Transfer of the tendon of tibialis anterior in relapsed congenital clubfoot

Abstract

A total of 38 relapsed congenital clubfeet (16 stiff, 22 partially correctable) underwent revision of soft-tissue surgery, with or without a bony procedure, and transfer of the tendon of tibialis anterior at a mean age of 4.8 years (2.0 to 10.1). The tendon was transferred to the third cuneiform in five cases, to the base of the third metatarsal in ten and to the base of the fourth in 23. The patients were reviewed at a mean follow-up of 24.8 years (10.8 to 35.6). A total of 11 feet were regarded as failures (one a tendon failure, five with a subtalar fusion due to over-correction, and five with a triple arthrodesis due to under-correction or relapse). In the remaining feet the clinical outcome was excellent or good in 20 and fair or poor in seven. The mean Laaveg-Ponseti score was 81.6 of 100 points (52 to 92). Stiffness was mild in four feet and moderate or severe in 23. Comparison between the post-operative and follow-up radiographs showed statistically significant variations of the talo-first metatarsal angle towards abduction. Variations of the talocalcaneal angles and of the overlap ratio were not significant. Extensive surgery for relapsed clubfoot has a high rate of poor long-term results. The addition of transfer of the tendon of tibialis anterior can restore balance and may provide some improvement of forefoot adduction. However, it has a considerable complication rate, including failure of transfer, over-correction, and weakening of dorsiflexion. The procedure should be reserved for those limited cases in which muscle imbalance is a causative or contributing factor.

Is Tibialis Anterior Tendon Transfer Effective for Recurrent Clubfoot?

“…Previous studies have noted improvements in passive ROM after tibialis anterior tendon transfer; however, many patients in these trials had undergone additional major surgical procedures, including joint releases and osteotomies [12,13]. It is unknown whether the preexisting loss in ROM in the tibialis anterior tendon transfer group is a result of the muscular imbalance or if it represents a more severe form of congenital talipes equinovarus.…”

“…Although long-term retrospective data have shown good outcomes after tibialis anterior tendon transfer surgery, the majority of trials include patients who have undergone various treatments, including serial plaster casting, and soft tissue and bony surgical procedures [6,10,13,23]. Furthermore, it is unknown whether improvements after tibialis anterior tendon transfer surgery result in outcomes comparable to those of children with congenital talipes equinovarus who do not require this surgery.…”

Correction of Residual Metatarsus Adductus Deformity Following Ponseti Management of Idiopathic Clubfoot in Toddlers by Tibialis Anterior Tendon Transfer

“…This decrease may be due to the abduction-eversion force caused by the tendon transfer that is able to shift the cuneiform and the whole forefoot more laterally. Also; the values of previous angles correlated with the clinical appearance of foot as the more negative angles the better the clinical results [13,14].…”

How Do Different Anterior Tibial Tendon Transfer Techniques Influence Forefoot and Hindfoot Motion?

“…Adequate deformity correction usually cannot be achieved in older patients with residual osseous deformity by cast treatment alone, and these patients require corrective osteotomy so that the transfer may function properly. Several different techniques of anterior tibial tendon transfer have been described [5,7,8,10,11,16,17,22], but little is known about the effect of those transfers on forefoot position and hindfoot motion. We used a cadaveric foot model to test the effect of three different anterior tibial tendon transfer techniques on forefoot positioning and hindfoot motion.…”

“…He originally anchored the tendon to the base of the fifth metatarsal, but later he and Palmer [8] modified the procedure by attaching the tendon in the cuboid if it was not of sufficient length. More recently, other authors have recommended that the tendon be placed in the third cuneiform to avoid overcorrection of the foot [5,16,17].…”