PROCEDURE 52

Split Transfer of the Tibialis Anterior Tendon

Travis Matheney

Indications

 Spastic, flexible equinovarus-cavovarus foot deformity in the ambulatory child or adult with cerebral palsy or brain injury

 Recurrent flexible clubfoot cavovarus deformity

 Weak peroneal muscles and relative “over-pull” of the tibialis anterior leading to foot supination and cavus deformity

Pitfalls

• Be certain to assess the gastrocnemius-soleus for contracture.

• Determine whether either isolated gastrocnemius or combined gastrocnemius-soleus lengthening is required.

• Assess the tibialis posterior and plantar fascia for contracture and determine whether they should be lengthened to decrease cavus.

• Consider gait analysis preoperatively to confirm activity of the tibialis anterior and posterior in the gait cycle.

Examination/Imaging

 The peroneus longus may be relatively weaker, allowing the tibialis anterior to “over-pull” the midfoot into supination and cavus, especially during early stance and during the swing phase of gait.

 The gastrocnemius-soleus and tibialis posterior must also be assessed for contracture.

 The goal is a balanced foot in both stance and gait.

 Hindfoot varus flexibility may be tested with the Coleman block test (Coleman and Chestnut, 1977).

 Preoperative plain films, including standing anteroposterior, lateral, and oblique views of both feet, should be obtained to confirm no fixed bony deformity.

Treatment Options

• Prior to surgery, attempts can be made to improve range of motion with serial casting.

• An articulated ankle-foot orthosis that can control the foot motion may be more desired by the patient and family.

Surgical Anatomy

 The tibialis anterior has a broad insertion and is best found proximal to the first ray through the medial incision.

 When transferring to the cuboid, care should be taken to protect sensory nerve braches from the superficial peroneal nerve.

 The surgeon should try to avoid injury to the short toe extensor muscle belly when exposing the cuboid.

Positioning

 The patient is positioned supine with a small rolled blanket beneath the ipsilateral greater trochanter.

 A nonsterile tourniquet is applied to the proximal thigh, and the remainder of the leg is prepped in sterile manner.

Portals/Exposures

 Three incisions are outlined in Figure 1:

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