Tibialis Anterior Tendon Transfer for Relapsing Idiopathic Clubfoot
IntroductionA relapsed idiopathic clubfoot can be effectively treated with transfer of the entire tibialis anterior tendon to the mid-dorsum of the foot following repeated manipulations and serial casts.
Step 1: Preoperative PlanningEnsure that the foot has been adequately corrected for tendon transfer by performing both clinical and radiographic evaluation.
Step 2: Prepare the PatientPosition the patient supine, induce general anesthesia, and perform a caudal block for postoperative pain management.
Step 3: Identify and Release the Tibialis Anterior Tendon from Its InsertionIdentify the tibialis anterior tendon and release its insertion on the medial cuneiform and first metatarsal bones.
Step 4: Prepare the Tendon and Surrounding Tissues for TransferRelease obstructing tissues and prepare the freed tendon for lateral transfer to the mid-dorsum of the foot.
Step 5: Prepare the Lateral Cuneiform for Tendon Transfer and FixationIdentify the lateral cuneiform with fluoroscopy and prepare it for transfer of the tibialis anterior tendon.
Step 6: Transfer and Secure the TendonMake a subcutaneous path, transfer the tendon, and secure it in the osseous tunnel of the lateral cuneiform.
Step 7: Postoperative CareWe apply a long leg cast and restrict patients to non-weight-bearing for six weeks.
ResultsThe tibialis anterior tendon transfer has been used to treat relapsing idiopathic clubfoot with great success for more than fifty years.
Tibialis anterior tendon transfer
First Skin Incision
Make a second incision
- make a second 1 cm incision at the anterior distal tibia directly over the anterior tibial tendon just lateral to the crest
- the location of the tendon can be easily identified by pulling on the distal tendon while palpating over tibia
- incise the tendon sheath to expose the tendon
Transfer the tendon
- use a hemostat or Ober tendon passer to pull the tendon until the tendon’s distal end is pulled into the proximal incision (take care to stay under the retinaculum and in the tendon sheath while retrieving and transporting the tendon)
- protect the tendon with a wet sponge wrap
Make a third incision
- this incision should be 1 cm long at the dorsum of the foot directly over the lateral cuneiform, found at the base of the third metatarsal
- alternatively this incision is overlying the peroneus tertius which is found just lateral to the lesser toe extensor tendons
Expose the cuboid
- retract the extensor tendons of the toes to expose the lateral cuneiform
- incise periosteum at the center of the lateral cuneiform
- can use c-arm to confirm the location of the cuboid
OR Exposure of Peroneus Tertius
- open sheath overlying peroneus tertius tendon
- The peroneus tertius is immediately lateral to the toe extensors
- confirm it is the tertius tendon. The foot should evert and dorsiflex when the tendon is pulled and the toes do not extend
- 10% of people do not have a peroneus tertius
Create a subcutaneous tunnel
- use a large curved hemostat or dissecting scissors to make a subcutaneous tunnel from the distal wound to the lower leg wound
- use the hemostat or a tendon passer to grasp the sutures in the tendon stump
Transfer the tendon to the third incision
- using the hemostat or tendon passer, pull the tendon distally and laterally into the third incision
Tendon Passage and Fixation
Fixation through the cuboid
- drill a hole in the cuboid
- use a drill bit that is slightly larger than the transferred tendon to make a drill hole through the lateral cuneiform in a dorsal to plantar direction
- keep a finger on the plantar area to prevent penetration of the drill bit through the skin
- prepare the tendons for passage through the drill holes
- attach the two ends of the suture in the anterior tibial tendon to separate long straight Keith needles
- push the Keith needles through the drill holes from the dorsal to plantar surface
- the exits of the 2 Keith needles should be 3 to 5 mm apart
- attach the sterile button
- with the needles attached to the two sutures, pierce through a small square of felt pad and a sterile button
- pass the tendons
- gently pull the tendon into the drill hole in the lateral cuneiform
Transfer to the peroneus tertius
- pull distally on the split anterior tibial tendon transfer
- place a right angle clamp under the split tendon transfer and the peroneus tertius
- complete the side-to-side transfer with a 2-0 non-absorbable suture
Tie the sutures
- hold the foot in neutral or mild dorsiflexion and eversion as the sutures are tied on top of the button which overlies a thick piece of felt to protect the skin
- alternatively the foot is held in neutral or mild dorsiflexion and eversion as the sutures are ties in a figure-8 fashion side by side to the peroneus tertius tendon
- 2-0 or 3-0 absorbable suture for subcutaneous tissue
- 3-0 running monofilament for skin
Dressings and immobilization
- place in a non weight bearing short leg cast if there is a button on the foot as they can develop a pressure sore with weight bearing
- place in a weight bearing short leg cast if the split anterior tibialis tendon was transferred to the peroneus tertius tendon