Split Posterior Tibial Tendon Transfer Research Articles

Effect of split posterior tibialis tendon transfer on foot progression angle in children with cerebral palsy

ObjectivesA common orthopedic issue for patients with spastic cerebral palsy (CP) is hindfoot varus deformity. One method of treatment is the split posterior tibialis tendon transfer (SPOTT). There is limited literature on the effect of SPOTT on foot progression angle (FPA) in children with CP who have equinovarus deformities. The objective of our study was to evaluate the change in FPA after SPOTT to determine if this procedure can improve FPA. Research QuestionThis study aims to determine what axial changes are generated from a split posterior tibial tendon transfer in children with CP. MethodsWe performed a retrospective analysis of all ambulatory children with a diagnosis of CP who underwent SPOTT at our institution. Patients with bony rotational procedures were excluded. Descriptive statistics including mean and standard deviation (SD) were used to characterize continuous variables. Paired t-tests were used to evaluate outcomes, in which a target outcome was defined as a post-operative FPA between 0–10° of external rotation. Results44 limbs were included. Demographics were as follows: 26/13 female/male; mean age[SD] (years): 9.8[3.5]; 30 hemiplegic, 9 diplegic, and 1 triplegic. Of the 44 limbs, 18 limbs had a target outcome, 4 had no change, and 22 had a non-target outcome. Of the 22 with an outcome outside of the target, 4 limbs trended away from a target outcome. The overall change in FPA measured was − 10.9 ± 14.7° (p < 0.0001) Age at time of surgery, CP involvement, pre-operative FPA, and GMFCS level were not predictors of outcome (p > 0.05). ConclusionsSPOTT produced a change of 10.9° external rotation in FPA post-operatively and its effects should be considered when planning a SEMLS.

Surgical Treatment of Severe Cavovarus Foot Deformity in Charcot-Marie-Tooth Disease.

A successful adjusted treatment algorithm for the correction of cavovarus foot deformity requires soft-tissue balancing procedures, in particular total split posterior tibial tendon transfer (T-SPOTT), in combination with adjunctive corrective procedures depending on the degree of deformity. Place the patient in a supine position and follow a standard aseptic surgical disinfection and draping protocol, allowing access to the iliac crest. Use a medial approach to access and transect the plantar aponeurosis. Transect the posterior tibial tendon near its insertion point. Make a medial incision in the distal part of the calf, retract the posterior tibial tendon (and flexor digitorum tendon if necessary), split it longitudinally in half, and pass it through the interosseous space. Expose the anterior tibial and peroneal tendons and pull the posterior-tibial-tendon halves (and flexor digitorum longus tendon of it is being used) to these tendons. Perform a Chopart, or triple or Lambrinudi 16 , arthrodesis when osseous correction and stabilization are required for fixed deformities. If the cavovarus foot displays flexible clawing of the big toe, carry out a modified Jones procedure. If the first metatarsal remains in a fixed plantar flexed position and cannot be corrected with the Jones procedure, perform a dorsal-based wedge extension osteotomy. Incise the plantar tendons, transect the long flexor tendons, and place a single Hohmann wire through the end of each claw toe. Depending on the severity of the remaining equinus, correct it with calf muscle or calcaneal tendon lengthening (the more severe the equinus, the more distal the corrective measure). If foot external rotation is increased after foot correction, supramalleolar derotation osteotomy should be added to avoid lever-arm problems postoperatively. Attach the transferred tendons to their respective target tendons using a Pulvertaft needle with a Pulvertaft weave technique, while keeping the foot in a plantigrade position. Reevaluate the foot and determine if all corrections have been made, perform necessary final radiographic documentation, release the tourniquet, perform hemostasis, clean the wounds, and close them. The achieved operative correction is only as good as the postoperative treatment allows. Various authors have recommended posterior tibial tendon transfer to the dorsum of the foot to correct foot drop.IndicationsContraindicationsPitfalls & Challenges.

Foot Drop Correction: By Active Dorsiflexion or Tenodesis Effect?

In their excellent paper, Dreher et al. attempt to answer the question of whether their previously described total split posterior tibial tendon transfer (“T-SPOTT”) works as an active dorsiflexor of the ankle or merely maintains ankle dorsiflexion through a tenodesis effect. The authors report the results of their T-SPOTT procedure performed in conjunction with other soft-tissue or osseous procedures on fourteen limbs in fourteen patients with a cavovarus foot and foot drop related to Charcot-Marie-Tooth disease. They performed preoperative and postoperative three-dimensional gait analysis using their previously validated foot model with seventeen well-defined osseous markers on the foot and leg to measure tibiotalar motion (actually plantar flexion and dorsiflexion of a line between the calcaneus and the navicular relative to the tibia), foot-tibia motion (plantar flexion and dorsiflexion of a line between the calcaneus and distal aspect of the first metatarsal relative to the tibia), and the medial arch angle (angle between the first metatarsal and a line from the medial aspect of the calcaneus to the navicular). The authors found that, at mean of twenty-nine months postoperatively, mean passive ankle dorsiflexion increased by 13° to 15° while mean passive ankle …

Split tendon transfers for the correction of spastic varus foot deformity: a case series study

BackgroundOveractivity of anterior and/or posterior tibial tendon may be a causative factor of spastic varus foot deformity. The prevalence of their dysfunction has been reported with not well defined results. Although gait analysis and dynamic electromyography provide useful information for the assessment of the patients, they are not available in every hospital. The purpose of the current study is to identify the causative muscle producing the deformity and apply the most suitable technique for its correction.MethodsWe retrospectively evaluated 48 consecutive ambulant patients (52 feet) with spastic paralysis due to cerebral palsy. The average age at the time of the operation was 12,4 yrs (9-18) and the mean follow-up 7,8 yrs (4-14). Eigtheen feet presented equinus hind foot deformity due to gastrocnemius and soleus shortening. According to the deformity, the feet were divided in two groups (Group I with forefoot and midfoot inversion and Group II with hindfoot varus). The deformities were flexible in all cases in both groups. Split anterior tibial tendon transfer (SPLATT) was performed in Group I (11 feet), while split posterior tibial tendon transfer (SPOTT) was performed in Group II (38 feet). In 3 feet both procedures were performed. Achilles tendon sliding lengthening (Hoke procedure) was done in 18 feet either preoperatively or concomitantly with the index procedure.ResultsThe results in Group I, were rated according to Hoffer's clinical criteria as excellent in 8 feet and satisfactory in 3, while in Group II according to Kling's clinical criteria were rated as excellent in 20 feet, good in 14 and poor in 4. The feet with poor results presented residual varus deformity due to intraoperative technical errors.ConclusionOveractivity of the anterior tibial tendon produces inversion most prominent in the forefoot and midfoot and similarly overactivity of the posterior tibial tendon produces hindfoot varus. The deformity can be clinically unidentifiable in some cases when Achilles shortening co-exists producing foot equinus. By identifying the muscle causing the deformity and performing the appropriate technique, very satisfying results were achieved in the majority of our cases. In three feet both muscles contributed to a combined deformity and simultaneous SPLATT and SPOTT were considered necessary. For complex foot deformities where the component of cavus co-exists, supplementary procedures are required along with the index operation to obtain the best result.

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.

The Use of Dynamic EMG in Predicting the Outcome of Split Posterior Tibial Tendon Transfers in Spastic Hemiplegia

The purpose of this study was to assess the outcome of split posterior tibial tendon transfers in patients with spastic cerebral palsy to determine whether the use of preoperative dynamic electromyography was predictive of surgical success. The study is a consecutive case series of 25 children with spastic hemiplegia who underwent unilateral split posterior tibial tendon transfers for varus foot deformities. Three patients were considered failures because of residual varus, which required further surgery. An additional 5 patients had mild residual varus. Preoperative dynamic electromyographic data were evaluated to determine the etiology of postoperative undercorrection. Undercorrection seems to be related to unrecognized anterior tibial muscle overactivity and advanced age at surgery. Overcorrection did not occur. Dropfoot was noted postoperatively in 52% of patients and was related to early cessation of anterior tibial muscle activity in swing. Split posterior tibial tendon transfer is a successful surgery on those patients with increased posterior tibial muscle activity. Undercorrection can be avoided by assessing the activity of the anterior tibial muscle before surgery. These results are expected to assist in surgical decision making for the equinovarus foot in cerebral palsy.

Split Posterior Tibial Tendon Transfer for Varus Deformity of Hindfoot

Sixteen patients (23 feet) who underwent split posterior tibial tendon transfers were evaluated. The patients were seen on a followup basis for a minimum of 1 year postoperatively. The causes were spastic cerebral palsy in 13 feet, spastic-athetoid cerebral palsy in 3 feet, hydrocephalus in 3 feet, and other diseases in 4 feet. The indication for surgery was varus deformity during the stance phase of gait and increased varus deformity during the swing phase of gait because of spasticity of the posterior tibial muscle. Heel cord lengthening was done on 17 feet. Preoperative and postoperative gaits were evaluated while the patients were walking. Axial radiographs of the calcaneus and the tibia were taken of all patients while they were weightbearing. There were 15 excellent, 6 good, and 2 poor results. The poor ratings were assigned to patients who had recurrence of varus deformity; there were no cases of overcorrection. Split posterior tibial tendon transfer was effective for treating spastic varus deformity of the hind part of the foot. This treatment also could be considered for a patient with spastic-athetoid cerebral palsy, if the deformity was determined to be caused by overactivity of the tibialis posterior muscle.

Split posterior tibial tendon transfer through the interosseus membrane in spastic equinovarus deformity.

The split posterior tibial tendon transfer procedure was first reported by Green for correction of equinovarus hindfoot deformity in patients with cerebral palsy. A modification of the split posterior tibial tendon transfer combined with an Achilles tendon lengthening is described in 17 children (21 procedures) with a minimum follow-up of 3 years. This modified technique is indicated in young children with a continuously spastic posterior tibial tendon to correct a dynamic equinovarus. It restores active dorsiflexion when the anterior tibial and extensor muscles are weak. The anterior half of the split tibialis posterior is transferred through the interosseus membrane to the dorsum of the foot. Excellent or good results and two poor results were noted after a mean follow-up of 29 months. In the patients with an excellent or good result, marked improvement of their equinovarus foot deformity in stance and swing phase of gait was seen. In two patients, the procedure failed because of technical errors.

Split Posterior Tibial Tendon Transfer for Spastic Equinovarus Foot Deformity

This paper describes a simplified technique for split posterior tibial tendon transfer in the treatment of spastic equinovarus deformity of the foot. Thirteen children with spastic equinovarus foot deformities were treated at Children's Rehabilitative Services in Phoenix, Arizona, from 1983 to 1986. The technique was modified in 10 of the 13 patients by attaching the split posterior tibial tendon more proximally to the peroneus brevis, compared to a more distal attachment as described by other authors. The mean length of followup was 21 months. Eleven patients obtained a good or excellent result. Two patients were considered to have a fair result. No poor results or complications were noted in any of the patients. It was felt that the split posterior tibial tendon transfer was an effective procedure for correction of spastic equinovarus as reported by other authors. Modification of the technique significantly simplifies the operation by requiring less dissection while still producing favorable results.

A Clinical Analysis on Split Posterior Tibial Tendon Transfers for Spastic Equinovarus Deformity in Cerebral Palsy

A Clinical Analysis on Split Posterior Tibial Tendon Transfers for Spastic Equinovarus Deformity in Cerebral Palsy

Split posterior tibial tendon transfers in children with cerebral spastic paralysis and equinovarus deformity: T.F. Kling, H. Kaufer, and R.M. Hensinger. J Bone Joint Surg 67A:186–194, (February), 1985

Split posterior tibial tendon transfers in children with cerebral spastic paralysis and equinovarus deformity: T.F. Kling, H. Kaufer, and R.M. Hensinger. J Bone Joint Surg 67A:186–194, (February), 1985

Split posterior tibial-tendon transfers in children with cerebral spastic paralysis and equinovarus deformity.

In the treatment of equinovarus deformity of the foot in children with cerebral spastic paralysis, to supplement heel-cord lengthening, we split the posterior tibial tendon and transferred its posterior half laterally into the peroneus brevis tendon. Thirty-seven operations were performed on thirty-one hemiplegic, quadriplegic, and diplegic children who were followed for a mean of eight years postoperatively (range, four to fourteen years), at which time twenty-six of the thirty-one children were skeletally mature. There were thirty excellent, four good, and three poor results. The results did not deteriorate with time. Thirty-two of thirty-four children with good or excellent results had functioning dorsiflexors of the foot and were brace-free postoperatively. The children who had a poor result had recurrent deformity, but none had development of a calcaneal or calcaneovalgus deformity.

Split posterior tibial tendon transfer in spastic cerebral palsy: N. E. Green, P. P. Griffin, and R. Shiavi. J Bone Joint Surg 65A:748–754, (July), 1983

Split posterior tibial tendon transfer in spastic cerebral palsy: N. E. Green, P. P. Griffin, and R. Shiavi. J Bone Joint Surg 65A:748–754, (July), 1983

Split posterior tibial-tendon transfer in spastic cerebral palsy.

Sixteen split posterior tibial-tendon transfers, usually with heel-cord lengthening, were performed on sixteen children with spastic cerebral palsy and equinovarus deformities. The patients were followed for a minimum of two years postoperatively. All of the varus deformities were corrected, although two patients required an osteotomy of the calcaneus because of fixed varus deformity. There were no recurrences of the varus deformities, nor were any valgus or calcaneal deformities produced, and the equinus element of the gait was eliminated.