Anterior Transfer Research Articles

Anatomic Comparison of Lateral Transfer of the Long Flexors for Concomitant Peroneal Tears

Lateral transfers of the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) tendons have been described for treatment of concomitant, irreparable peroneal tears. This study evaluated the anatomic benefits and constraints of lateral FHL and FDL tendon transfers with regard to available tendon length, diameter, and proximity to the posterior neurovascular bundle. In 9 cadaveric specimens, the FHL and FDL tendons were transected through a medial approach distal to the knot of Henry. Each tendon was transferred into a lateral incision, passing the FDL tendon both posterior and anterior to the tibial neurovascular bundle. The tendons were individually secured to the base of the fifth metatarsal with the foot in maximal eversion and dorsiflexion. The length of donor tendon available for fixation at the fifth metatarsal was measured. After the FDL tendon transfer was secured, the posterior neurovascular bundle was examined for signs of compression. Average FHL tendon diameter measured 5.1 mm; the FDL measured 4.5 mm. After passage through a bone tunnel, an additional 4.9 cm of FHL tendon remained to suture to itself; only 0.5 cm remained for the posterior and anterior FDL transfers. Transfer of the FHL did not increase muscle bulk within the retrofibular groove. Every FDL transfer posterior to the neurovascular bundle produced obvious visual compression of the tibial nerve with plantar flexion and inversion of the foot. Use of the FHL tendon for lateral transfer consistently provided sufficient length of tendon for multiple fixation options and a stronger muscle for transfer. Fixation options for the FDL were limited due to its shorter length. Lateral transfer of the FDL tendon posterior to the neurovascular bundle caused visible compression on the tibial nerve with ankle and hindfoot range of motion. This anatomic study confirmed several advantages for the use of the FHL tendon transfer in cases of concomitant peroneal tears.

Classification of relapse pattern in clubfoot treated with Ponseti technique

Background:Relapse of clubfoot deformity following correction by Ponseti technique is not uncommon. The relapsed feet progress from flexible to rigid if left untreated and can become as severe as the initial deformity. No definitive classification exists to assess a relapsed clubfoot. Some authors have used the Pirani score to rate the relapse while others have used descriptive terms. The purpose of this study is to analyze the relapse pattern in clubfeet that have undergone treatment with the Ponseti method and propose a simple classification for relapsed clubfeet.Materials and Methods:Ninety-one children (164 feet) with idiopathic clubfeet who underwent treatment with Ponseti technique presented with relapse of the deformity. There were 68 boys and 23 girls. Mean age at presentation for casting was 10.71 days (range 7-22 days). Seventy three children (146 feet, 80%) had bilateral involvement and 18 (20%) had unilateral clubfeet. The mean Pirani Score was 5.6 and 5.5 in bilateral and unilateral groups respectively. Percutaneous heel cord tenotomy was done in 65 children (130 feet, 89%) in the bilateral group and in 12 children (66%) with unilateral clubfoot.Results:Five relapse patterns were identified at a mean followup of 4.5 years (range 3-5 years) which forms the basis of this study. These relapse patterns were classified as: Grade IA: decrease in ankle dorsiflexion from15 degrees to neutral, Grade IB: dynamic forefoot adduction or supination, Grade IIA – rigid equinus, Grade IIB – rigid adduction of forefoot/midfoot complex and Grade III: combination of two or more deformities: Fixed equinus, varus and forefoot adduction.In the bilateral group, 21 children (38 feet, 28%) had Grade IA relapse. Twenty four children (46 feet, 34%) had dynamic intoeing (Grade IB) on walking. Thirteen children (22 feet, 16%) had true ankle equinus of varying degress (Grade IIA); eight children (13 feet, 9.7%) had fixed adduction deformity of the forefoot (Grade IIB) and seven children (14 feet, 10.7%) had two or more fixed deformities. In the unilateral group seven cases (38%) had reduced dorsiflexion (Grade IA), six (33%) had dynamic adduction (Grade IB), two (11%) had fixed equinus and adduction respectively (Grade IIA and IIB) and one (5%) child had fixed equinus and adduction deformity (Grade III). The relapses were treated by full time splint application, re-casting, tibialis anterior transfer, posterior release, corrective lateral closing wedge osteotomy and a comprehensive subtalar release. Splint compliance was compromised in both groups.Conclusion:Relapse pattern in clubfeet can be broadly classified into three distinct subsets. Early identification of relapses and early intervention will prevent major soft tissue surgery. A universal language of relapse pattern will allow comparison of results of intervention.

Ponseti method for management of neglected idiopathic clubfoot

Background Although the Ponseti method has been effective in early presented clubfoot, limited information is available on the use of this method in older patients. Methods We prospectively followed 20 children (30 feet) with neglected idiopathic clubfoot. We sought to determine whether initial correction of the deformity (a plantigrade foot) could be achieved using the Ponseti method in untreated idiopathic clubfeet in patients presenting between the ages of 12–36 months. Results Older children needed more casts than younger children. Twenty-one of 30 (70%) feet needed percutaneous tendo-Achilles tenotomy for residual equinus deformity. The mean dorsiflexion after removal of the last cast was 12.5°. Six feet relapsed (20%) and were treated with recasting and tibialis anterior transfer in four feet, and two feet needed limited medial release, tendo-Achilles tenotomy, abductor hallucis tenotomy, and tibialis anterior transfer. Conclusions The Ponseti technique was effective in treatment of neglected clubfoot in patients between the ages of 12–36 months.

King’s procedure for Aitken B/Paley 2a proximal femoral focal deficiency with 19-year follow-up — a case report

A girl was born in 1984 with congenital anomalies in all 4 limbs. These included bilateral proximal femoral focal deficiency (PFFD), an absent right fibula, abnormal right foot and ankle, short left fibula, and rudimentary forearms with only single digits below the humerus bilaterally. The etiology remains unknown. Cerebral function was normal. Her father had spina bifida. At the age of 1 year, she underwent a Symes amputation of the right foot and was fitted with a below-knee orthosis, with which she began to walk. During the following year, radiographs suggested a pseudarthrosis between the right femoral head and the upper femoral shaft (Figure 1). Both acetabulae were developing well, with femoral heads enlocated. This was in keeping with an Aitken type-A or type-B PFFD of the right hip (Aitken 1969). The left proximal femur, although not normal, appeared in solid continuity with the femoral head. Figure 1. Both hips at 1 year of age. Exploration and bone grafting of the right hip was carried out at the age of 2 years through a modified Smith-Peterson approach. At operation, there appeared to be no pseudarthrosis between the head and neck, only cartilaginous tissue at this level with a marked flexion deformity of the femur. Corticocancellous graft strips from the iliac crest were taken, laid upon the neck, and sutured in place, with the hope of encouraging ossification. In the months following this, she began to walk again without pain or dysfunction relating to the hip joint. At the age of 5, the patient underwent a Grice procedure to arthrodese her left subtalar joint. Simultaneous examination under anesthesia of both hips was performed: there was found to be no contact between the head and upper femoral shaft on the right side. Therefore, shortly after this, the right hip was re-explored, using the previous approach. There was only fibrous tissue between the head and upper femur. It was felt that it would be impossible to perform a femoral neck reconstruction, so King’s procedure was carried out (King 1966, 1969). The upper end of the femur was sharpened and driven into a hole in the remnant of the femoral neck. The periosteal sleeve removed from the proximal femur was wrapped around this, and the construct was stabilized with a Kirschner wire (Figure 2). A full hip spica was applied. Figure 2. King’s procedure: immediately after surgery. The spica was left for 3 months, after which the Kirschner wire was removed and the hip was left free. Radiographs taken at this stage showed good bone formation around the proximal femur (Figure 3). 1 year after this, the patient fell and suffered a fracture across the neck of the right femur; this was treated in a hip spica and healed without incident. She continued to walk and run with the use of an orthosis. Figure 3. Right hip 3 months postoperatively. Further surgical procedures included a valgus osteotomy to the left femoral neck when 8 years old for a coxa vara of 90° causing impingement, a left foot tibialis anterior transfer for a varus hindfoot at age 10, and talonavicular and calcaneocuboid arthrodeses of this foot at age 22 (effectively making a triple arthrodesis, given her previous Grice subtalar arthrodesis). She has had no surgery to her upper limbs and functions well with these. At 24 years of age, the patient is currently able to walk 5 km with only mild-to-moderate pain in her hips. Stairs present no difficulty, and she does not use any walking aid. Running is possible for short distances, but co-ordination is difficult for this. She is gainfully employed in journalism. Current radiographs show a solid femoral neck with an enlocated hip joint (Figure 4). She has not had any surgery to the acetabulum of this hip: the radiograph shows evidence of heterotopic ossification at the superolateral margin of the hip joint. Figure 4. Hip 19 years postoperatively.

Management of idiopathic clubfoot in toddlers by Ponseti's method

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.

Multiple Tenotomies after Ponseti Method for Management of Severe Rigid Clubfoot

The purpose of the present study was to evaluate the efficacy of multiple tenotomies performed after application of the Ponseti method in reducing the tendency for recurrence in the severe rigid idiopathic clubfoot and limiting the need for application of the hyperabduction brace in the prewalking age. From November 2002 to December 2004, 30 severe (Pirani >5), rigid (nonresilient), idiopathic clubfeet in newly born infants aged 2 to 24 days were treated by the Ponseti method of weekly manipulations and castings until achieving full correction, apart from equinus. With the patient under general anesthesia, through 2 small incisions (2 cm), tenotomy of the Achilles tendon, tibialis posterior, and flexor digitorum longus was performed, together with posterior capsulotomy of the ankle to achieve >30° dorsiflexion in 26 feet. An above the knee plaster cast in extreme dorsiflexion and 70° hyperabduction was applied for 6 to 8 weeks. This was followed by a hyperabduction brace on a full-time basis (23 hours daily) for an additional 6 months. A satisfactory result was achieved after a follow-up period of 2 to 5 (mean 3.8) years. The Pirani score on initial presentation was 5 to 6 and on the final visit was 0 to 0.25, with 10° to 20° passive dorsiflexion of the ankle in those who underwent posterior capsulotomy compared with 5° to 10° in the 4 patients who had not. The number of manipulations needed before tenotomy was 5 to 7 (mean 5.9), reflecting the rigidity of the studied feet. Active plantarflexion to almost normal power was regained at 18 to 30 months of age. A relapse developed in only 1 foot that failed to respond to manipulation and casting. It required posteromedial release and tibialis anterior transfer at 2 years of age. The proposed minimally invasive procedure of open multiple tenotomies and posterior capsulotomy of the ankle is safe and effective. If performed in newly born infants with severe rigid clubfeet followed by strict application of the hyperabduction brace on a full time basis for 6 months, it will ensure full correction of the deformity. Thus, the brace can be discarded before the infant reaches walking age, with no tendency for relapse.

Clinical research of functional reconstruction with BTA for treatment on equinovarus foot of spasitic cerebral palsy

Objective To observe the clinical therapial value of functional reconstruction with Botulinum Toxin A (BTA) on spasitic cerebral palsy. Methods Thirty-two patients were treated by Achilles tendon lengthening and anterior transfer of posterior tibial tendon.According to the spasticity of triceps surae muscle,all cases were arranged by BTA injection 2 months later after operation.Results From Jan.2000 to Jan.2009,thirty-two cases with equinovarus foot of spasticitical cerebral palsy were collected,the muscle strength of ankle dorsal extensor increased from 0-2 grades to 4-5 grades,there was significant difference between preoperational muscle strength and postoperational one.There was also significant improvement to adjust yarus degrees of ankle joint.the musclar tension of triceps muscle of calf decreased from Ⅱ-Ⅳ grades to Ⅰ-Ⅱ grades. Conclusion Anterior transfer of posterior tibial tendon corresponding with Botulinum Toxin A injection not only release muscle spasticity but also improve dorsal extending strength of ankle joint.The clinical effect of these methods was reliable on cerebral palsy. Key words: Cerebral palsy; Eguinovarus foot; Functional reconstruction; Botulinum toxin A (BTA)

Unilateral foot abduction orthosis

The use of foot abduction orthosis [Denis Browne boot (DBB)] is vital for maintaining correction after the Ponseti technique for treating idiopathic clubfoot. Lack of adherence to DBB regimen is reported to be a potent cause for recurrence. Adherence to the boots and bars programme is difficult and patients sometimes resist their use. The evaluation of alternatives that may facilitate adherence is therefore necessary and reasonable. There are less data published regarding the outcome after the use of alternative splints. In patients who showed poor adherence to DBB, we introduced a novel unilateral foot abduction orthosis (UFAO) as an alternative. The aim of this study was to determine whether the recurrence rates were increased by exchanging DBB with UFAO in nonadherent patients and to find out whether UFAO was more acceptable to families who had refused to use DBB. We reviewed 27 children with 35 idiopathic clubfeet. Twenty-three patients used the boots and bars programme for the first 3 months after completion of serial casting, before UFAO was introduced into the treatment plan for resistance to DBB usage. In four cases, UFAO was commenced immediately after the serial casting. The mean follow-up was 25 months (16-36 months). Most families reported that UFAO was easier for their child to use and facilitated adherence was observed. Recurrence (the need for further casting or operation) was observed in 11 feet. Six of these 11 recurrences responded favourably to a further period of serial casting with or without repeated tendoachilles tenotomy. Three of these 11 patients responded favourably to tibialis anterior transfer and two required a traditional posteromedial release. The recurrence rates in patients using UFAO were higher compared with those reported by others using DBB after Ponseti serial casting. Our results indicated that although a unilateral orthosis is preferred and accepted by families who do not adhere to a DBB regimen, recurrence with UFAO use is higher. This study therefore questions the effectiveness of UFAO as an alternative to DBB. The importance of following the original method described by Ponseti should be stressed.

MUSCLE TRANSFER FROM TRICEPS TO BICEPS IN PATIENTS WITH CHRONIC INJURY OF THE UPPER TRUNK OF THE BRACHIAL PLEXUS

Objective: To evaluate the results from transposition of the triceps for elbow flexion in patients with chronic and complete injury to the upper trunk of the brachial plexus. Methods: This was a retrospective study, including only patients who had biceps grade 0 and triceps grade 5, who underwent anterior transfer of the triceps muscle, performed between 1998 and 2005. The affected side, sex, type of accident, strength of elbow flexion, complications and patient satisfaction were investigated in 11 cases. Results: 10 patients were male; the age range was from 24 to 49 years, with a mean of 33.7 years. The minimum time between injury and surgery was 21 months (range 21-74 months). The left side was affected in eight cases, and the right only in three. Good results were obtained in 10 patients, who acquired elbow flexion strength of grade 3 (two cases) and grade 4 (eight cases), while one evolved unfavorably with grade 2 strength. Two cases had complications (initial compartment syndrome and insufficient tensioning). All the patients said that they were satisfied with the procedure. Conclusion: Anterior transposition of the triceps muscle provided patient satisfaction in all cases except one, attaining strength grade 4 in eight cases, grade 3 in two cases and grade 2 in one case.

Transferência do músculo tríceps para bíceps em pacientes com lesão crônica do tronco superior do plexo braquial

OBJETIVO: Avaliar os resultados da transposição do tríceps para a flexão do cotovelo em pacientes portadores de lesão crônica e completa do tronco superior do plexo braquial. MÉTODOS: Estudo retrospectivo, com inclusão apenas de pacientes que apresentassem bíceps grau 0 e tríceps grau 5, submetidos à transferência anterior do músculo tríceps, operados entre 1998 e 2005. Foram pesquisados o lado acometido, o sexo, o tipo de acidente, a força de flexão do cotovelo, as complicações e a satisfação do pacientes, em 11 casos. RESULTADOS: 10 pacientes eram do sexo masculino; a idade variou de 24 a 49 anos, com média de 33,7 anos. O tempo mínimo entre a lesão e o procedimento cirúrgico foi de 21 meses (variando de 21 a 74 meses). O lado esquerdo foi acometido em oito casos, enquanto o direito apenas em três. Obtiveram-se bons resultados em 10 pacientes, que adquiriram força de flexão do cotovelo grau 3 (dois casos) e grau 4 (oito casos), enquanto um evoluiu desfavoravelmente, com força grau 2. Dois casos evoluíram com complicações (síndrome compartimental inicial e tensionamento insuficiente). Todos os pacientes definiram-se como satisfeitos com o procedimento. CONCLUSÃO: A transposição anterior do músculo tríceps proporcionou satisfação dos pacientes em todos os casos, exceto um, obtendo-se forças grau 4 em oito casos, grau 3 em dois casos e grau 2 em um caso.

Aberrant Perfusion of the Serratus Anterior Muscle Flap: Report of Two Cases and a Review of the Literature

Free serratus anterior muscle flap, classified as Mathes-Nahai type III, is a versatile and frequently preferred choice for soft tissue coverage of small to moderate-sized defects owing to its reliable circulation pattern; however, some anatomic variations in the flap vascularity can result in partial flap loss. Here we present two cases with free serratus anterior muscle transfer where the distalmost portion of the flap was not perfused by the thoracodorsal pedicle. The most likely explanation seems to be the large flap size and the lack of distal interconnections between lateral thoracic artery and thoracodorsal artery branches. Our clinical experience suggests that anatomic variations of serratus anterior muscle circulation might end up with distal perfusion loss if a large flap is to be harvested.

A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method

In the treatment of idiopathic clubfeet, the Ponseti method and the French functional method have been successful in reducing the need for surgery. The purpose of this prospective study was to compare the results of these two methods at one institution. Patients under three months of age with previously untreated idiopathic clubfeet were enrolled. All feet were rated for severity prior to treatment. After both techniques had been described to them, the parents selected the treatment method. Outcomes at a minimum of two years were classified as good (a plantigrade foot with, or without, a heel-cord tenotomy), fair (a plantigrade foot that had or needed to have limited posterior release or tibialis anterior transfer), or poor (a need for a complete posteromedial surgical release). Two hundred and sixty-seven feet in 176 patients treated with the Ponseti method and 119 feet in eighty patients treated with the French functional method met the inclusion criteria. The patients were followed for an average of 4.3 years. Both groups had similar severity scores before treatment. The initial correction rates were 94.4% for the Ponseti method and 95% for the French functional method. Relapses occurred in 37% of the feet that had initially been successfully treated with the Ponseti method. One-third of the relapsed feet were salvaged with further nonoperative treatment, but the remainder required operative intervention. Relapses occurred in 29% of the feet that had been successfully treated with the French functional method, and all required operative intervention. At the time of the latest follow-up, the outcomes for the feet treated with the Ponseti method were good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the French functional method were good for 67%, fair for 17%, and poor for 16%. Nonoperative correction of an idiopathic clubfoot deformity can be maintained over time in most patients. Although there was a trend showing improved results with use of the Ponseti method, the difference was not significant. In our experience, parents select the Ponseti method twice as often as they select the French functional method.

A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method

Background: In the treatment of idiopathic clubfeet, the Ponseti method and the French functional method have been successful in reducing the need for surgery. The purpose of this prospective study was to compare the results of these two methods at one institution. Methods: Patients under three months of age with previously untreated idiopathic clubfeet were enrolled. All feet were rated for severity prior to treatment. After both techniques had been described to them, the parents selected the treatment method. Outcomes at a minimum of two years were classified as good (a plantigrade foot with, or without, a heel-cord tenotomy), fair (a plantigrade foot that had or needed to have limited posterior release or tibialis anterior transfer), or poor (a need for a complete posteromedial surgical release). Two hundred and sixty-seven feet in 176 patients treated with the Ponseti method and 119 feet in eighty patients treated with the French functional method met the inclusion criteria. Results: The patients were followed for an average of 4.3 years. Both groups had similar severity scores before treatment. The initial correction rates were 94.4% for the Ponseti method and 95% for the French functional method. Relapses occurred in 37% of the feet that had initially been successfully treated with the Ponseti method. One-third of the relapsed feet were salvaged with further nonoperative treatment, but the remainder required operative intervention. Relapses occurred in 29% of the feet that had been successfully treated with the French functional method, and all required operative intervention. At the time of the latest follow-up, the outcomes for the feet treated with the Ponseti method were good for 72%, fair for 12%, and poor for 16%. The outcomes for the feet treated with the French functional method were good for 67%, fair for 17%, and poor for 16%. Conclusions: Nonoperative correction of an idiopathic clubfoot deformity can be maintained over time in most patients. Although there was a trend showing improved results with use of the Ponseti method, the difference was not significant. In our experience, parents select the Ponseti method twice as often as they select the French functional method. Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Soft Tissue Reconstruction With Sagittal Split Anterior Tibial Muscle Transfer and Medial Gastrocnemius Transposition in Limb-Salvage Surgery of Bone Tumors in a Proximal Tibia

Twenty-six patients with bone tumors in a proximal tibia underwent limb-salvage surgery with custom prosthesis. The soft tissue reconstruction included gastrocnemius flap transposition to cover the upper part of the prosthesis and to reconstruct the extensor mechanism with its muscle fascia intact, in conjunction with sagittal split anterior tibial muscle transfer to provide soft tissue coverage of the lower part. The mean follow-up time was 43.0 months. One patient had deep infection. One patient had marginal skin necrosis and delayed healing. The average Musculoskeletal Tumor Society system score was 26.0 (23-29). The average range of motion was 91.9 degrees (50-120 degrees) with 4.4 degrees (0-20 degrees) of average extension lag. Compared with the traditional method of medial gastrocnemius transposition, the combination of sagittal split anterior tibial muscle transfer and medial gastrocnemius transposition is a technically easier, less invasive method to provide satisfactory soft tissue coverage and reconstruction of the extensor mechanism with better functional results in limb-salvage surgery of a proximal tibia.

Classic and modified Barr's technique of anterior transfer of the tibialis posterior tendon in irreparable peroneal palsies.

Peroneal palsy with loss of active dorsal flexion in foot can be surgically treated by anterior transfer of tibialis posterior tendon. Two techniques are available, classic and modified Barr's technique of the anterior transfer of tibialis posterior tendon, with different place of tendon's reinsertion. The aim of the study is evaluation of the degree of active dorsal flexion in foot, and appearance of varus position and hipercorrection of the foot, by comparing the results of the two operative techniques. The study included 40 patients with peroneal irreparable palsies, divided into two equally sized groups. The first group was treated by classic Barr's technique. The other group of patients was treated by modified Barr's technique. The group treated by modified Barr's technique exhibited better functional results. Active dorsal flexion achieved between 950 (in 35% cases) and 900 (in 50% cases), while varus position and hipercorrection of the foot were absent. In the second group of 20 patients, treated by classic Barr's technique, 800 (40%) and 900 (25%) of active dorsal flexion, indicated worse functional postoperative results. Active dorsal flexion of 700 achieved by this method in two cases (10%), represents unsatisfactory functional result. Varus position of the foot was recorded in 5 cases (25%) and hipercorrection in 4 cases (20%). Modified Barr's technique is surgical method with better functional and postoperative results in treatment of irreparable peroneal palsy.

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.

EFFECT OF THE STEINDLER PROCEDURE ON THE MEDIAN NERVE BRANCHES TO THE MEDIAL EPICONDYLAR MUSCLES

Usually the median nerve gives off six branches to the muscles arising from the medial epicondyle, which could be tightened during Steindler's procedure. We studied these branches before and after Steindler's procedure in 20 fresh cadavers and observed a considerable variation in the origin of the branches. The muscular branches arising from the median nerve did not seem to limit the mobilization of the medial epicondyle when performing Steindler's transfer. The limitation of the flexion observed after Steindler's procedure was mainly related to the tension of the transferred forearm flexor muscles. The variability of the origin of the branch to the flexor digitorum superficialis muscle could explain a lesion of this branch when Steindler's procedure is carried out with Brunelli's modification. The lateral transfer and the anterior transfer on to the humeral shaft did not influence the limitation of elbow flexion or result in tightness in any nerve branch to the transferred muscles.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Tibial tuberosity transfer, for patellar instability and malalignment: a new technique

We describe a new surgical procedure of tibial tubercle transfer for patellar malalignment and instability, aimed at addressing the different reposition components independently. The results of 15 knees (12 patients) which have been followed for over 5 years are presented. Anterior transfer is achieved by using local bone graft. Distal replacement is performed, to obtain normal patellar index. The amount of medial transfer of tuberosity is determined intra-operatively by activation of the extensor mechanism. All operated knees presented with patellofemoral pain, and 73% of knees had recurrent episodes of patellar dislocation. Post-operatively, no recurrence of dislocation occurred. The Lysholm knee score improved from an average of 60 to 85, and the Tegner activity score improved from an average of 3.5 to 6.3. Our suggested method gives the surgeon the possibility to tailor the procedure to the specific abnormality, and check the obtained effect intra-operatively.

Tendon Transfer for Equinovarus Deformed Foot Caused by Cerebrovascular Disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.