SLR - June 2021 - Matthew D. Doxey
Reference: Agarwal P, Gupta M, Kukrele R, Sharma D. Tibialis Posterior (Tp) Tendon Transfer for Foot Drop: A Single Center Experience. J Clin Orthop Trauma. 2020; 11:457–61.Level of Evidence: Level IV
Scientific Literature Review
Reviewed By: Matthew D. Doxey, DPM
Residency Program: Southern Arizona Veterans Affairs Health Care System – Tucson, AZ
Podiatric Relevance: Foot drop is a debilitating condition that affects gait and functional status with potential for progressive foot deformity. Tibialis posterior tendon transfer presents a surgical treatment option which potentially improves gait, limits reliance on orthosis, and restores functional status. The purpose of this study was to assess the functional outcome of tibialis posterior transfer for patients with foot drop.
Methods: A retrospective study was performed on 20 patients with foot drop of greater than one-year duration. All patients underwent tibialis posterior tendon transfer with bisection of the tendon and attachment of one slip to the tibialis anterior tendon and the second slip to the tendons of extensor digitorum longus. Tendons were passed between the tibia and fibula. Functional postoperative outcomes measured include active ankle joint range of motion, attainment of heel to toe gait, and active toe range of motion. Range of motion was rated as excellent, good, fair, poor, or no-improvement based on level of functional status obtained.
Results: At average follow up of two years, 19 of the 20 operated ankles had active dorsiflexion of the foot and toes. Additionally, 19 of the 20 patients could walk with heel to toe gait without any orthotic support. There was no pain, ruptures or infections of the transferred tendons. The one patient with a poor outcome had loosening of the tendon requiring revision to shorten the tendon. After tendon shortening, patient had a good result. Eighteen of 20 patients were given good functional rating, one had a fair rating and one had a poor rating.
Conclusions: The authors conclude that patients with foot drop who have failed direct surgical repair of nerve lesions and have waited a minimum of one year for nerve regeneration without improvement may benefit from tibialis posterior tendon transfer. Insertion of the tendon into the bones of the midfoot can be difficult. Attachment to the tendons allows for functional control of the forefoot and the toes. Additionally, this spares the bones of the midfoot from surgical trauma avoiding insertion of a tendon anchor. Dividing the tibialis posterior into two slips allows for tensioning between the slips to produce a more neutral foot and ankle joint instead of a single-pull effect. Tibialis posterior tendon transfer provides a surgical treatment option with good levels of functional improvement. Future higher-level studies are needed to compare functional outcomes of tendon to tendon attachment in comparison to tendon to bone, as well as single attachment in comparison to split tendon slip attachment.