Lateral Intra-Articular Transposition of the Anterior Tibialis Tendon for the Treatment of Relapsed Clubfoot in Toddlers: A Previously Unreported Surgical Technique

Dayton Opel,Kenneth Noonan,Matthew Halanski,Samuel Abrams

doi:10.4236/ojo.2014.43010

Abstract

Dynamic supination of the foot is a common residual deformity in children with clubfeet treated with the Ponseti method. Transfer of the anterior tibialis tendon (ATT) to the lateral cuneiform is an effective method for correcting this deformity when the cuneiform is ossified in children who are 3 to 5 years of age. We describe two cases of a previously unreported method of ATT transposition for correction of bilateral residual dynamic supination in a 26-month-old and a 19-month-old patient. Both patients presented shortly after birth with bilateral congenital idiopathic clubfoot and were initially treated with the Ponseti method. Both had residual deformity following initial treatment that included posterior contracture and metatarsus adductus with dynamic forefoot supination. This was surgically corrected with a posterior release and medial release of the 1st metatarsal/1st cuneiform joint. To correct dynamic supination, the ATT was transplanted laterally into the released midfoot joint. These two patients were followed post-operatively for 7.5 years and have correction of their residual deformity in both feet based on subjective functioning, appearance, range of motion, strength, and gait. Both have excellent lateral pull of their ATT, which functions as a strong foot dorsiflexor. No residual supination is present. This is the first report of lateral transposition of the ATT as an interposition graft at the released 1st metatarsal/1st cuneiform joint in patients with relapsed clubfoot. We suggest that this method should provide a high level of functioning in children with relapsed supination deformity and whose 3rd cuneiform has not yet ossified.

Highlights

The Ponseti technique of clubfoot correction is an internationally utilized method to correct congenital clubfoot
The rate of reoperation for recurrent or residual deformity may approach 35 percent of patients treated with the Ponseti method [1]-[5]
It has been hypothesized by Ponseti that residual medial displacement of the navicular on the head of the talus will essentially translate the anterior tibialis tendon (ATT) insertion medially and transform the function of the ATT from foot dorsiflexor to foot supinator [3]

Summary

Introduction

The Ponseti technique of clubfoot correction is an internationally utilized method to correct congenital clubfoot. Occasionally a child who is less than 3 years may have a combination of deformity that is recalcitrant to repeat casting and becomes indicated for surgical “à la carte” approach of the residual deformity In these operations on young patients with severe equinus, we have treated the functional medial displacement of the ATT with lateral translation of the ATT tendon into a midfoot capsulotomy, which serves to correct metatarsus adductus. DW was a 6-day-old boy who presented for evaluation of bilaterally stiff idiopathic clubfoot He underwent Ponseti casting, and was noted to have good correction with bilateral percutaneous tendoachilles lengthening at age of 5 weeks; 3 weeks later his casts were removed and he was fitted with a foot abduction orthosis. X-rays at 7.5 years post-op show stable alignment of the hindfoot and midfoot with continued pes cavus of the left foot, and no sign of radiographic abnormality where the AT was transposed (Figure 7)

Discussion

Findings

Opel et al Congenital Clubfoot