Anterior or Posterior Tibial Tendon Transfer to the Peroneus Tertius for Equinovarus Deformity

Abstract

Background: Equinovarus deformity correction was performed by soft tissue release and bone deformity correction, and tendon transfer to maintain deformity correction. Because of the high complication rate of tendon fixation methods, partial or total anterior tibial tendon or posterior tibial tendon transfer to the peroneus tertius tendon was reported. The purpose of this study was (i) to review the results of this tendon transfer technique after release and correction of talipes equinovarus, and (ii) to analyze the complication of this technique.

Methods: Between February 2017 and May 2022, 176 patients (210 feet) with equinus and/or varus foot and ankle deformities underwent anterior or posterior tibial tendon transfer to the peroneus tertius in our institute. Preoperative and postoperative foot and ankle range of motion (passive and active) were checked. The postoperative radiographic assessment included antero-posterior (AP), lateral, and hindfoot alignment radiographs. Preoperative and postoperative lateral tibio-talar, talo-calcaneal, talo-first metatarsal, tibial-sole angles, hindfoot alignment, and anterior subluxation of the talus were checked. The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and visual analog scale (VAS) were used to assess pain. Paired Student’s t-test was used to compare the clinical scores and radiographic angles before the operation and at the last follow-up.

Results: The mean age of the patients was 23.27 ± 13.44 years (range, 3–69 years). The mean follow-up time was 25.56 ± 16.37 months (range, 12–68 months). There were significant differences between the preoperative and postoperative measurements of the lateral tibio-talar angle, lateral talo-calcaneal angle, lateral talo-first metatarsal angle, lateral tibial-sole angle, and hindfoot alignment (p < 0.001). There was significant difference between the preoperative and postoperative AOFAS and VAS scores (p < 0.001). The early complications included infection in one patient, skin necrosis in two patients, and plantar numbness in three patients. The late complications included pin infection in three patients, tibio-talar joint compression in four patients, forefoot pain in two patients, toe flexion in two patients, and plantar numbness in one patient. There were three cases of complications (1.43%) related to the transferred tendons.

Conclusion: Tibialis anterior or posterior tendon transfer to the peroneus tertius is a safe and effective method for equinovarus deformity correction. It yielded excellent outcomes that produced high patient satisfaction and few complications.

Keywords

anterior tibial tendon / complication / equinovarus / peroneus tertius / posterior tibial tendon / transfer

References

[1] Hoffer MM, Reiswig JA, Garrett AM, Perry J. The split anterior tibial tendon transfer in the treatment of spastic varus hindfoot of childhood. Orthop Clin North Am. 1974; 5(1): 31–38.

[2] Kitaoka HB, Alexander IJ, Adelaar RS, A. Nunley J, Myerson MS, Sanders M, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1997; 18(3): 187–188.

[3] Lullo B, Nazareth A, Rethlefsen S, Illingworth KD, Abousamra O, Kay RM. Split tibialis anterior tendon transfer to the peroneus brevis or tertius for the treatment of varus foot deformities in children with static encephalopathy: a retrospective case series. J Am Acad Orthop Surg Glob Res Rev. 2020; 4(5): e2000044.

[4] Wenz W. Double and triple tarsal fusions in the complex cavovarus foot. Foot Ankle Clin. 2022; 27(4): 819–833.

[5] Kroon M, Faber FWM, van der Linden M. Joint preservation surgery for correction of flexible pes cavovarus in adults. Foot Ankle Int. 2010; 31(1): 24–29.

[6] Pfeffer GB, Gonzalez T, Brodsky J, Campbell J, Coetzee C, Conti S, et al. A consensus statement on the surgical treatment of charcot-marie-tooth disease. Foot Ankle Int. 2020; 41(7): 870–880.

[7] Cates NK, Bunka TJ, Kavanagh AM, Wynes J. Split anterior tibial tendon transfer to dorsal lateral foot for cavovarus deformities with neuropathic ulcerations: a case series. J Foot Ankle Surg. 2022; 61(1): 189–194.

[8] Dreher T, Wolf SI, Heitzmann D, Fremd C, Klotz MC, Wenz W. Tibialis posterior tendon transfer corrects the foot drop component of cavovarus foot deformity in charcot-marie-tooth disease. J Bone Joint Surg Am. 2014; 96(6): 456–462.

[9] Clanton TO, Betech AA, Bott AM, et al. Complications after tendon transfers in the foot and ankle using bioabsorbable screws. Foot Ankle Int. 2013; 34(4): 486–490.

[10] Hosalkar H, Goebel J, Reddy S, Pandya NK, Keenan MA. Fixation techniques for split anterior tibialis transfer in spastic equinovarus feet. Clin Orthop Relat Res. 2008; 466(10): 2500–2506.

[11] Wu KW, Huang SC, Kuo KN, Wang TM. The use of bioabsorbable screw in a split anterior tibial tendon transfer: a preliminary result. J Pediatr Orthop B. 2009; 18(2): 69–72.

[12] Radler C, Gourdine-Shaw MC, Herzenberg JE. Nerve structures at risk in the plantar side of the foot during anterior tibial tendon transfer. J Bone Joint Surg Am. 2012; 94(4): 349–355.

[13] Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop Relat Res. 2000; 371: 216–227.

[14] Vlachou M, Dimitriadis D. Split tendon transfers for the correction of spastic varus foot deformity: a case series study. J Foot Ankle Res. 2010; 3(1): 28.

[15] Aun C, Lam YM, Collett B. Evaluation of the use of visual analogue scale in chinese patients. Pain. 1986; 25(2): 215–221.

[16] Ferreira RC, Costo MT, Frizzo GG, Fonseca Filho FF. Correctionof neglected clubfoot using the Ilizarov external fixator. Foot Ankle Int. 2006; 27(4): 266–273.

[17] Kay RM. Lower-extremity surgery in children with cerebral palsy. In: DL Skaggs, MS Kocher, editors. Master Techniques in Orthopaedic Surgery. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2016. p. 149–192.

[18] Yammine K, Erić M. The fibularis (peroneus) tertius muscle in humans: A meta-analysis of anatomical studies with clinical and evolutionary implications. Biomed Res Int. 2017; 2017: 6021707.

[19] Demir BT, Üzel M, Bilecenoğlu B. Clinical and variational evaluation of peroneus tertius muscle. Anat Sci Int. 2022; 98(2): 220–227.

[20] Pinzur MS. Principles of balancing the foot with tendon transfers. Foot Ankle Clin. 2011; 16(3): 375–384.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.