Tendon Transfers in Foot Surgery Dr. Edvin Selmani, Dr. Fatmir Brahimi, Dr. Leart Duraj, Prof. Dr. Gjergji Caushi Service of Orthopaedic and Trauma, University Hospital Center “Mother Theresa” Tirana.

Introduction Tendon transfers in the foot and ankle area are used mainly for these causes: Paralytic disorders (drop foot) Routine treatment for clubfoot protocol

Causes of paralytic disorders Trauma of sciatic (or peroneal) nerve from Hip dislocation (1 case) Fracture of posterior wall of acetabulum (2 cases) Knee dislocation (1 case) Iatrogenic form syringe injection (2 cases) Stub wound with knife in peroneal region (1 case) Neurodegenerative disorders ( 2 cases) Inability to dorsiflex the ankle and toes Damaged muscles :Tibialis anterior, extensor hallucis longus and extensor digitorum comunis

Clubfoot patients There is inbalance of invertor and evertor muscles of the foot with predominance of the Tibialis anterior pull. In patients older than 3 years ( ossification of the cuneiforms bone) tibialis anterior tendon transfer to lateral cuneiform bone is suggested routinely according to Ponseti

Diagnosis Clinical view; inability to walk on heels , limping, drop foot, loss of sensation MRI EMG and nerve conduction studies Plains X-ray for bony causes

Initial treatment Conservative Physiotherapy Orthosis Electrostimulation

Surgical treatment When conservative treatment fails Installation of drop foot at least one year Surgery options: Tendon Transfer for flexible foot Arthrodesis in rigid foot (polio or charco joint)

Goal of Study To evaluate the results of treatment of 22 cases with tibialis anterior or posterior tendon transfers Prospective study

Material and Method 22 cases during 2007 - 2014 7 Tibialis posterior tendon transfer (drop foot) 15 Tibialis anetrior tendon transfer (Clubfoot patients)

Surgical technique in Tib. Post. Transfer ( 7 cases – 1 bilateral) Transfer of Tibialis Posterior tendon through the interosseous membrane into the middle cuneiform or cuboid with “pull out” suture or interference bone screw

Traumatic injury of peroneal nerve

Isciatic nerve injury

Dorsiflexion force

Tibialis anterior tendon transfer in pediatric clubfoot ( 15 cases)

Results Clinical follow-up average 1,5 year postop All free from brace and without limp 40% of patients could run again 100% could walk without assistence of orthoses. Muscle strength of dorsiflection was: 5/5 in 40% of patients 3/5 and 4/5 in 20 % of patients 2/5 in 20% of patients 1/5 in 20% of patients

Discussion Many authors have reported very good outcomes with this procedure: Watkins MB, Jones JB, Ryder CT Jr, Brown TH Jr: Transplantation of the posterior tibial tendon. J Bone Joint Surg Am 1954, 36-A:1181–1189. Prahinski JR, McHale KA, Temple HT, Jackson JP: Bridle transfer for paresis of the anterior and lateral compartment musculature. Foot Ankle Int 1996, 17:615–619. Wagenaar FC, Louwerens JW: Posterior tibial tendon transfer: results of fixation to the dorsiflexors proximal to the ankle joint. Foot Ankle Int 2007, 28:1128–1142. Pinzur MS, Kett N, Trilla M: Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy. Foot Ankle 1988, 8:271–275.

Discussion ( cont) Tendon transfer procedure can be augmented with Tendo Achilles lengthening or Gastrocnemius muscle resection as in our patients Combination of tendon transfer with nerve repair or nerve transfer procedures show better results recentley 

Conclusion Tendon transfer of Tibialis Posterior is an efective procedure to treat drop foot in combination with Achilles tendon lengthening. Tendon transfer of tibialis anterior is a routine procedure in the Ponseti protocol to treat the relapses of clubfoot from tibialis anterior tendon overpull

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