Main etiology of Foot deformity in neuro-muscular disorder is muscular weakness & tone imbalance. Most of time this 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.

1. 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 Varma
Ex. President IFAS
Ex HOD Deptt of orthopedic,
MLN Medical College, Allahabad

2. 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.

3. Indication
Cerebral palsy
Poliomyelitis
Nerve injury
Charcot-Marie-Tooth disease
Leprosy
CTEV

4. Deformity where tendon transfer are
required?
Equino-varus
Fore foot inversion
Hind foot inversion
Calcaneus gait
Foot drop

5. 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

6. Fundamental rules
Correction of fixed deformity prior to tendon transfer
Joints 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

7. Method of fixation
Bone anchor
Pull out Using button to fix the tendon suture
Loop through bone
Tendon to tendon
interference screw techniques

8. Methods of tendon transfer
Single tendon transfer- Single insertion / split
transfer to two insertion site
Multiple tendon transfer
Split (half) tendon transfer

9. 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 )

10. 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

11. 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

12. 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

13. 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.

14. 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

15. Tib Post half tendon transfer in hindfoot
varus deformity in cerebral palsy
Tibialis post half tendon
pass to peroneus brevis

16. 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

17. PPRP
Mx by Peroneus Longus transfer to middle cuneiform
Modified johns procedure
Gastrocnemius aponeurotic Release
Dropping of first metatarsal head
TA& TP weak, Overworking FHL
Gastroc tightness

18. 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

19. Tibialis anterior half tendon transfer in
CTEV
Tibialis ant half tendon
pass to lateral cuniformForefoot supination deformity

20. Foot drop
Peroneal nerve injury
L5 nerve root lesion
Tibialis posterior transfer to act as dorsiflexor
Shifting of tibialis anterior to center of foot

21. Foot drop
Tibialis Post pass to dorsum of foot
through interroseus window

22. Our experience : tendon transfer in foot
surgery
Problem Procedure No. of
Pt.
CP with hind foot varus Tib Post half tend transfer 4
CTEV with supinat. deformity Tib Ant split half transfer- 10
CP with Forefoot varus 5
Meningo-myelocoel Tib Ant split half transfer 3
Tib Ant transfer to middle cuneiform 4
Peroneus longus transfer to dorsum 2
PPRP Peroneus longus transfer to dorsum of foot- 4
Tib Ant transfer to middle cuneiform 4
Tib Post Trans to dorsum 5
Foot drop Tibialis posterior transfer to dorsum of foot 7
Calcaneus gait FDL / Peron brevis + Tibialis anterior transfer to
calcaneus
2

23. 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

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