SLR - August 2015 - Stephanie Fields

Long-Term Results of Tibialis Anterior Tendon Transfer for Relapsed Idiopathic Clubfoot Treated With Ponseti Method

Reference: Holt JB, Oji DE, Yack HJ, Morcuende JA. Long-term Results of Tibialis Anterior Tendon Transfer for Relapsed Idiopathic Clubfoot Treated with Ponseti Method. JBJS. 2015 Jan 23;370(4):352-60.

Scientific Literature Review

Reviewed By: Stephanie Fields, DPM
Residency Program: Wyckoff Heights Medical Center

Podiatric Relevance: Clubfoot is a deformity that requires early intervention. Most cases can be treated conservatively, however, in refractory cases where bracing was done for an inadequate amount of time or bracing cannot be tolerated, surgical management can be implemented. Tibialis anterior tendon transfer to the lateral aspect of the foot can be used to augment and maintain position obtained by failed casting methods. It is important for the foot and ankle surgeon to recognize refractory cases and provide proper surgical management where indicated. This article is a level IV study assessing the long-standing clinical outcomes of a tibialis anterior tendon transfer for a relapsed clubfoot treated with Ponseti method.

Methods: Thirty-five patients with refractory clubfoot who were initially treated with Ponseti method from 1950 to 1967 were followed. The mean age of the patient group was 47 years old. The patients underwent a detailed musculoskeletal examination, radiographic evaluation, force analysis, and EMG studies. The tibialis anterior tendon was transferred based on severity of relapse, biomechanical deformities, and brace compliance issues predominately seen in older patients.  Of the 35 patients, 14 had a tibialis anterior tendon transfer and the remaining 21 patients were used as a control group. The tibialis anterior tendon was transferred to the third cuneiform most frequently but also transferred to the 2nd cuneiform and cuboid. Patients were also asked to complete questionnaires to evaluate pain, foot function, and overall quality of life.

Results:  All patients who had tibialis anterior tendon transfers did not have clinical relapses after tendon transfer was performed. No relapses were noted in the control group as well. Upon x-ray evaluation, the tendon transfer group showed a smaller AP talocalcaneal angle and slightly increased talar flattening compared to the reference group. Mean ankle dorsiflexion, peak pressures, total force distribution, and surface EMG results were not significantly different between groups. The questionnaires showed no significant difference in terms of patient's pain level or limitation in activity level.

Conclusions: Tibialis anterior tendon transfer with Ponseti method is effective at preventing relapse of deformity in refractory cases or cases treated at a later age with similar results to non-refractory cases. Other studies have showed that tendon transfers provide good results in a shorter follow-up period, whereas this study demonstrates tibialis anterior tendon transfer is effective over a longer follow-up time period.

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