PRINCIPLE: Transfer the right tendon to the right location at the right tension (see Management Principle #22-1, Chapter 4).
Anchoring techniques—it is not known if a tendon can reliably anchor/heal into a cartilage anlage of a bone. The reliable anchoring techniques are:
1. Pulvertaft weave into another tendon
2. Drill hole in a bone with lead sutures tied over a button and felt pad on the plantar aspect of the foot
a. Commercial tendon anchor (rarely indicated in children)
Jones Transfer of Extensor Hallucis Longus to 1st MT Neck
1. Indications
a. Claw deformity of the hallux (see Chapter 5) that causes pain and skin irritation over the dorsum of the IP joint and/or under the 1st MT head
i. usually associated with a cavovarus foot deformity, as in CMT or other neuromuscular disorder (see Cavovarus Foot, Chapter 5)
b. Can be performed as an isolated procedure, but is most often performed during the second stage of a two-stage reconstruction for cavovarus deformity with clawing of the hallux
c. Combine with percutaneous tenotomy of the FHL (see this chapter)
2. Technique (Figure 7-20)
a. If this is an isolated procedure, perform a percutaneous tenotomy of the FHL (see this chapter)
b. If this procedure is being performed in conjunction with other procedures during the second-stage reconstruction of a cavovarus foot, the FHL was already released in stage 1.
Figure 7-20. Jones transfer. A. Extensor hallucis longus is released from the hallux asymmetrically. B. The long lateral slip is passed transversely through a drill hole in the distal metaphysis of the 1st MT. C. The transferred EHL slip is brought back firmly into the split in the tendon and sutured securely. Ensure that the FHL has been released.
c. Make a longitudinal incision dorsal to the extensor halluces longus (EHL) starting just distal to the hallux IP joint and extending proximally to the base of the 1st MT
d. Release the EHL from its tendon sheath and release all soft tissue attachments to it
e. Split the EHL longitudinally
f. Release the lateral half of the tendon from its insertion on the distal phalanx and insert a Bunnell-type 2-0 absorbable suture in its end
g. Divide the medial half of the tendon immediately proximal to the metatarsophalangeal (MTP) joint and insert a tagging 2-0 absorbable suture in both ends
h. Make a transverse tunnel in the 1st MT neck with a small-diameter power drill
i. Pass the long lateral half of the EHL through the tunnel from lateral to medial
j. Complete all other bone and soft tissue procedures. Importantly, complete the medial cuneiform plantar-based opening wedge osteotomy. Setting the tension on this transfer should be the last procedure performed (or second to last if a SPLATT [see this chapter] is being performed concurrently) before final wound closure and cast application (see Management Principle #24, Chapter 4).
k. With the foot and ankle in anatomic alignment, pull the lateral half of the EHL through the tunnel in the 1st MT and firmly back upon itself
l. Position the transferred half of the EHL in the proximal extent of the split in the EHL and suture the 3 half tendons together with 2-0 absorbable sutures. This effectively simulates a Pulvertaft weave.
m. Pass the long medial distally-based slip of the EHL through a transverse slit in the extensor hallucis brevis/dorsal capsule of the MTP joint. Pull the tendon firmly back upon itself, thereby extending the IP and MTP joints, and suture the afferent and efferent limbs to each other with 2-0 absorbable sutures. This creates an extension tenodesis (Figure 7-21).
n. The alternative is a hallux IP joint arthrodesis (see Chapter 8), which is not indicated in children with open growth plates. The described tenodesis works very well in most cases.
o. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
p. Apply a short-leg non–weight-bearing cast
q. Change to a short-leg walking cast after 6 weeks and maintain it until 8 weeks postoperatively
3. Pitfalls
a. Insufficient tension on the distal tenodesis of the EHL to the extensor hallucis brevis to create an extension tenodesis
b. Insufficient tension on the transfer of the EHL to the 1st MT
Figure 7-21. EHL tenodesis. The long medial distally-based slip of the asymmetrically cut split EHL is passed transversely through a slit in the extensor hallucis brevis/dorsal capsule of the MTP joint. It is pulled back firmly to extend the IP joint and then sutured securely to itself to create a tenodesis.
c. Failure to release the FHL
d. Failure to release the volar capsule of the IP joint and longitudinally pin across the joint if it does not fully extend following FHL tenotomy
e. Assuming that the EHL transfer will correct forefoot pronation deformity. It will not. A medial cuneiform osteotomy is needed to correct the deformity, whereas the EHL transfer will help prevent recurrent deformity by supplementing the weak anterior tibialis (see Management Principles #5, 6, 15, 22-2, Chapter 4).
4. Complications
a. Drop toe due to insufficient tension, rupture, or stretching out of the tenodesis
i. Avoid by
• setting exaggerated tension initially
• cautioning against barefoot walking
Reverse Jones Transfer of FHL to 1st MT Neck
1. Indications
a. Dorsal bunion (see Chapter 5)
i. Often combined with transfer of the anterior tibialis to the middle (2nd) cuneiform (see this chapter) and a medial cuneiform plantar flexion osteotomy (see Chapter 8)
2. Technique (Figure 7-22)
a. Make a longitudinal incision along the medial border of the forefoot from the 1st MTP joint to the base of the 1st MT
b. Perform an intramuscular recession of the tendon of the abductor hallucis
c. Retract the abductor hallucis plantarward
d. Isolate and release the FHL tendon sheath under the 1st MT from the distal phalanx to the base of the 1st MT. Hyperflex the IP and MTP joints to aid with exposure of the FHL insertion on the distal phalanx
e. Release the FHL from the distal phalanx and split it longitudinally
f. Insert a Bunnell-type 2-0 absorbable suture in the end of one slip of the FHL, leaving long tails on both limbs of the suture; and insert a tagging 2-0 absorbable suture in the other slip
g. If it is not possible to easily dorsiflex the MTP joint past neutral, release the plantar capsule sharply from medial to lateral
h. Make a vertical tunnel in the 1st MT neck with a drill bit a little larger than the thickness of the split half of the FHL
i. Pass the FHL slip with the Bunnell suture through the tunnel from plantar to dorsal
j. Importantly, complete the medial cuneiform plantar flexion osteotomy before setting the tension on the transfer. Setting the tension on this transfer should be the second to last procedure performed before final wound closure and cast application. The last procedure should be setting the tension on the anterior tibialis tendon transfer to the middle (2nd) cuneiform (see Management Principle #24, Chapter 4).
k. With the foot and ankle in anatomic alignment, pull the transferred slip of the FHL (that was passed through the tunnel in the 1st MT) firmly back upon itself
l. Position the transferred slip in the proximal extent of the split in the FHL and suture the 3 half tendons together with 2-0 absorbable sutures. This effectively simulates a Pulvertaft weave.
m. Tension the anterior tibialis tendon transfer to the middle (2nd) cuneiform, if applicable
n. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
o. Apply a short-leg non–weight-bearing cast
p. Change to a short-leg walking cast after 6 weeks and maintain it until 8 weeks postoperatively
3. Pitfalls
a. Failure to release a contracted volar capsule of the 1st MTP joint
b. Insufficient tension placed on the transfer
c. Assuming that the transfer will correct forefoot supination deformity. It will not. A medial cuneiform osteotomy is needed to correct the deformity, whereas the FHL transfer will help prevent recurrent deformity by substituting for the weak peroneus longus (see Management Principles #5, 6, 15, 22-2, Chapter 4).
4. Complications
a. None
Hibbs Transfer of Extensor Digitorum Communis to Cuboid or Peroneus Tertius
1. Indications
a. Claw deformity of the lesser toes (see Chapter 5) that causes pain and skin irritation over the dorsum of the IP joints and/or under the MT heads
i. usually associated with a cavovarus foot deformity, as in CMT or other neuromuscular disorder (see Cavovarus Foot, Chapter 5)
b. Can be performed as an isolated procedure, but is most often performed during the second stage of a two-stage reconstruction for cavovarus deformity with clawing of the lesser toes
c. Combine with percutaneous tenotomy of the FDL to all affected toes (see this chapter)
2. Technique (Figure 7-23)
a. If this is an isolated procedure, perform a percutaneous tenotomy of the FDL to toes 2 to 5 (see this chapter)
b. If this procedure is being performed in conjunction with other procedures during the second-stage reconstruction of a cavovarus foot, the FDL to toes 2 to 5 was already released in stage 1.
c. Make a longitudinal incision over the dorsolateral midfoot following the course of the extensor digitorum communis (EDC) and peroneus tertius. Avoid/retract the superficial peroneal nerve.
d. Isolate the peroneus tertius if one exists (approximately 15% of people do not have a peroneus tertius)
Figure 7-22. Reverse Jones transfer. A. The site of the abductor hallucis intramuscular recession is marked. The FHL is exposed, retracted, and released from its insertion on the distal phalanx of the hallux. B. The FHL is split longitudinally and a tagging suture is inserting in both ends. C. One slip of the FHL is passed through a vertical drill hole in the 1st MT from plantar to dorsal. D. The slip is pulled back on itself. E. A plantar-based wedge of bone has been removed from the medial cuneiform. Plantar flexion of the 1st ray brings the osteotomy surfaces into apposition. F. A wire staple has been inserted from plantar to dorsal to internally fixate the osteotomy. The tendon slip of the FHL that was passed through the drill hole is firmly pulled back upon itself and sutured to itself as well as the other slip of the tendon.
e. Release the EDC slip to the 5th toe as far distal as possible and insert a Bunnell-type #0 absorbable suture in its end, leaving long tails on both limbs of the suture
f. Resect a 2-cm section from the EDC slips to toes 2 to 4
g. If there is a peroneus tertius:
i. pass the EDC slip #5 through a slit in the tertius
ii. complete all other bone and soft tissue procedures. Setting the tension on this transfer should be the last, or second to last (before the Jones transfer), procedure performed before final wound closure and cast application (see Management Principle #24, Chapter 4).
iii. with the foot and ankle in anatomic alignment, pull the EDC slip #5 firmly through the slit in the peroneus tertius while the latter tendon is pulled proximally with a button hook
iv. repair this Pulvertaft weave with figure-of-8 2-0 absorbable sutures
h. If there is no peroneus tertius:
i. drill a hole in the cuboid from dorsal to plantar that is slightly larger in diameter than the EDC slip #5
ii. thread one of the long suture tails into each of two large Keith needles. Pass one of the needles through the hole until the tip pierces the plantar skin, but do not pull it through yet. Leave the needle shaft in the hole. Pass the other needle, exiting 5 to 7 mm away from the first on the plantar surface of the midfoot. If the first suture were left bare in the hole, the second Keith needle would almost certainly pierce and weaken it. Pull both needles and sutures through the hole and out the plantar surface of the foot.
iii. pass the needles through a thick felt pad and through different holes in a large button
iv. complete all other bone and soft tissue procedures. Setting the tension on this transfer should be the last, or second to last (before the Jones transfer), procedure performed before final wound closure and cast application (see Management Principle #24, Chapter 4).
v. with the foot and ankle in anatomic alignment, pull the EDC slip #5 firmly into the hole in the cuboid and tie the sutures over a button and thick felt pad on the plantar aspect of the midfoot
Figure 7-23. Hibbs transfer. A. The EDC slip to the 5th toe was released distally. Other three EDC slips are exposed. B. Kocher clamps are placed on the EDC slips to toes 2 to 4 approximately 2 cm apart. C. Those three slips are divided immediately proximal to the proximal clamp. D. The three slips are divided immediately distal to the distal clamp to complete the segmental resections. E. For feet in which there is no peroneus tertius (˜15%), the lead sutures on EDC slip #5 are passed through a drill hole in the cuboid on Keith needles. F. They exit 5 to 7 mm apart on the plantar surface of the midfoot. G. The tendon is pulled into the hole and the sutures are tied under tension over a thick felt pad and button. H. For feet with a peroneus tertius (˜85%), EDC slip #5 is passed through a slit in that tendon for repair as a Pulvertaft weave.
vi. supplement the button fixation by suturing the tendon to the dorsal periosteum of the cuboid with a 2-0 absorbable suture
i. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
j. Apply a short-leg non–weight-bearing cast
k. Change to a short-leg walking cast after 6 weeks and maintain it until 8 weeks postoperatively
3. Pitfalls
a. Insufficient tension on the transfer of the EDC to the peroneus tertius or the cuboid
b. Failure to release the FDL to toes 2 to 5
c. Failure to longitudinally pin the toes temporarily if they do not fully passively extend following release of the FDL
d. Assuming that the EDC transfer will correct foot deformity. It will not (see Management Principles #5, 6, 15, 22-2, Chapter 4).
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by careful dissection, identification, and retraction
b. Pull-out of the tendon from the bone
i. Avoid by:
• anchoring the tendon securely with the #0 lead suture tied over a plantar button and adding a supplemental suture between the tendon and the dorsal periosteum of the cuboid
• immobilizing in a cast for at least 6 weeks
Anterior Tibialis Tendon Transfer to the Lateral (3rd) Cuneiform (ATTTx)
1. Indications
a. Clubfoot (see Chapter 5) with full correction of all deformities and with good flexibility, but with muscle imbalance that is characterized by overpull of the anterior tibialis in relation to the peroneus longus and peroneus tertius
i. If residual or recurrent deformities coexist, preoperative serial casting should be performed to correct them.
ii. If any of the segmental deformities cannot be corrected by a series of preoperative casts, they can be surgically corrected concurrent with the tendon transfer (see Management Principles #5, 6, 15, 22-2, Chapter 4).
2. Technique (Figure 7-24)
a. If any residual deformities exist despite preoperative serial casting, they should be corrected before performing the tendon transfer. For example, a TAT (see this chapter) or plantar fasciotomy (PF) (see this chapter) should be performed first.
Figure 7-24. Anterior tibialis tendon transfer to the lateral (3rd) cuneiform. See text within figures. (From Mosca VS. In: Lynn Staheli, ed. Clubfoot: Ponseti Management, 3rd ed., www.Global-HELP.org, 2009.)
Anterior Tibialis Transfer
Indication
Transfer is indicated if the child has persistent varus and supination during walking. The sole shows thickening of the lateral plantar skin. Make certain that any fixed deformity is corrected by two or three casts before performing the transfer. Transfers are best performed when the child is between 3 and 5 years of age.
Often, the need for transfer is an indication of poor compliance with brace management.
Mark the sites for incisions
The dorsolateral incision is marked on the mid-dorsum of the foot [A].
Make medial incision
The dorsomedial incision is made over the insertion of the anterior tibialis tendon [B].
Expose anterior tibialis tendon
The tendon is exposed and detached at its insertion [C]. Avoid extending the dissection too far distally to avoid injury to the growth plate of the first metatarsal.
Place anchoring sutures
Place a #0 dissolving anchoring suture [D]. Make multiple passes through the tendon to obtain secure fixation.
Transfer the tendon
Transfer the tendon to the dorsolateral incision [E]. The tendon remains under the extensor retinaculum and the extensor tendons. Free the subcutaneous tissue to allow the tendon a direct course laterally.
Option: localize site for insertion
Using a needle as a marker, radiography may be useful in exactly localizing the site of transfer in the third cuneiform [F]. Note the position of the hole in the radiograph (arrow).
Identify site for transfer
This should be in the mid-dorsum of the foot and ideally into the body of the third cuneiform. Make a drill hole large enough to accommodate the tendon [G].
Thread sutures
Thread a straight needle on each of the securing sutures. Leave the first needle in the hole while passing the second needle to avoid piercing the first suture [H]. Note that the needle penetrates the sole of the foot (arrow).
Pass two needles
Place the needles through a felt pad and then through different holes in the button to secure the tendon [A].
Secure tendon
With the foot held in dorsiflexion, pull the tendon into the drill hole by traction on the fixation sutures and tie the fixation sutures with multiple knots [B].
Supplemental fixation
Supplement the button fixation by suturing the tendon to the periosteum at the site where the tendon enters the cuneiform [C], using a heavy absorbable suture.
Neutral position without support
Without support, the foot should rest in approximately 5–10 degrees of plantar flexion [D] and neutral valgus-varus.
Local anesthetic
A long-acting local anesthetic is injected into the wound [E] to reduce immediate postoperative pain.
Skin closure
Close the incisions with absorbable subcutaneous sutures [F]. Tape strips reinforce the closure.
Cast immobilization
A sterile dressing is placed [G], and a long leg cast is applied [H].
Postoperative care
This patient was discharged on the same day of the procedure. Usually, the patients remain hospitalized overnight. The sutures absorb. Remove the cast at 6 weeks. No bracing is necessary after the procedure. See the child again in 6 months to assess the effect of the transfer.
b. Make a 4-cm longitudinal incision over the dorsomedial midfoot in line with the anterior tibialis tendon
c. Expose and isolate the anterior tibialis tendon from the distal edge of the extensor retinaculum to the base of the 1st MT. Carefully expose the distal end of the tendon without injuring the 1st MT physis
d. Taper the flared end of the tendon to the thickness of the more proximal visible portion and release it from the 1st MT far distally.
e. Insert a Bunnell-type #0 absorbable suture in its end, leaving long tails on both limbs of the suture
f. Make a 4-cm longitudinal incision over the central midfoot in line with the 3rd MT/lateral (3rd) cuneiform. Avoid/retract the superficial peroneal nerve.
g. Bluntly expose the lateral cuneiform between the EDC and the peroneus tertius
h. Using a 25G needle and mini-fluoroscopy, identify the lateral cuneiform
i. Make a cruciate incision in the periosteum and elevate the four triangular corners with a Freer elevator
j. Make a drill hole through the lateral cuneiform, including the plantar cortex, aimed somewhat lateral to the mid-arch. The diameter of the hole should be slightly greater than the diameter of the tendon.
k. Transfer the tendon laterally from the dorsomedial incision to the central incision remaining deep to the extensor tendons, and certainly deep to the extensor retinaculum. Release fatty or fibrous bands that prevent the tendon from assuming a reasonably straight vector from proximal to distal in its new location.
l. Thread one of the long suture tails into each of two large Keith needles. Pass one of the needles through the hole until the tip pierces the plantar skin, but do not pull it through yet. Leave the needle shaft in the hole. Pass the other needle, exiting 5 to 7 mm away from the first on the plantar surface of the midfoot. If the first suture were left bare in the hole, the second Keith needle would almost certainly pierce and weaken it. Pull both needles and sutures through the hole and out the plantar surface of the foot.
m. Pass the needles through a thick felt pad and through different holes in a large button
n. With the foot held in at least 10° of dorsiflexion, pull the tendon firmly into the drill hole and tie the sutures over the felt pad and button on the plantar surface of the midfoot
o. Supplement the button fixation by suturing the tendon to the dorsal periosteum of the lateral cuneiform with a 2-0 absorbable suture
p. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
q. Apply a long-leg, bent knee clubfoot cast with maximum dorsiflexion and abduction/eversion molding
r. Remove the cast 6 weeks later
s. A CAM boot can be used for an additional 2 weeks in children over 4 years of age
3. Pitfalls
a. Failure to correct residual or recurrent deformities either before surgery with serial casting or during the operation with the appropriate surgical procedure(s) (see Management Principles #5, 6, 15, 22-2, Chapter 4)
b. Incorrect destination for transfer, because of failure to confirm the site with mini-fluoroscopy
c. Insufficient tension placed on the transfer
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by careful dissection, identification, and retraction
b. Pull-out of the tendon from the bone
i. Avoid by:
• waiting to operate until there is a large ossification center in the lateral cuneiform. Tendon likely heals better to bone than to cartilage, though this has not been proven
• anchoring the tendon securely with the #0 lead suture tied over a plantar button and adding a supplemental suture between the tendon and the dorsal periosteum of the lateral cuneiform
• immobilizing in a cast for at least 6 weeks
Anterior Tibialis Tendon Transfer to the Middle (2nd) Cuneiform
1. Indications
a. Dorsal bunion (see Chapter 5)
i. Often combined with a reverse Jones transfer of the FHL to the 1st MT (see this chapter) and a medial cuneiform plantar flexion osteotomy (see Chapter 8)
2. Technique (see Figure 7-24, above)
a. Make a 4-cm longitudinal incision over the dorsomedial midfoot in line with the 2nd MT/middle (2nd) cuneiform
b. Expose and isolate the anterior tibialis tendon from the distal edge of the extensor retinaculum to the base of the 1st MT. Carefully expose the distal end of the tendon without injuring the 1st MT physis
c. Taper the flared end of the tendon to the thickness of the more proximal visible portion and release it from the 1st MT far distally.
d. Insert a Bunnell-type #0 absorbable suture in its end, leaving long tails on both limbs of the suture
e. Bluntly expose the dorsum of the middle (2nd) cuneiform and confirm its location using a 25G needle and mini-fluoroscopy
f. Make a cruciate incision in the periosteum and elevate the four triangular corners with a Freer elevator
g. Make a drill hole through the middle cuneiform, including the plantar cortex. The diameter of the hole should be slightly greater than the diameter of the tendon
h. Shift the tendon laterally releasing any fatty or fibrous bands that prevent the tendon from assuming a straight vector from proximal to distal in its new location
i. Thread one of the long suture tails into each of two large Keith needles. Pass one of the needles through the hole until the tip pierces the plantar skin, but do not pull it through yet. Leave the needle shaft in the hole. Pass the other needle, exiting 5 to 7 mm away from the first on the plantar surface of the midfoot. If the first suture were left bare in the hole, the second Keith needle would almost certainly pierce and weaken it. Pull both needles and sutures through the hole and out the plantar surface of the foot.
j. Pass the needles through a thick felt pad and through different holes in a large button
k. Complete all other bone and soft tissue procedures, including the medial cuneiform osteotomy and the reverse Jones transfer of the FHL to the first MT, and close all other incisions (see Management Principle #24, Chapter 4)
l. With the foot held in at least 10° of dorsiflexion, pull the tendon firmly into the drill hole and tie the sutures over the felt pad and button on the plantar aspect of the midfoot
m. Supplement the button fixation by suturing the tendon to the dorsal periosteum of the middle cuneiform with a 2-0 absorbable suture
n. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
o. Apply a short-leg non–weight-bearing cast with neutral positioning of the ankle and subtalar joints and with forefoot pronation
p. Change the cast to a short-leg walking cast after 6 weeks and remove that 1 to 2 weeks later
3. Pitfalls
a. Incorrect destination for transfer, because of failure to confirm the site with mini-fluoroscopy
b. Insufficient tension placed on the transfer
4. Complications
a. Pull-out of the tendon from the bone
i. Avoid by:
• anchoring the tendon securely with the #0 lead suture tied over a plantar button and adding a supplemental suture between the tendon and the dorsal periosteum of the middle cuneiform
• immobilizing in a cast for at least 6 weeks
Split Anterior Tibial Tendon Transfer (SPLATT)
1. Indications
a. Varus or cavovarus foot deformity in a child with cerebral palsy (see Chapter 5)
b. Cavovarus foot deformity in a child with other neuromuscular disorder, such as CMT (see Chapter 5)
c. Often combined with a posterior tibialis tendon recession or lengthening with or without a medial or plantar-medial release (see this chapter)
2. Technique (Figure 7-25)
a. Make a 4-cm longitudinal incision over the dorsomedial midfoot in line with the anterior tibialis tendon
b. Expose and isolate the anterior tibialis tendon from the distal edge of the extensor retinaculum to the base of the 1st MT. Carefully expose the distal end of the tendon without injuring the 1st MT physis
c. Split the anterior tibialis tendon longitudinally (there is often a natural longitudinal cleft/split in the tendon, as if there are two adjacent adherent tendons, that can be used to easily create the split)
d. Release one of the slips from the 1st MT
e. Insert a Bunnell-type #0 absorbable suture in its end, leaving long tails on both limbs of the suture
f. Without releasing the extensor retinaculum, split the anterior tibialis as far proximal as possible while removing all soft tissue connections, including vinculae. Dorsiflexion of the ankle and distal traction on the 2 limbs of the tendon will help with proximal exposure of the tendon
g. Make a 5- to 6-cm longitudinal incision anterior to the crest of the distal tibial metaphysis
h. Release the anterior compartment fascia longitudinally
i. The anterior tibialis is the thick tendon immediately lateral to the tibial crest. Release all soft tissue attachments to the tendon.
j. Dorsiflex the ankle while pulling the anterior tibialis tendon proximally into the anterior ankle incision using a button hook. The split in the tendon should become visible just proximal to the extensor retinaculum. Retrieve the split half and pull it retrograde into the anterior ankle wound
k. Continue splitting the tendon proximally to the level of the musculoskeletal junction
l. At that level, place a simple 2-0 absorbable suture on both corners of the limit of the split. This will prevent the tendon from splitting any further, thereby ensuring that the tension that is set will persist
m. Make a longitudinal incision over the dorsolateral midfoot following the course of the peroneus tertius. Avoid/retract the superficial peroneal nerve
n. Isolate the peroneus tertius, if one exists (approximately 15% of people do not have a peroneus tertius)
o. Using a retrograde tonsil clamp, pull the lead sutures on the split half of the anterior tibialis antegrade deep to the extensor retinaculum and adjacent to the peroneus tertius from the anterior ankle incision to the dorsolateral incision
p. If there is a peroneus tertius:
i. pass the split half of the anterior tibialis through a slit in the tertius
ii. complete all other procedures and close all other incisions. Setting the tension on this transfer should be the last procedure performed before final wound closure and cast application (see Management Principle #24, Chapter 4)
iii. with the ankle in slight dorsiflexion and the subtalar joint everted, pull the split half of the anterior tibialis firmly through the slit in the peroneus tertius while the latter tendon is pulled proximally with a button hook. Repair this Pulvertaft weave with figure-of-8 2-0 absorbable sutures
Figure 7-25. Split anterior tibialis tendon transfer. A. The anterior tibialis has been exposed through a dorsomedial incision, split longitudinally, and one of the slips has been released from the 1st MT. That slip has been retracted retrograde (blue arrow) to an incision anterior to the distal tibial metaphysis. B.The peroneus tertius is exposed through a dorsolateral incision. For the approximately 15% of individuals without a peroneus tertius, the cuboid can be exposed through this incision for transfer of the tendon into a drill hole in that bone. C. Absorbable 2-0 sutures are placed at the proximal extent of the split in the tendon (at the musculoskeletal junction—black circle) to prevent further inadvertent splitting of the tendon. D. A tonsil clamp is passed retrograde deep to the peroneus tertius and extensor retinaculum to the anterior ankle incision (black arrow). E. There, it captures the sutures on the split half of the anterior tibialis for antegrade delivery (blue arrow) of the tendon to the dorsolateral incision. F. The anterior tibialis tendon is passed through a slit in the peroneus tertius for later tensioning. G. The pathway for the split transfer is indicated by the blue arrows. H. With the subtalar joint everted and the ankle dorsiflexed, the Pulvertaft weave is being tensioned and secured with 2-0 absorbable sutures. Note that the other incisions have already been sutured closed. Securing the tendon transfer and closing that incision are the last procedures performed before cast application (see Management Principle #24, Chapter 4).
q. If there is no peroneus tertius:
i. drill a hole in the cuboid from dorsal to plantar
ii. thread one of the long suture tails into each of two large Keith needles. Pass one of the needles through the hole until the tip pierces the plantar skin, but do not pull it through yet. Leave the needle shaft in the hole. Pass the other needle, exiting 5 to 7 mm away from the first on the plantar surface of the midfoot. If the 1st suture were left bare in the hole, the second Keith needle would almost certainly pierce and weaken it. Pull both needles and sutures through the hole and out the plantar surface of the foot
iii. complete all other procedures and close all other incisions. Setting the tension on this transfer should be the last procedure performed before final wound closure and cast application (see Management Principle #24, Chapter 4)
iv. with the ankle in slight dorsiflexion and the subtalar joint everted, pull the split half of the anterior tibialis firmly into the hole in the cuboid and tie the sutures over a button and thick felt pad on the plantar aspect of the midfoot
v. supplement the button fixation by suturing the tendon to the dorsal periosteum of the cuboid with a 2-0 absorbable suture
r. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
s. Apply a short-leg non–weight-bearing cast with neutral rotation of the forefoot, eversion of the subtalar joint, and slight dorsiflexion of the ankle
t. Change the cast to a short-leg walking cast after 6 weeks and remove that one 2 weeks later
3. Pitfalls
a. Insufficient tension placed on the transfer
b. Failure to recognize and concurrently correct structural deformities of the foot, such as fixed inversion of the subtalar joint, severe cavus, and rigid pronation of the forefoot (see Management Principles #5, 6, 15, 22-2, Chapter 4)
c. If there is severe pronation of the forefoot (plantar flexion of the 1st ray), a SPLATT will further weaken dorsiflexion of the 1st ray and potentiate the power of the peroneus longus (the plantar flexor of the 1st ray), resulting in further pronation of the forefoot. In this scenario, one should consider a PF (see this chapter), a medial cuneiform dorsiflexion osteotomy (see Chapter 8), and/or a peroneus longus to peroneus brevis transfer (see this chapter).
4. Complications
a. Injury to the superficial peroneal nerve
i. Avoid by careful dissection, identification, and retraction
b. Pull-out of the tendon from the bone
i. Avoid by:
• anchoring the tendon securely with the #0 lead suture tied over a plantar button and adding a supplemental suture between the tendon and the dorsal periosteum of the cuboid
• immobilizing in a cast for at least 6 weeks
Peroneus Longus to Peroneus Brevis Transfer (PL to PB tx)
1. Indications
a. Cavovarus foot deformity with pronation of the forefoot in a child with CMT or other neuromuscular disorder, including some with CP (see Chapter 5)
i. This is the most important tendon transfer for most cavovarus foot deformities. The primary deformity in a cavovarus foot is plantar flexion of the 1st ray (pronation of the forefoot). The peroneus longus plantar flexes the 1st ray. The second deformity in a cavovarus foot is inversion of the hindfoot because of relative weakness of the evertor (peroneus brevis) compared with the invertor (posterior tibialis). Transfer of the peroneus longus to the peroneus brevis removes the primary deforming forces and enhances the power of hindfoot eversion (see Management Principle #22, Chapter 4).
b. Often performed as one of several concurrent or staged procedures to correct cavovarus deformity, including plantar-medial release (see this chapter), medial cuneiform dorsiflexion osteotomy (see Chapter 8), SPLATT (see this chapter), Jones transfer (see this chapter), Hibbs transfer (see this chapter), and posterior calcaneus displacement osteotomy (see Chapter 8)
2. Technique (Figure 7-26)
a. This transfer is usually performed along with one or more other procedures during the second stage of a two-stage cavovarus foot reconstruction.
b. Make a slightly curved incision on the lateral aspect of the calcaneus following the course of the peroneal tendons starting posterior to the lateral malleolus and ending at the glabrous skin plantarward. This is the same incision used for a posterior calcaneus displacement osteotomy (see Chapter 8).
c. Isolate and protect the sural nerve
d. Release the peroneus longus and brevis from their tendon sheaths
e. Resect the septum (the conjoined tendon sheaths) that separates them. Resect the peroneal tubercle if it is large
f. Make a long Z-cut in the peroneus longus and place a tagging 2-0 absorbable suture in the free end of the proximal slip. Pass this slip through a slit in the peroneus brevis for later tensioning
g. The exposed portion of the distal slip of the peroneus longus can be resected. If there is concern that the forefoot might overcorrect to supination, this slip can be sutured to the periosteum on the lateral surface of the calcaneus, thereby changing the tendon into a ligament and creating a tenodesis.
h. Complete all other procedures and close all other incisions. If a posterior calcaneus displacement osteotomy (see Chapter 8) is being performed concurrently, displace and internally fixate the posterior bone fragment before setting the tension on the tendon transfer. Setting the tension on this transfer should be the last (or one of the last) procedure performed before final wound closure and cast application (see Management Principle #24, Chapter 4)
Figure 7-26. Peroneus longus to brevis transfer. A. The peroneus longus is plantar to the peroneus brevis tendon along the lateral surface of the calcaneus. Both are released from their tendon sheaths. Ensure that they are appropriately identified by observing the effect of traction on each one using a button/tendon hook. B–D. The peroneus longus is cut in a Z-fashion. E. A lead suture is placed in the end of the proximal slip as a handle. F. The proximal slip of the peroneus longus is passed through a slit in the peroneus brevis. E. A lead suture is placed in the end of the proximal slip as a handle. F. The proximal slip of the peroneus longus is passed through a slit in the peroneus brevis. G. This Pulvertaft weave is secured under firm tension with figure-of-8 sutures of 2-0 absorbable sutures.
i. Dorsiflex the ankle to neutral and fully evert the subtalar joint. Firmly pull the proximal slip of the peroneus longus tendon distally through the slit in the peroneus brevis while the latter tendon is pulled proximally with a button hook. Repair this Pulvertaft weave with multiple figure-of-8 2-0 absorbable sutures
j. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
k. Apply a short-leg cast with weight-bearing status and duration of casting dependent the other procedures that were performed concurrently. Generally, a short-leg non–weight-bearing cast is used for 6 weeks followed by 2 weeks in a short-leg weight-bearing cast
3. Pitfalls
a. Failure to recognize and concurrently correct structural deformities of the foot, such as fixed inversion of the subtalar joint, severe cavus, and rigid pronation of the forefoot (see Management Principles #5, 6, 15, 22-2, Chapter 4)
b. Insufficient tension placed on the transfer
4. Complications
a. Injury to the sural nerve
i. Avoid by careful dissection, identification, and retraction
Anterior Tibialis Tendon Transfer to the Tendo-Achilles (AT to TA tx)
1. Indications
a. Acquired calcaneus foot deformity (see Chapter 5) due to a strong anterior tibialis and a weak triceps surae, typically in a child with myelomeningocele
2. Technique (Figure 7-27)
a. Make a 4-cm longitudinal incision over the dorsomedial midfoot in line with the anterior tibialis tendon
b. Expose and isolate the anterior tibialis tendon from the distal edge of the extensor retinaculum to the base of the 1st MT. Carefully expose the distal end of the tendon without injuring the 1st MT physis
c. Taper the flared end of the tendon to the thickness of the more proximal visible portion and release it from the 1st MT far distally.
d. Insert a Bunnell-type #0 absorbable suture in its end, leaving long tails on both limbs of the suture
e. Make a 5- to 6-cm longitudinal incision anterior to the crest of the distal tibial metaphysis
f. Release the anterior compartment fascia longitudinally. The anterior tibialis is the thick tendon immediately lateral to the tibial crest.
g. Release all soft tissue attachments from the tendon and pull the entire tendon retrograde from the foot to this incision on the lower leg.
h. Expose the interosseous membrane by retracting the soft tissues laterally away from the tibia. Gently retract the NV bundle.
i. Approximately 5 to 7 cm proximal to the ankle joint, make a window in the interosseous membrane that is the full width of the membrane and at least 1.5 cm long
j. Make a longitudinal incision along the posteromedial aspect of the ankle half way between the tendo-Achilles and the tibia. Expose and isolate the tendo-Achilles
k. Pass a tonsil clamp through the window in the interosseous membrane from anterior/proximal (in the anterior ankle incision) to posteromedial/distal (in the posteromedial incision). Keep the tonsil clamp adjacent to the tibia while spreading the soft tissues without closing the clamp in the depths of the wound.
l. The tonsil clamp should emerge in the distal aspect of the posteromedial incision lateral to the posterior tibial NV bundle and anteromedial to the tendo-Achilles.
m. Perform a reverse passage of a second tonsil clamp (clamped to the first clamp). Use it to clamp the lead suture on the anterior tibialis tendon and pull the tendon distally into the posteromedial wound
n. Confirm that the path of the tendon is fairly straight and not bound or deviated by the window in the interosseous membrane
o. Pass the anterior tibialis tendon through a slit in the tendo-Achilles
p. Ensure that the ankle can be plantar flexed beyond neutral. If not, release any tethering anterior and dorsal soft tissues.
q. Plantar flex the ankle 10° by pulling the tendo-Achilles proximally with a button hook, while pulling the anterior tibialis firmly through the slit in the tendo-Achilles and back upon itself. Repair this Pulvertaft weave with multiple figure-of-8 #0 absorbable sutures
r. Approximate the skin edges with interrupted subcutaneous 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture
Figure 7-27. Anterior tibialis tendon transfer to tendo-Achilles. A. Through a dorsomedial foot incision, the anterior tibialis is released from the 1st MT and a tagging suture is placed in its distal end. Through an incision anterior to the distal tibial metaphysis, the tendon is again identified. B. The anterior tibialis anterior tendon is retracted proximally. While protecting the anterior tibial NV bundle, the interosseous membrane is exposed. An adequate size window is made in the membrane at least 5 to 7 cm proximal to the ankle joint (green U). C. The lead sutures are passed from anterior/proximal to posteromedial/distal through the window in the membrane, exiting through a longitudinal incision anteromedial to the tendo-Achilles. D. The anterior tibialis is pulled through the window. The sutures/tendon pass lateral to the posterior tibial NV bundle. E. The anterior tibialis is passed through a slit in the tendo-Achilles. The tendo-Achilles is pulled proximally to place the ankle in slight plantar flexion while the anterior tibialis is pulled distally. This Pulvertaft weave is sutured under tension with 2-0 absorbable sutures. F. The anterior tibialis is pulled back upon itself where additional sutures are placed.
s. Apply a short-leg non–weight-bearing cast with the ankle in 10° of plantar flexion
t. Remove the cast after 6 weeks and take a mold for an ankle-foot-orthotic (AFO)
u. Apply a short-leg walking cast that will be worn for the 1 to 2 weeks needed to fabricate the AFO
3. Pitfalls
a. Failure to release a dorsiflexion contracture at the ankle that is due to structures other than the anterior tibialis
b. Insufficient tension placed on the transfer
4. Complications
a. Injury to the anterior tibial NV bundle
i. Avoid by careful dissection, identification, and retraction
b. Injury to the posterior tibial NV bundle
i. Avoid by careful dissection, identification, and passage of the tendon posterior to the bundle
Posterior Tibialis Tendon Transfer to the Dorsum of the Foot (PT tx dorsum)
1. Indications
a. Cavovarus foot (see Chapter 5) in which the posterior tibialis is the only functioning muscle, i.e., not cavovarus due to CMT
i. This is an out of phase transfer, so it should not be a transfer of first choice in most cavovarus foot deformities. In most cases, this transfer acts as a tenodesis (see Management Principle #22-1, Chapter 4).
2. Technique (Figure 7-28)
a. Make a longitudinal incision along the medial border of the midfoot/hindfoot over the posterior tibialis tendon extending posteriorly to the posterior tibial NV bundle
b. Release the posterior tibialis tendon sheath from the tip of the medial malleolus distally
c. Release the tendon from the navicular as far plantar-distally as possible, so as to have enough tendon length for transfer
d. Insert a Bunnell-type #0 absorbable suture in its end, leaving long tails on both limbs of the suture
e. Make a 5- to 6-cm longitudinal incision anterior to the crest of the distal tibial metaphysis
f. Release the anterior compartment fascia longitudinally
g. Expose the interosseous membrane by retracting the soft tissues laterally away from the tibia. Gently retract the anterior tibial NV bundle.
h. Approximately 5 to 7 cm proximal to the ankle joint, make a window in the interosseous membrane that is the full width of the membrane and at least 1.5 cm long
i. Make a 5-cm longitudinal incision along the posterior edge of the medial face of the tibia approximately 8 to 10 cm proximal to the tip of the medial malleolus
j. Release the fascia from the edge of the tibia
k. The first muscle encountered is the FDL. Confirm its identity by pulling proximally on its intramuscular tendon and observing flexion of the lesser toes. Retract it posteriorly.
l. The next muscle/tendon unit identified is the posterior tibialis. Confirm its identity by pulling distally on the released tendon in the foot
m. Pull the tendon retrograde to the proximal wound
n. Pass a tonsil clamp or tendon passer through the window in the interosseous membrane from anterolateral to posteromedial. Remain strictly adjacent to the posterior surface of the tibia while spreading the soft tissues, without closing the clamp in the depths of the wound. Also, keep the clamp anterior to the posterior tibial NV bundle
o. Clamp the lead sutures on the posterior tibialis tendon and pull them through the interosseous membrane from posteromedial to anterolateral. By staying anterior to the posterior tibial NV bundle, the tendon will not wrap around and compress the NV bundle.
p. Make a longitudinal incision on the dorsolateral midfoot. Avoid/retract the superficial peroneal nerve.
q. Expose the dorsum of the cuboid or the lateral cuneiform depending on your assessment of the degree of lateral positioning required
Figure 7-28. Posterior tibialis tendon transfer to the dorsum. A. The posterior tibialis tendon is exposed through a longitudinal midfoot/hindfoot incision. B. It is released from its distal/plantar-most insertion on the navicular. A tagging Bunnell-type #0 absorbable lead suture is inserted. The tendon remains anterior to the posterior tibial NV bundle at all times. C. Through a longitudinal incision anterior to the distal tibial metaphysis, the anterior compartment fascia is released. The interosseous membrane is exposed by retracting the soft tissues laterally and protecting the anterior tibial NV bundle. An adequate size window is made in the membrane at least 5 to 7 cm proximal to the ankle joint (green U). D. A longitudinal incision is made along the posteromedial edge of the tibia approximately 8 to 10 cm proximal to the tip of the medial malleolus. The posterior tibialis is pulled retrograde to that incision. A tonsil clamp is passed from anterior to posteromedial through the window in the interosseous membrane staying strictly adjacent to the posterior surface of the tibia and anterior to the posterior tibial NV bundle. The lead sutures on the tendon are grasped. E. The sutures are pulled through the window from posteromedial to anterior. F. The posterior tibialis follows. G. The tendon should have free excursion and a straight line vector through the window in the interosseous membrane. H. A tonsil clamp is passed retrograde (dashed black arrow) from an incision on the dorsolateral midfoot staying deep to the extensor retinaculum and ending in the anterior compartment that was previously exposed. The lead sutures are grasped. I–K. The sutures are pulled antegrade (dashed black arrow) until the tip of the tendon is exposed in the dorsolateral midfoot incision. L. A drill hole is made in the bone that is to accept the transfer (typically the lateral cuneiform). In adolescents, it is appropriate to supplement fixation with a suture anchor. M and N. The tendon has been pulled into the hole in the bone by the lead sutures that are tied under tension over a thick felt pad and button. O. The supplemental suture anchor has been used.
r. Drill a hole through the entire bone that is chosen
s. Pass a tonsil clamp or a tendon passer retrograde from the dorsal foot wound to the anterior leg wound staying deep to the extensor retinaculum
t. Pull the lead sutures on the posterior tibialis and, thereby, the end of the posterior tibialis tendon into the dorsal foot wound
u. Thread one of the long suture tails into each of two large Keith needles. Pass one of the needles through the hole in the bone until the tip pierces the plantar skin, but do not pull it through yet. Leave the needle shaft in the hole. Pass the other needle, exiting 5 to 7 mm away from the first on the plantar surface of the midfoot. If the first suture were left bare in the hole, the second Keith needle would almost certainly pierce and weaken it. Pull both needles and sutures through the hole and out the plantar surface of the foot.
v. Pass the needles through a thick felt pad and through different holes in a large button
w. Complete all other procedures and close all other incisions. Setting the tension on this transfer should be the last procedure performed before final wound closure and cast application (see Management Principle #24, Chapter 4)
x. With the foot held in at least 10° of dorsiflexion and full eversion, pull the tendon firmly into the drill hole and tie the sutures over the felt pad and button on the plantar surface of the midfoot
y. Supplement the button fixation by suturing the tendon to the dorsal periosteum of the bone with a 2-0 absorbable suture
i. A suture anchor can also be used in older children and adolescents
z. Apply a short-leg non–weight-bearing cast
aa. Convert to a short-leg walking cast 6 weeks later after taking a mold for an AFO
ab. Remove the final cast 2 weeks later and transition to the AFO
3. Pitfalls
a. Failure to recognize and concurrently correct structural deformities of the foot, such as fixed inversion of the subtalar joint, severe cavus, and rigid pronation of the forefoot (see Management Principles #5, 6, 15, 22-2, Chapter 4)
b. Insufficient tension placed on the transfer
4. Complications
a. Injury to the anterior tibial NV bundle
i. Avoid by careful dissection, identification, and retraction
b. Injury to the posterior tibial NV bundle
i. Avoid by careful dissection, identification, and passage of the tendon anterior to the bundle
c. Pull-out of the tendon from the bone
i. Avoid by:
• anchoring the tendon securely with the #0 lead suture tied over a plantar button and adding a supplemental suture between the tendon and the dorsal periosteum of the bone
• supplementing the tendon fixation to the bone with a suture anchor in older children and adolescents
• immobilizing in a cast for at least 6 weeks