Tibialis Anterior Tendon Transfer Research Articles

Tendon Transfers for the Balancing of Hind and Mid-foot Deformities in Adults and Children

Tendon transfer surgery (soft-tissue balancing) is one of the most important steps for the correction of complex foot deformities in adults and children. Often, tendon transfers are accompanied by additional bony procedures for the correction of the structural component of the foot deformity. Detailed preoperative planning (patient history, clinical examination, radiographs, dynamic pedobarography, and 3D gait and foot analysis) is considered to be necessary for the indication of the technique. The surgical technique of different tendon transfers (total split posterior tibial tendon transfer, split posterior tibial tendon transfer, spilt anterior tibial tendon transfer, posterior tibial tendon transfer, Hiroshima procedure) as a part of complex foot deformity correction is presented. Furthermore, pitfalls and complications as well as salvage strategies are discussed. The key for successful soft-tissue balancing is the consideration of the underlying pathology. The main focus is on the selection of the appropriate tendon transfers in different pathologies (eg, Charcot-Marie-Tooth disease, cerebral palsy, stroke, etc.). Bony procedures may only correct structural deformity but do not address the dynamic component of the deformity (muscular imbalance, instability, etc.). This may lead to inadequate correction and recurrence. It is therefore essential to combine bony correction with tendon transfers (soft-tissue balancing) in nearly every neurogenic foot deformity.

Tendon Transfer Fixation in the Foot and Ankle: A Biomechanical Study

Tendon transfers are often used in foot and ankle surgery. Different fixation devices and techniques have been described. The most recently developed ones are bone anchors and interference screws. A biomechanical study was designed to compare tendon transfer fixation, using Corkscrew bone anchors 5 x 15.5 mm and Bio-interference screws (8 x 23 mm). Fifteen fresh cadaver specimens underwent both fixation techniques for split anterior tibial tendon transfer at the cuboid bone. All the specimens underwent standardized X-rays in order to evaluate mineral bone density using a standardized measurement system. All were tested until maximal load to failure. The ultimate load to failure of the tendon secured to the cuboid using anchors was 103 N (SD, 52), compared with 150 N (SD, 68) for tendons secured to the bone with interference screws (p = 0.003). No difference was found between the techniques that could be related to bone density. Interference screws provided greater strength than bone anchors. This study demonstrated increased strength in securing bone to tendon in vitro for SPLATT tendon transfer with interference screws as compared to suture anchors.

Selective soft-tissue release for recurrent or residual deformity after conservative treatment of idiopathic clubfoot

We reviewed the results of a selective à la carte soft-tissue release operation for recurrent or residual deformity after initial conservative treatment for idiopathic clubfoot by the Ponseti method. Recurrent or residual deformity occurred in 13 (19 feet) of 33 patients (48 feet; 40%). The mean age at surgery was 2.3 years (1.3 to 4) and the mean follow-up was 3.6 years (2 to 5.3). The mean Pirani score had improved from 2.8 to 1.1 points, and the clinical and radiological results were satisfactory in all patients. However, six of the 13 patients (9 of 19 feet) had required further surgery in the form of tibial derotation osteotomy, split anterior tibialis tendon transfer, split posterior tibialis transfer or a combination of these for recurrent deformity. We concluded that selective soft-tissue release can provide satisfactory early results after failure of initial treatment of clubfoot by the Ponseti method, but long-term follow-up to skeletal maturity will be necessary.

Orthopaedic issues in the musculoskeletal care of adults with cerebral palsy

Orthopaedic care of adults with cerebral palsy (CP) has not been well documented in orthopaedic literature. This paper focuses on some of the common problems which present themselves when adults with CP seek orthopaedic intervention. In particular, we review the most common orthopaedic issues which present to the Penn Neuro-Orthopaedics Program. A formal review of consecutive surgeries performed by the senior author on adults with CP was previously conducted. This paper focuses on the health delivery care for the adult with orthopaedic problems related to cerebral palsy. Ninety-two percent of these patients required lower extremity surgery. Forty percent had procedures performed on the upper extremities. The majority of problems seen in the Penn Neuro-Orthopaedics Program are associated with the residuals of childhood issues, particularly deformities associated with contractures. Patients are also referred for treatment of acquired musculoskeletal problems such as degenerative arthritis of the hip or knee. A combination of problems contribute most frequently to foot deformities and pain with weight-bearing, shoewear or both, most often due to equinovarus. The surgical correction of this is most often facilitated through a split anterior tibial tendon transfer. Posterior tibial transfers are rarely indicated. Residual equinus deformities contribute to a pes planus deformity. The split anterior tibial tendon transfer is usually combined with gastrocnemius-soleus recession and plantar release. Transfer of the flexor digitorum longus to the os calcis is done to augment the plantar flexor power. Rigid pes planus deformity is treated with a triple arthrodesis. Resolution of deformity allows for a good base for standing, improved ability to tolerate shoewear, and/or braces. Other recurrent or unresolved issues involve hip and knee contractures. Issues of lever arm dysfunction create problems with mechanical inefficiency. Upper extremity intervention is principally to correct contractures. Internal rotation and adductor tightness at the shoulder makes for difficult underarm hygiene and predispose a patient to a spiral fracture of the humerus. A tight flexor, pronation pattern is frequently noted through the elbow and forearm with further flexion contractures through the wrist and fingers. Lengthenings are more frequently performed than tendon transfers in the upper extremity. Arthrodesis of the wrist or on rare occasions of the metacarpal-phalangeal joints supplement the lengthenings when needed. The Penn Neuro-Orthopaedics Program has successfully treated adults with both residual and acquired musculoskeletal deformities. These deformities become more critical when combined with degenerative changes, a relative increase in body mass, fatigue, and weakness associated with the aging process.

The use of bioabsorbable screw in a split anterior tibial tendon transfer: a preliminary result

The split anterior tibial tendon transfer is a procedure commonly used to correct equinovarus deformity of the foot, primarily in children with spastic cerebral palsy. The procedure has been reported to yield satisfactory results; it can be combined with other soft tissue lengthening. Typically, the transferred tendon can be fixed by either button, staple, metal screw, or anchored into two bony tunnels. Occasionally, failure to maintain transferred tendon fixation may result from conventional surgical methods and therefore lead to undesirable results. The technique of using bioabsorbable interference screw has been proved to be effective in securing the graft as anterior cruciate ligament reconstruction in knee joint. To our knowledge, only few literatures have reported on the use of bioabsorbable screw in the treatment of tendon transfers around the foot. From 2004 to 2006, split anterior tibial tendon transfers with concomitant tendo-Achilles lengthening were applied to 13 patients (16 feet) who had a dynamic equinovarus deformity secondary to spastic cerebral palsy. Mean age at surgery was 8 years and the average follow-up period was 16 months (range, 12-28 months). A 7 x 23 mm cannulated bioabsorbable interference screw was used to fix the transferred tendon. Postoperatively, we used the rating system of Kling et al. to assess the clinical results. Our findings showed that there were 10 excellent, six good, and no poor results. All patients had improved gait at their latest follow-ups. At final follow-up, there was no graft failures or postoperative complications related to the bioabsorbable screw in our series. Although the study is based on a small number of cases, we suggest this technique is an additional armamentarium in fixation for tendon transfers in children's feet.

Tibialis anterior tendon transfer after clubfoot surgery.

Recurrent dynamic and structural deformities following clubfoot surgery are commonly due to residual muscle imbalance from a strong tibialis anterior muscle and weak antagonists. We asked whether subcutaneous tibialis anterior tendon transfer effectively treated recurrent deformities following clubfoot surgery and whether the presence of structural deformities influenced the outcome. The patients were divided into two groups: Group I, dynamic supination deformity only (51 patients, 76 feet); and Group II, dynamic supination with other structural deformities (44 patients, 61 feet). The mean age at surgery was 4.3 years (range, 1.4-10.7 years); the minimum followup was 2 years (mean, 5.2 years; range, 2-12.5 years) for both groups. The results were graded according to our subjective rating system of restoration of muscle balance: good, restoration of muscle balance; fair, partial restoration of muscle balance; and poor, no improvement. The two groups had similar outcomes: in Group I, there were 65 good (87%), 11 fair (13%), and no poor results and in Group II, there were 54 good (88%), seven fair (12%), and no poor results. Our data suggest the tibialis anterior tendon transfer restores muscle balance in recurrent clubfeet; we observed no recurrences. This transfer improves function and may prevent secondary osseous changes. We believe the muscle imbalance supports, at least in part, the neuromuscular etiological aspects of congenital clubfeet. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluation of a Disease-specific Instrument for Idiopathic Clubfoot Outcome

In 2001, Roye et al. developed a disease-specific instrument (DSI) to measure outcomes of treatment for clubfoot. We assessed this instrument using a cohort of 62 patients, ages 5 through 12 years (mean, 8.6 years), with idiopathic clubfoot who were treated as infants by various methods. Treatment groups were defined by whether the patient received joint-invasive surgery (posterior or posteromedial release surgery) or joint-sparing treatment only (manipulation and casting with or without tendo-Achilles lengthening or anterior tibial tendon transfer). The DSI scales demonstrated internal consistency reliability of 0.74 to 0.85 using Cronbach's alpha. Higher (better) DSI scores were associated with "excellent" general health ratings and better health-related quality of life; lower DSI score were related to special healthcare needs. Patients treated using joint-sparing techniques only (eg, Ponseti technique) had higher DSI scores than those who had received joint-invasive surgery. DSI scores for patients who had received posterior or posterior medial release surgery were very similar to those reported by Roye et al. in New York for a comparable group of patients. Our findings suggest the DSI is sensitive to differences in treatment technique or underlying severity of disease. These data support the use of the Roye DSI as an outcome measure for idiopathic clubfoot in children. Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ponseti Treatment for Idiopathic Clubfoot: Minimum 5-year Followup

Ponseti clubfoot treatment has become more popular during the last decade. We reviewed the medical records of 74 consecutive infants (117 club feet) who underwent Ponseti treatment. Minimum followup was 5 years (mean, 6.3 years; range, 5-9 years). We studied age at presentation, previous treatment, the initial severity score of the Pirani scoring system, number of casts, need for Achilles tenotomy or other surgical procedures, and brace use. We measured final ankle motion and parents' perception of outcome. Late presentation and previous non-Ponseti treatment were associated with lower initial severity score, fewer casts, and less need for tenotomy. Forty-four percent of patients had poor brace use. We observed better brace use (75%) in babies who presented late for treatment. Good brace use predicted less need for extensive surgical procedures. Twenty-four (32%) babies underwent additional surgical procedures other than tenotomy, including 21% who underwent tibialis anterior tendon transfer. At followup, 89% of feet had adequate dorsiflexion (5 degrees or greater). Parents indicated high satisfaction with the treatment results. Ankle motion was not associated with parents' satisfaction. The Ponseti method is effective, even if treatment starts late or begins after failure at other centers. Brace use influenced the success of treatment. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Treatment of the Resistant Idiopathic Clubfoot with Toe-in Gait

Purpose: We evaluated the degree of femoral and tibial torsion in, and the efficacy of two operative procedures for, resistant idiopathic clubfoot with toe-in gait. Materials and Methods: Thirty one feet in 23 patients (average age at the time of revision surgery 4.3 years) were studied. CT was used to determine femoral anteversion and tibial torsion. Two different operative procedures were applied, depending on the degree of toe-in gait: group 1 (10 feet whose toe-in gait was not severe) - soft tissue release, anterior tibial tendon transfer and mid-foot (cuboid closing and cuneiform opening) osteotomy; group 2 (21 feet which had relatively severe toe-in gait) - supramalleolar external rotation osteotomy of the distal tibia (SEROT), along with the same procedure as group 1. Mean follow-up period after revision surgery was 6.3 years. Results were assessed radiologically and clinically with the Dimeglio classification and Clubfoot Assessment Protocol. Results: The mean femoral anteversion and external-tibial torsion of the affected side were increased. Twenty eight of 31 feet (90.3%) demonstrated excellent or good results. In group 2, we obtained 19 excellent (90.5%) and 2 good (9.5%) results. Group 1 had 6 excellent (60%), one good (10%) and 3 fair (30%) results. Conclusion: Surgical treatment of the relapsed clubfoot with toe-in gait including soft-tissue release, tendon transfer and mid-foot osteotomy, along with SEROT in cases of severe toe-in gait, is effective in correcting residual clubfoot deformities.

Correcting Residual Deformity Following Clubfoot Releases

There are many possible pitfalls of clubfoot releases and it is important to recognize the problems and provide proper timely treatment. Late residual deformity following clubfoot releases include: dynamic or stiff supination and forefoot adduction deformities, intoeing gait, overcorrection, rotatory dorsal subluxation of the navicular, vascular insult to the talus with collapse, and dorsal bunion. We reviewed 134 clubfeet in 95 children who had primary clubfoot releases between 1988 and 1991. In general, the patients who underwent surgery before 6 months of age had poorer results compared with older children. Twenty-one feet (15.7%) underwent additional procedures. The most common additional procedure was split anterior tibial tendon transfer. Not all patients with residual deformities underwent additional procedures. In treating recurrent and residual deformity following a clubfoot surgery, it is most important to keep function in mind. From this series of patients treated with comprehensive clubfoot release, we have identified the most common residual deformities encountered after the initial release and effective surgical treatment when necessary. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Surgical Treatment of Calcaneal Deformity in a Select Group of Patients with Myelomeningocele

The surgical treatment of calcaneal deformity in patients with myelomeningocele has not been uniformly successful in correcting the deformity and preventing recurrence. The purpose of the present study was to examine the results of posterior transfer of the anterior tibial tendon with concurrent procedures in an attempt to balance the muscular forces on the foot and ankle and to obtain a plantigrade foot. We investigated whether surgery improved pressure distribution over the plantar surface of the foot and whether concurrent abnormal movements observed at the knee, hip, and pelvis influenced the surgical outcome. Thirty-one feet in eighteen patients who were able to walk were included in the study. The mean age at the time of surgery was seven years and four months, and the mean duration of follow-up was forty-seven months. Eight patients were classified as having an L5-level myelomeningocele, and ten patients were classified as having a sacral level myelomeningocele. A tibialis anterior tendon transfer was performed in all patients, and accompanying osseous deformities were also corrected in twelve feet. Measurements on plain radiographs, the results of gait analyses, and dynamic foot pressures that were determined before surgery and at the time of the final follow-up were compared. No recurrence or worsening of the deformity was observed in any of the patients, and no other types of foot deformity developed after surgery. Postoperative kinematic studies showed a significant (p < 0.0001) increase in peak plantar flexion and a significant decrease in peak dorsiflexion force of the ankle in the stance phase of gait. Peak pressures under the forefoot and midfoot were increased after surgery, and the relative amount of weight-bearing on the heel as compared with the forefoot was shifted toward more equal weight-bearing. However, less improvement in foot-pressure distribution was observed in patients with increased pelvic rotation before surgery. Those patients also had decreased knee extension in stance phase and increased hip abduction and pelvic obliquity both before and after surgery in comparison with patients who had normal pelvic rotation. Appropriately combined corrective surgical procedures for the treatment of calcaneal deformity in patients with myelomeningocele can effectively reduce the pressure placed on the calcaneus, increase pressures in the forefoot and midfoot, and prevent recurrence of the calcaneal deformity. However, in the presence of excessive pelvic movement in the coronal and transverse planes and decreased knee extension in stance phase, adequate improvement in pressure distribution over the plantar surface of the foot is not likely to occur after this type of foot surgery. Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Lateral and Medial Plantar Pressures after Split versus Whole Anterior Tibialis Tendon Transfer

If whole and split transfer of the anterior tibialis tendon (SPLATT) do not differ in balancing the forefoot, whole tendon transfer would provide a simpler alternative as part of treatment of an equinovarus deformity. We hypothesized that no significant differences in percent plantar lateral forefoot pressures would be observed between split and whole tendon transfer. We used a spastic model to test the hypothesis that overcorrection would not occur with whole tendon transfer. In ten specimens from five lower extremity matched pairs, a SPLATT was anchored to the cuboid. After loading, simulated whole tendon transfer to the lateral cuneiform was done. Normal loading was Achilles, 250 N, tibialis anterior, 200 N, peroneals/tibialis posterior, 142 N; and spastic loading was Achilles, 500 N, tibialis anterior, 400 N, peroneals/tibialis posterior, 142 N. Pressure data were collected for both normal and spastic conditions. Percent of forefoot pressure was calculated for the lateral and medial sector. Percent lateral pressure was slightly lower after whole tendon transfer (normal, p < 0.01; spastic, p < 0.01). This difference was not clinically important. Medial pressure did not differ in the spastic versus the normal model after split or whole tendon transfer. Whole and split anterior tibialis tendon transfer both resulted in a balanced forefoot. Neither whole tendon nor split tendon transfer resulted in overcorrection in a simulated spastic model. Whole tendon transfer may be an effective and simpler alternative to SPLATT for unloading the lateral forefoot in both a normal and a spastic foot.

Fixation Techniques for Split Anterior Tibialis Transfer in Spastic Equinovarus Feet

Equinovarus of the foot is the most common lower extremity deformity following traumatic brain injury. We evaluated outcomes of the split anterior tibialis tendon transfer (SPLATT) for correction of equinovarus in 47 patients with hemiplegic traumatic brain injury and specifically studied differences in outcomes with two tendon fixation techniques. Seventeen patients constituting Group I underwent fixation with one technique and 30 constituting Group II had another technique. Patients in both groups had appropriate procedures based on dynamic electromyography and gait analyses. Both groups were demographically comparable. All 47 feet were corrected to plantigrade position. Thirty-six of 47 patients became brace-free at final followup. There was a notable decrease in the use of ambulatory aids and ambulatory status improved in both groups. There were three fixation-related complications in Group I and none in Group II. Surgical correction of the spastic equinovarus with SPLATT, in the appropriate patient, with or without associated tendon procedures helps to achieve and maintain correction, improves the ambulatory status of the patient, and eliminates the need for bracing in as much as 77% of patients. We recommend the Group II construct owing to the considerably lower complication rate.

Use of the Ponseti method for recurrent clubfoot following posteromedial release.

Background:A child with recurrent or incompletely corrected clubfoot after previous extensive soft tissue release is treated frequently with revision surgery. This leads to further scarring, pain and limitations in range of motion. We have utilized the Ponseti method of manipulation and casting and when indicated, tibialis anterior tendon transfer, instead of revision surgery for these cases.Materials and Methods:A retrospective review of all children treated since 2002 (n = 11) at our institution for recurrent or incompletely corrected clubfoot after previous extensive soft tissue release was done. Clinical and operative records were reviewed to determine procedure performed. Ponseti manipulation and casting were done until the clubfoot deformity was passively corrected. Based on the residual equinus and dynamic deformity, heel cord lengthening or tenotomy and tibialis anterior transfer were then done. Clinical outcomes regarding pain, function and activity were reviewed.Results:Eleven children (17 feet) with ages ranging from 1.1 to 8.4 years were treated with this protocol. All were correctable with the Ponseti method with one to eight casts. Casts were applied until the only deformities remaining were either or both hindfoot equinus and dynamic supination. Nine feet required a heel cord procedure for equinus and 15 required tibialis anterior transfer for dynamic supination. Seven children have follow-up greater than one year (average 27.1 months) and have had excellent results. Two patients had persistent hindfoot valgus which required hemiepiphyseodesis of the distal medial tibia.Conclusion:The Ponseti method, followed by tibialis anterior transfer and/or heel cord procedure when indicated, can be successfully used to correct recurrent clubfoot deformity in children treated with previous extensive soft tissue release. Early follow-up has shown correction without revision surgery. This treatment protocol prevents complications of stiffness, pain and difficulty in ambulating associated with multiple soft tissue releases for clubfeet.

Balancing of the Transmetatarsal Amputation with Peroneus Brevis to Peroneus Longus Tendon Transfer

The transmetatarsal amputation (TMA) is a commonly used procedure in salvage of the diabetic foot. The goal of the procedure is to provide a plantigrade foot that can fit into a shoe with appropriate insole and allow the patient to continue ambulating with a low risk of ulceration. This goal can be achieved with appropriate tendon balancing to avoid development of or address existing equinovarus deformity, a commonly reported complication of the TMA (1–4). To prevent this deformity, several authors have recommended a combination of Achilles’ tendon lengthening or gastrocnemius recession along with tibialis anterior tendon transfer (2–6).

Treatment of idiopathic clubfoot using the Ponseti method: minimum 2-year follow-up

One hundred and thirty-seven idiopathic clubfeet were treated by the Ponseti technique and followed for at least 2 years. Nine feet (7%) were not corrected with initial casting and required early surgery. Recurrence after correction was related to compliance with bracing. At latest follow-up, two-thirds of those noncompliant with brace had recurrences with one-third of these recurrences requiring more extensive surgery than Achilles tenotomy and anterior tibial tendon transfer while only 14% of those compliant with brace had recurrences with none requiring more than Achilles tenotomy and anterior tibial tendon transfer. Early failures and recurrences constituted about 20% of our 137 feet by 2 years of follow-up. When the Ponseti method was fully followed, including initial casting, compliance with brace and treatment of recurrences by recasting, Achilles tenotomy and/or anterior tibial tendon transfer, our success rate was 93%.

Tibialis Anterior Tendon Transfer for Calcaneus Deformity in Children with Myelomeningocele: A Preliminary Report

Purpose : To examine the results of tibialis anterior tendon transfer for the treatment of a calcaneus deformity in children with a myelomeningocele. Materials and Methods : Twenty-seven feet in sixteen children were examined in this study. The mean age at the time of surgery was 7+2 years (range, 4+11-14+9) and the mean follow up duration was 25 months (range, 15-50). Three-dimensional gait analysis and dynamic foot-pressure measurement were performed to analyze the results of the index operation. Results : There was no recurrence or aggravation of the deformity. The sagittal kinematics of the ankle improved, and the relative impulse of the calcaneus decreased postoperatively. Those patients with an increased range of motion of the pelvic rotation during gait showed less improvement in the relative impulse of the calcaneus than those with a good range of pelvic rotation. They also had a lower range of knee sagittal motion and an increased range of abduction of the hip, and up-obliquity of the pelvis. Conclusion : A good range of motion of the hip and pelvis in coronal and transverse planes, and of the knee in the sagittal plane are important predictors of the functional transfer of tibialis anterior tendon in patients with a calcaneal gait in a myelomeningocele.

Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complex deformities

The aim of this study is to evaluate the effectiveness of the Ponseti method in children presenting before 1 year of age with either untreated or complex (initially treated unsuccessfully by other conservative methods) idiopathic clubfeet. The authors report 134 feet of 92 patients with Dimeglio grade 2, 3, or 4 deformities treated with the Ponseti method. Twenty-four percent of feet were of complex deformities at initial presentation to the authors' clinics. At a mean follow-up of 46 months (range 24-89) we avoided joint release surgery in 97% of feet. Sixty-seven percent required a percutaneous tenotomy of the Achilles tendon. Relapse rate was 31% (41 feet). We treated 2 relapses by restarting the use of orthosis, 17 with re-casting, 18 with anterior tibial tendon transfer following a second relapse, and 4 feet with extensive joint surgery. Compliance with the use of orthosis was identified as the most important risk factor (P<0.0001) for relapses. Previous unsuccessful treatment attempts by other conservative methods did not adversely affect the results unless the cases had iatrogenic deformities. Cases with iatrogenic deformities from previous treatment had a significantly increased risk of non-compliance and relapse. Experience of the treating surgeon and cast complications were also related to relapses. Our results show that the Ponseti technique is reproducible and effective in children at least up to 12 months of age. It can also produce good correction in children presenting with complex idiopathic deformities. Therefore, extensive joint releases should not be considered immediately in such cases. The treating surgeon should be meticulous in using the technique and ensure compliance to foot abduction brace in order to avoid recurrences.

The use of the absorbable interference screw for a split anterior tibial tendon (SPLATT) transfer procedure.

A split anterior tibial tendon transfer combined with an interference screw ensures superior tendon transfer fixation in the treatment of equinovarus deformity of the foot in children and adults with static encephalopathy.

Selective botulinum toxin injection in the treatment of recurrent deformity following surgical correction of club footA preliminary report of 3 children

Management of a child with club foot deformity that recurs after an apparently successful posteromedial soft tissue release remains a challenge. Revision surgery is often attempted, but this carries a high risk of significant scarring or neurovascular complications. We have treated 3 children (3 feet) with relapsed club foot and fixed deformities, using Botulinum toxin A (BTX-A) injection into muscle groups clinically thought to be responsible for recurrent deformity, followed by moulded plaster casts. Two cases have maintained a good foot position with an minimum follow-up of 18 months, and one other is also doing well having had a tibialis anterior tendon transfer as well as the BTX-A therapy. In our limited experience, targeted BTX-A injection with plaster casting has been safe, and may obviate the need for major revision surgery in a proportion of cases with recurrent club foot deformity following previous posteromedial soft tissue release.