Tendon transfer in Neuromuscular

disorder

Dr Jitendra Kumar Jain Pediatric orthopedic surgeon

Chairman , Trishla foundation & Secretary, Samvedna

Allahabad

www.samvednatrust.com, www.trishlaortho.com

Prof A N VarmaEx. President IFAS

Ex HOD Deptt of orthopedic, MLN Medical College, Allahabad

Introduction

Main aetiology of Foot deformity in neuromuscular disorder is muscular weakness & tone imbalance.

Most of time deformity is progressive so it is very important to have a permanent solution

Tendon transfer plays a very important role in balancing the muscle tone & power around the foot.

Indication

Cerebral palsyPoliomyelitisNerve injuryCharcot-Marie-Tooth disease

LeprosyCTEV

Deformity where tendon transfer are required?

Equino-varus

Fore foot inversion

Hind foot inversion

Calcaneus gait

Foot drop

Role of tendon transfer Balance the power and tone

Restore lost functions

Neutralize the deforming forces

Reduce the recurrence of deformity

Long term correction of foot deformity

Eliminate the need for bracing during gait

Fundamental rules Correction of fixed deformity prior to tendon transferJoints must be mobile

Plan to achieve single function

Donor muscle must have sufficient strength, adequate excursion Donors MTU - Functional , expendable & synergism

Tendons must have a straight course from origin to insertion

Pass the tendon through gliding surface of tissue

The transfer must be attached under tension (not too loose nor to tight )

Insertion of the tendon to bone

Method of fixation

Bone anchor

Pull out Using button to fix the tendon suture

Loop through bone

Tendon to tendon

interference screw techniques

Methods of tendon transfer

Single tendon transfer- Single insertion / split transfer to two insertion site

Multiple tendon transfer

Split (half) tendon transfer

Route of transfer Circumtibial – more plantiflexion, More chance of residual deformity, less ROM, subcutaneous feeling of tendon

Interosseous window-Benefit- a physiologic way, strong dorsiflexion,Problem- less plantiflexor, chance of adhesion , risk of vascular injury, narrowing of the transition tunnel in the late-term. Tricks- tunnel should wide opened and muscle belly should traverse the window

Deep to extensor retinaculam (short lever arm, less power, more ROM)

Superficial to extensor retinaculam (long Lever arm, better power, less ROM )

Assessment & Planning

Muscle chart to evaluate power of each musculotendinous unit

Evaluation of deformity by clinical & radiological assessment

Check for alternative approach for achieving the required function

Condition of soft tissue at the route of transfer and attachment site

Charcot-Marie-Tooth disease Cavo-varus is commonest deformity

Aetiology- Weak tibialis anterior & peroneus brevis

Osteotomy with tendon transfer is preferable than arthrodesis

Power of transferred tendon can go away but foot will be remain in plantigrade

Bridle procedure- Tibialis posterior passed through Tibialis anterior and attach to dorsum of foot. Distal part of Peroneus Longus attached to tibialis anterior , Prox part of Pero Long to Brevis

Bridle procedure

Incision mark Anterior transfer of Tibialis posterior

Distal portion of Peroneus longus

rerouted to tibialis anterior

Tib Post and Pero longus pass to tib ant and Tib post attached distally to middle cuneiform

Cerebral Palsy

Tendon transfer in only selected cases

Contraindicated in athetoid & dystonic CP

Tendon transfer has second place in treatment of foot deformity in spastic CP

Split tendon transfer is most useful technique to balance the foot deformity

Tibialis anterior half tendon transfer in forefoot varus & tibialis posterior half tendon in hind foot varus.

Tibialis anterior half tendon transfer in fore foot varus in Cerebral Palsy

Incision mark Lateral half of tib ant

Transferred to lateral cuneiform

Pull out suture

Forefoot varus deformity

Tib Post half tendon transfer in hindfoot varus deformity in cerebral palsy

Tibialis post half tendon pass to peroneus brevis

PPRP

Varieties of foot presentation based on the involvement of MTU

Tendon transfer are decided on the basis of working & Paretic MTU

Can be used in different combination

Purpose to have a plant grade foot with minimum bracing as much as possible

PPRP

Mx by Peroneus Longus transfer to middle cuneiformModified johns procedure

Gastrocnemius aponeurotic Release

Dropping of first metatarsal headTA& TP weak, Overworking FHL

Gastroc tightness

CTEV

Ponseti technique plaster application is the standard

Tendon transfer is indicated in residual forefoot supination deformity

Perpose is to balance the muscle power

Split TA is the best option

Age – ideally not before 4 year age

Tibialis anterior half tendon transfer in CTEV

Tibialis ant half tendon pass to lateral cuniformForefoot supination deformity

Foot drop

Peroneal nerve injury

L5 nerve root lesion

Tibialis posterior transfer to act as dorsiflexor

Shifting of tibialis anterior to center of foot

Foot drop

Tibialis Post pass to dorsum of foot through interroseus window

Our experience : tendon transfer in foot surgery

Problem Procedure No. of Pt.

CP with hind foot varus Tib Post half tend transfer 4CTEV with supinat. deformity Tib Ant split half transfer- 10

CP with Forefoot varus 5Meningo-myelocoel Tib Ant split half transfer 3

Tib Ant transfer to middle cuneiform 4Peroneus longus transfer to dorsum

2PPRP Peroneus longus transfer to dorsum of foot- 4

Tib Ant transfer to middle cuneiform 4Tib Post Trans to dorsum 5

Foot drop Tibialis posterior transfer to dorsum of foot 7Calcaneus gait FDL / Peron brevis + Tibialis anterior transfer to

calcaneus 2

Take home message

• Excellent procedure for balancing the foot deformity

• Each step should be followed carefully • Protection of tendon minimum for 3 month• Other modality should be tried before tendon

transfer• Correction of deformity prior to tendon transfer• Mobile joint for success of this procedure

More info on www.samvednatrust.com& www.trishlaortho.com

Thanks