The Tibialis Posterior Tendon Transfer for Foot Drop procedure is a surgical solution for patients suffering from foot drop, a condition where there is a loss of dorsiflexion, leading to difficulty in lifting the foot during walking. This condition can occur due to several reasons, including nerve injuries (such as peroneal nerve damage), neurological disorders, and trauma. Foot drop can severely affect gait, leading to high stepping, foot slapping, and difficulty in clearing the foot during the swing phase of walking. This article provides a detailed overview of the procedure, its indications, planning, surgical steps, and post-operative recovery.
Indications for Tibialis Posterior Tendon Transfer
The procedure is primarily indicated for patients who have foot drop due to:
- Common peroneal or deep peroneal nerve injury that has not recovered, whether from trauma or other causes.
- Compartment syndrome where there is loss of anterior compartment muscle function, but the deep posterior compartment muscles remain strong.
- Neuromuscular conditions that cause isolated weakness of ankle dorsiflexion.
Historically, this procedure was used for treating foot drop caused by leprosy, but it has evolved to address foot drop from other causes as well. A common assessment involves observing the patient’s walking pattern, including the absence of heel strike and foot slap, as well as difficulty in clearing the foot during the swing phase of walking. This results in a high-stepping gait that can be unattractive and functionally limiting.
Preoperative Planning and Workup
The success of the procedure heavily depends on thorough preoperative evaluation:
Clinical examination: This includes testing for high-stepping gait, foot slap, and the absence of active dorsiflexion.
Muscle strength: The strength of the tibialis posterior muscle (the tendon used for the transfer) is evaluated. If this muscle is not strong enough, other muscles like the flexor digitorum longus may be considered for supplementation.
Passive range of motion: It is crucial to assess whether the ankle can be dorsiflexed to at least 15 degrees. If not, additional procedures may be required to restore this motion.
Imaging studies: X-rays are taken to rule out any co-existing ankle arthritis or other conditions that may suggest alternative treatments like ankle fusion.
The Surgical Procedure
The tibialis posterior tendon transfer is performed through several carefully planned incisions around the ankle and foot:
Incisions: Typically, three incisions are made: one near the navicular (for tendon harvesting), one on the medial leg near the medial malleolus (to access the tibialis posterior tendon), and one on the dorsum of the foot (to route the tendon to the target insertion site).
Harvesting the tendon: The tibialis posterior tendon is carefully released from its insertion on the navicular and prepared for transfer.
Routing the tendon: The tendon is passed through the interosseous membrane (a fibrous structure between the tibia and fibula) to reach the foot. During this step, great care is taken to avoid damaging nerves and blood vessels in the area, as these structures are crucial for proper foot function.
Anchoring the tendon: Once the tendon reaches the foot, it is anchored to the target bone or tendons using a fixation system. This ensures the tendon can provide the necessary dorsiflexion to correct the foot drop.
Postoperative Plan and Recovery
The recovery process focuses on reducing postoperative swelling and ensuring the proper function of the tendon:
Initial care: After the surgery, the patient is immobilized in a cast to keep the foot in dorsiflexion. This is important to allow the tendon to heal in the proper position.
Physiotherapy: After about six weeks, rehabilitation begins to re-educate the tibialis posterior tendon to activate and support dorsiflexion.
Follow-up care: Patients are regularly assessed to ensure the transfer is functioning as intended. This includes evaluating the patient’s ability to achieve a heel-to-toe gait and their range of motion in the ankle.
Risks and Complications
As with any surgical procedure, there are risks associated with tibialis posterior tendon transfer:
General risks: These include infection, scarring, nerve injury, and blood clots.
Specific risks: These include failure of the tendon transfer, further surgery, or complications like compartment syndrome.
Postoperative rehabilitation: The patient must avoid passive plantarflexion during physiotherapy to prevent detachment or stretching of the tendon.
Conclusion
In conclusion, tibialis posterior tendon transfer is a highly effective treatment for foot drop when nerve recovery is not expected. It offers patients the potential to regain functional use of their foot, improving their gait and overall mobility
Do you have more questions?
Q. What is Tibialis Posterior Tendon Transfer?
A. Tibialis posterior tendon transfer is a surgical procedure used to treat foot drop by rerouting the tibialis posterior tendon to restore dorsiflexion and improve walking ability, particularly when the nerve recovery is not expected.
Q. What are the indications for Tibialis Posterior Tendon Transfer?
A. This procedure is indicated for patients with foot drop due to peroneal nerve injury, neuromuscular conditions, or trauma, especially when other treatments like bracing have failed.
Q. How is the Tibialis Posterior Tendon Transfer performed?
A. The tibialis posterior tendon is harvested from the foot and re-routed through the interosseous membrane to a new location on the foot to improve dorsiflexion and restore normal gait.
Q. What is the recovery process after Tibialis Posterior Tendon Transfer?
A. Recovery involves immobilization in a cast, followed by physiotherapy to re-educate the tendon and improve foot movement. Full recovery can take several months.
Q. What are the risks associated with Tibialis Posterior Tendon Transfer?
A. Risks include infection, nerve injury, tendon failure, and the possibility of the tendon not achieving the desired dorsiflexion function.
Q. How long does the Tibialis Posterior Tendon Transfer procedure take?
A. The procedure typically takes about 2 to 3 hours, depending on the complexity of the case and whether additional procedures are needed.
Q. Can Tibialis Posterior Tendon Transfer be performed on both feet at the same time?
A. While it is possible, it is generally recommended to perform the procedure on one foot at a time to allow for proper healing and rehabilitation.
Q. Will I be able to return to sports after Tibialis Posterior Tendon Transfer?
A. High-impact activities should be avoided for 6 to 12 months after surgery, but most patients can return to light activities once the tendon has healed and normal foot movement is restored.
Q. How effective is Tibialis Posterior Tendon Transfer for restoring foot function?
A. The procedure is highly effective, with many patients experiencing significant improvement in foot function, including better dorsiflexion, walking ability, and reduced foot drop, allowing for normal or near-normal gait.
Q. Is physical therapy necessary after Tibialis Posterior Tendon Transfer surgery?
A. Yes, physical therapy is essential to help restore strength, flexibility, and mobility in the foot and ankle. It also aids in re-training the foot to use the new tendon pathway effectively.
Q. Will I experience any pain after Tibialis Posterior Tendon Transfer?
A. Some discomfort and swelling are expected during the recovery process, but pain is generally manageable with prescribed medications. Most patients report significant pain relief once the tendon has healed.
Q. Can Tibialis Posterior Tendon Transfer correct severe foot deformities?
A. While it is primarily used to address foot drop, Tibialis Posterior Tendon Transfer can also improve alignment and function in patients with moderate foot deformities related to nerve damage or tendon dysfunction.
Q. How soon can I walk after Tibialis Posterior Tendon Transfer?
A. You will be non-weight bearing for the first several weeks after surgery, typically using crutches or a walking boot. Gradual weight-bearing is introduced once healing begins, usually after 6 weeks.
Q. Are there any long-term complications associated with Tibialis Posterior Tendon Transfer?
A. While complications are rare, some potential long-term issues include tendon failure, recurrence of foot drop, or development of other foot deformities. Proper rehabilitation and follow-up care reduce the risk of these complications.
Q. How long will the results of Tibialis Posterior Tendon Transfer last?
A. The results are generally long-lasting, with most patients maintaining improved foot function and gait for years. However, the longevity of the results depends on factors such as rehabilitation, activity level, and any underlying conditions.
Dr. Mo Athar
