SLR - August 2014 - Adisa Mujkic

Plantar Pressures Following Anterior Tibialis Tendon Transfers in Children with Clubfoot

Reference: Jeans KA, Tulchin-Francis K, Crawford L, Karol LA. Plantar Pressures Following Anterior Tibialis Tendon Transfers in Children With Clubfoot. Journal of Pediatric Orthopaedics 34.5 (2014): 552-58.

Scientific Literature Review

Reviewed By: Adisa Mujkic, DPM
Residency Program: Montefiore Medical Center

Podiatric Relevance: The management of a relapsing or residual idiopathic clubfoot following serial casting with either the Ponseti or French Physiotherapy method remains a challenging clinical entity. A multitude of bony and soft tissue balancing procedures exist, each with the goal of obtaining a plantigrade and functional foot. This study evaluates the impact of a tibialis anterior tendon transfer (ATTT) on functionality via gait analysis and pedobarography. ATTT outcome data will help further define the role of this procedure when faced with this deformity.

Methods: Children with recurrent idiopathic clubfoot deformity underwent ATTT between April 2003 and March 2010. Utilizing pedobarograph testing plantar pressure data was obtained preoperatively and postoperatively at one and two years. Variables analyzed included peak pressure, contact area, contact time, forefoot adductus angle, displacement of the pressure line center in relation to line of progression and region of initial contact. Children with non-idiopathic clubfoot or who had concomitant posteromedial release or bony surgery were excluded from the study. The patient cohort was further divided into isolated ATTT versus those with concomitant procedures and full ATTT versus split ATTT.  The outcomes of the cohort were compared to age-matched controls. 

Results: Thirty children (37 clubfeet) with ages ranging from 2.2 years to 7.6 years were included in the analysis with a mean follow-up of two years. Of the 37 clubfeet, 28 underwent full ATTT and nine underwent split ATTT. Twenty-one feet underwent an isolated ATTT. There were no differences between isolated ATTT and those with concomitant surgery, thus they were grouped into one single cohort. Peak pressure, contact area and contact time showed significant increase in the medial hindfoot, midfoot and rearfoot, signifying a shift from lateral peak pressures associated with dynamic supination in clubfoot deformity. The hindfoot to forefoot angle was significantly decreased from 32.9 +/-9.7 degrees to 23.2 +/- 12.6 degrees postoperatively. Postoperatively 76 percent had a heel strike at initial contact. When compared to the control, persistence of increased pressures in the lateral midfoot and forefoot and a greater hindfoot to forefoot angle remained. Comparison of a full to a split ATTT showed no differences in peak pressures, however, contact area was decreased in the first metatarsal area with full ATTT.  

Conclusions: This study presented a novel analysis depicting the utility of ATTT for treatment of recurrent clubfoot deformity using pedobarograph analysis.  In this prospective study, ATTT, as an isolated or adjunctive procedure did achieve an improved distribution of peak pressures and contact time. However, when compared to the normal foot a degree of residual forefoot adductus did persist. 

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