tibial tendon. 15 No significant postoperative complications were observed in either group, only one patient had a surgical site infection adequately treated with antibacterial prophylaxis. The results of the surgeries, six months after the operation, confirmed that the majority of patients in both groups were classified as excellent to good, according to the scale described by Carayon et al And the researchers were able to confirm statistically that, in this sample, the insertion in the second metatarsal presents more favorable results in relation to the insertion in the tibialis anterior.…”

“…The results showed little or almost no intercurrence unfavorable to the patients and the researchers reported that ten patients returned to daily activities and four returned to the practice of physical activity without using the orthosis. 14 In the study carried out by Khan et al, 15 the researchers also stated, as seen in Wen et al, 11 regarding the existence of controversies regarding the transfer procedure (circumtibial versus interosseous) and location of fixation on the dorsum of the foot (tendon-bone or tendon-tendon), but it agrees with the favorable authors, seen in this review, on the choice of the dynamic tendon transfer technique being considered the gold standard for restoring foot dorsiflexion and allowing almost normal functional activity, in addition to preventing equinovarus deformity caused by the posterior tibial tendon. Their research was based on the technique described by Carayon et al, and on a modification of the classic Barr procedure, when they used two different fixation sites on the foot, one with tendon-bone fixation, that is, rolling the posterior tibial tendon around the second metatarsal and, the second, to the anterior tibial tendon.…”

“…Khan et al 15 Retrospective 32 patients chosen based on the medical records because they suffered foot drop and became permanent after injury to the peroneal nerve without soft injury, tissue loss or concomitant tendon or bone injury of the same limb treated with transfer of the posterior tibial tendon to the dorsum of the foot via interosseous.…”

“…Their research was based on the technique described by Carayon et al, and on a modification of the classic Barr procedure, when they used two different fixation sites on the foot, one with tendon-bone fixation, that is, rolling the posterior tibial tendon around the second metatarsal and, the second, to the anterior tibial tendon. 15 The target audience consisted of analyzing the medical records of thirty-two (32) patients who had undergone peroneal nerve surgery due to a foot drop secondary to a foot drop injury and the posterior tibial tendon being transferred to the dorsum of the foot and who, after a certain time, were unable to recover their movements. The posterior tibial tendon was harvested and taken subcutaneously to the dorsum of the foot after passing through an interosseous tunnel.…”

“…The posterior tibial tendon was harvested and taken subcutaneously to the dorsum of the foot after passing through an interosseous tunnel. 15 For tendon-to-tendon transfer, the posterior tibial tendon was fixed to the anterior tibial tendon by the Pulvertaft method with non-absorbable suture while for tendon-to-bone transfer, when the posterior tibial tendon was brought to the lateral face of the leg after passing through the interosseous membrane, an "L" lengthening of the posterior tibial tendon was performed to overcome the insufficient length. The patients were divided into two groups according to the type of surgical technique for fixing the posterior tibial tendon to the dorsum of the foot (tibial posterior to the 2nd metatarsal, n=17), in group 1, and group 2 (n=15), in the posterior tibial tendon for transferring the anterior tibial tendon.…”