Tendon Transfers and Treatment Strategies in Foot and Ankle Surgery

Contents

Preface ix

Bruce E. Cohen

Neuromuscular Problems in Foot and Ankle: Evaluation and Workup 1

Kenneth J. Hunt and Jessica H. Ryu

It is essential to determine the functional goals of the patient during theworkup and treatment planning stages of neuromuscular disorders involv-ing the foot and ankle. Accurate diagnosis, and informed discussionof treatment options, must be in the context of the patient’s disease,cognition, comorbidities, functional attributes, and family environment. Athorough history and physical examination aid in appropriate diagnosticworkup and optimal orthopedicmanagement of each patient. In this article,general considerations in the workup of suspected neuromuscular disor-ders and issues pertinent to specific congenital and acquired neuromuscu-lar disorders affecting foot and ankle function are reviewed.

Tendon Transfers—How Do They Work? Planning and Implementation 17

Thomas Dowd and Eric M. Bluman

The purpose of this article is to update the orthopedic community on theplanning and implementation of tendon transfers in the foot and ankle.This information will serve to reinforce those principles and factors thatare inherent in successful performance of tendon transfer. In addition,the authors highlight recent updates that impact decision-making for theseprocedures.

Tendon Transfers in the Treatment of the Adult Flatfoot 29

Jonathon D. Backus and Jeremy J. McCormick

Tendon transfers are critical to successful surgical correction of adult flex-ible flatfoot deformity and may be beneficial in correcting rigid deformitiesas well. Patients with refractory stage I and II deformities often requireselective osteotomies in addition to tendon transfer. Patients with stageIII and IV deformities typically require hindfoot arthrodesis. One of severaltendons can be used for transfer based on surgeon’s preference. Flexordigitorum longus (FDL) and flexor hallucis longus (FHL) transfers havebeen shown to have good results. A peroneus brevis transfer is typicallyused to supplement small FDL or FHL transfer donors or in revision cases.

Tendon Transfers in Cavovarus Foot 49

Cristian Ortiz and Emilio Wagner

The use of tendon transfers in the cavovarus foot is a common surgicalprocedure because of the muscular imbalance present in this pathologiccondition. Therefore, deforming forces are transferred to obtain movementand function. General principles must be followed for transfers to work;

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depending on the muscle deficiency and the function to restore, differenttendon transfer options exist. The authors do not recommend tendontransfers for forefoot deformities in this setting. Postoperatively tendontransfers should be protected in a removable boot, but early protectedweight bearing and motion is stimulated to obtain a well-functioning trans-fer and not a tenodesis.

Hallux Claw Toe 59

Mostafa Abousayed and John Y. Kwon

Claw hallux is a deformity of the great toe attributed to muscular imbal-ance. This article describes diagnosis and treatment of this condition.Particular attention is given to surgical techniques such as Jones tech-nique and modified Jones technique.

Tendon Transfers for the Drop Foot 65

Karl M. Schweitzer Jr and Carroll P. Jones

The paralytic drop foot represents a challenging problem for even the mostexperienced orthopedic surgeon. Careful patient selection, thorough pre-operative examination and planning, and application of tendon transferbiomechanical and physiologic principles outlined in this article can leadto successful results, either through a posterior tibialis tendon transfer,Bridle transfer, or variations on these procedures. Achilles lengthening orgastrocnemius recession may also be needed at the time of tendontransfer.

Tendon Transfers in the Treatment of Achilles’ Tendon Disorders 73

Steven K. Neufeld and Daniel C. Farber

The Achilles tendon is the strongest tendon in the human body and, assuch, has its share of problems. Although many conditions affecting thistendon can be treated nonoperatively, surgical intervention is often neces-sary. Local, regional, distant, and allograft tendon can be used to supple-ment or enhance reconstruction or repair of the Achilles tendon. Specifictechniques are explored and described, and the published results fromthe literature summarized. This article explores the use of tendon transfersand supplementation in the treatment of insertional and noninsertionalAchilles tendinosis as well as in cases of neglected or chronic rupturesof the tendoachilles.

Salvage Options for Peroneal Tendon Ruptures 87

Emmanouil D. Stamatis and Georgios C. Karaoglanis

Reports have demonstrated that peroneal tendon tears can be success-fully treated by direct repair or debridement and tubularization, based onthe extent and nature of the pathology. Irreparable peroneal tendon tearsor completely unsalvageable tendons after failure of previously attemptedrepairs are rare, and as a result there is a lack of high-level evidence toguide the management of these complex injuries. When irreparable tearsare encountered the salvage options include tenodesis, bridging of thedefect using allografts or autografts, and tendon transfers. The choice of

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treatment strategy depends on the presence of a functioning tendon ortendons and the viability and excursion of the peroneal musculature.

Spastic Foot and Ankle Deformities: Evaluation and Treatment 97

Brandon W. King, David J. Ruta, and Todd A. Irwin

Spastic foot and ankle deformities can occur from various causes andhave profound effects on individuals and society. Presentations can varyclinically and a thorough clinical evaluation, potentially with a dynamicelectromyogram, is essential to selecting the most appropriate treatment.Nonoperative treatments, such as orthotics, casting, oral medications, andnerve blocks, can be effective but surgery is indicated if they are no longereffective. Of the various operative procedures to treat this condition, splitanterior tibialis tendon transfer and tendo Achilles lengthening are themost commonly performed. Multiple surgical options have been shownto be effective.

Percutaneous Techniques for Tendon Transfers in the Foot and Ankle 113

Vinod Kumar Panchbhavi

Tendon transfer procedures are useful for replacing a dysfunctional ordiseased tendon or for restoring muscle imbalance. The tendon to betransferred is harvested as distal as is necessary to provide adequatelength for rerouting and attachment at the different site. The harvestingof tendon itself can be attained using an open surgical approach or mini-mally invasive percutaneous techniques that limit surgical exposure. Thisarticle describes percutaneous techniques for tendon transfer proceduresused to address foot and ankle disorders.

Forefoot Tendon Transfers 123

Andrea Veljkovic, Edward Lansang, and Johnny Lau

Flexible forefoot deformities, such as hallux varus, clawed hallux, hammertoes, and angular lesser toe deformities, can be treated effectively withtendon transfers. Based on the presentation of the flexible forefootdeformities, tendon transfers can be used as the primary treatment or asadjuncts to bony procedures when there are components of fixeddeformities.

Index 139