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Journal Club: Long term results of tibialis anterior transfer for relapsed idiopathic clubfoot treated with the ponseti method

Holt JB, Oji DE, Yack HJ, Morcuende JA. Long-term results of tibialis anterior tendon transfer for relapsed idiopathic clubfoot treated with the Ponseti method: a follow-up of thirty-seven to fifty-five years. J Bone Joint Surg Am. 2015 Jan 7;97(1):47-55. doi: 10.2106/JBJS.N.00525. PubMed PMID: 25568394.

Methods: Retrospective study with mean follow up of 43 years. 35 patients (60 clubfeet) were included. The control group of 21 patients (58%) were treated with Ponseti casting without relapse. The study group of 14 patients (42%) were treated with Ponseti casting initially then had relapse requiring repeat casting and tibialis anterior transfer.

Patients with congenital anomalies, neuromuscular dx, previous surgery, or prior treatment for clubfoot other than the Ponseti method were excluded. 126 patients met inclusion criteria and were attempted to be contacted. Many were unable to be contacted or unwilling to return because of travel expense, time requirement or general health conditions. The end result was a follow up rate of only 28%.

Patients included underwent a detailed MSK examination, radiographic evaluation, pedobarographic analysis, surface EMG and 3 quality of life questionnaires ( AAOS foot and ankle outcomes, Laaveg-Ponseti, and foot function index).

All treatments were performed by Dr. Ponseti. The decision to proceed with tibialis anterior tendon transfer was based on severity of the relapse, amount of dynamic supination deformity and varus heel malalignment and anticipated difficulties with bracing compliance 2/2 patient age.

Treatment details: The tib ant tendon was transferred to the 3rd cuneiform in 22 feet, 2nd cuneiform in 2 and cuboid in 1. Percutaneous Achilles tendon was performed in 10 feet. Plantar fasciotomy performed in 3 feet. Operative limb was immobilized in a long leg cast for 6 weeks postoperatively. No additional bracing was used thereafter. Average age at tendon transfer was 5 yrs.

Results: No patient in either study or control group had subsequent relapse or required additional operative intervention associated with clubfoot deformity. No significant differences in demographic data or Achilles tenotomy rates in the 2 groups. 7 feet in the control group did have a relapse treated with repeat casting not requiring surgical intervention.

Questionnaires: no significant differences. The most common complaint in both groups was mild pain along the Achilles tendon, no patient that had pain had radiographic evidence of Achilles tendon calcification. More patients in the tendon transfer group were taking NSAIDs for foot pain but this did not reach significance.

Physical exam: passive ankle plantar & dorsiflexion and forefoot inversion/eversion not significantly different. Motor strength of TA and peroneals comparable. Patients s/p tib ant transfer performed significantly more single-leg toe ups.

Radiographs: Patients who underwent tib ant transfer had a significantly smaller anteroposterior talocalcaneal angle and increased talar flattening. They also had increased ostophytes in the navicular-cuneiform joint, but other than that location, degenerative changes were similar across both groups.

Pedobarographic Analysis: no difference between groups

Surface EMG: no difference in muscle firing times across groups or compared with healthy subjects. Mean TA and GSC muscle amplitudes slightly decreased in TA transfer group compared to healthy subjects.

Summary: Tibialis anterior transfer is an effective procedure to correct residual dynamic supination deformity. It demonstrates no delayed or recurrent adverse outcomes and shows maintenance of foot function into the 5th decade of life. They did have a smaller AP talocalcaneal angle and greater talar flattening but this was not associated with clinical symptoms.

Limitations: only 28% followup, retrospective. A few study patients had foot/ankle pain related to concomitant etiologies (ankle trauma, rheumatoid arthritis) and outcomes in these patients were assumed to be sequelae of these other etologies- could their clubfoot have contributed? Impossible to discern.

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