Reviews on Tendon Transfers for Drop Foot Correction
Indian J Plast Surg. 2019 Jan; 52(1): 100–108.
Tendon Transfers in Foot Drop
Sridhar Krishnamurthy
1Found for Craniofacial Artful and Plastic Surgery, SRM Institute for Medical Sciences, Chennai, Tamil Nadu, Republic of india
Mohamed Ibrahim
oneInstitute for Craniofacial Aesthetic and Plastic Surgery, SRM Institute for Medical Sciences, Chennai, Tamil Nadu, India
Abstract
The common peroneal nerve is the nigh commonly injured nerve in the lower extremity. Peroneal nerve pathology results in loss of dorsiflexion at the tibiotalar articulation, loss of eversion at the subtalar articulation, and loss of extension of toes resulting in foot driblet. The varied etiology of the trouble is discussed. The various treatment modalities like bourgeois direction, steroid therapy, nerve decompression, nerve repair, or reconstruction are described, only due to uncertain outcomes later master nerve procedures, secondary procedures like tendon transfers oftentimes end up as definitive treatment. The rationale and technique of tibialis posterior transfer is discussed in detail.
Keywords: foot drop, tibialis posterior transfer, tendon transfer for foot drop
Mutual peroneal nervus is the most commonly injured nerve in the lower limb one and commonly manifests with foot driblet. Peroneal nerve pathology results in loss of dorsiflexion at the tibiotalar articulation, loss of ankle eversion at the subtalar joint, and loss of extension of toes which is much more complicated than what the term "human foot drib" conveys.
During normal walking, heel strike and swing phase are two of import phases. When the heel strikes the ground, the ankle is kept in either neutral position or in minimal extension. Then, during swing phase the toes must clear the ground, which requires active extension of the toes and the ankle to be held in neutral position. In patients with peroneal nervus palsy, these motors are absent and the patient slaps the foot on ground in heel strike and drags the toe along the footing in swing stage. To avoid this, the patient flexes the hip more than normal to lift the entire foot and toe off the ground as if he is walking up the stairs (high stepping gait). 2
The Anatomical Ground
The mutual peroneal nerve winds around the neck of the fibula and divides into superficial and deep branches ( Fig. ane ). The superficial peroneal nerve supplies the peroneus longus and brevis muscles and continues as sensory co-operative. Hence, it is also called as the musculocutaneous nerve. The deep branch supplies the tibialis anterior, extensor digitorum, extensor hallucis, and peroneus tertius muscles. Consequently, in lesions of the mutual peroneal nervus at that place is too loss of eversion of human foot. In long-continuing cases, especially in leprosy, nosotros can see callosity and ulceration developing on the lateral aspect of the foot as inversion is maintained by the tibialis posterior muscle. In partial lesions, the superficial branch is commonly spared and hence eversion of the foot is preserved. The decision to perform tendon transfer depends on whether but the anterior group is involved or if both the anterior and lateral groups are involved.
Mutual peroneal nervus course and muscles supplied.
Etiological Factors
Both neurological and muscular involvement can produce pes drop. Amongst the neurological factors, common peroneal nerve neuropathy (of idiopathic etiology), diabetic neuropathy, compression at the level of the neck of the fibula, lumbar disc prolapse, and nervus injury form the majority of neurologic etiologies. In leprosy, the nerve gets compressed at the site where information technology winds around the fibular neck. At this place the nerve is also susceptible to injury as information technology lies comparatively superficially. Tumors of the nervus or fibula, cerebral palsy, poliomyelitis, multiple sclerosis, Charcot–Marie–Tooth disease, stroke, and spinal cord lesions are some of the other causes. Muscle injury, rupture of the tibialis anterior tendon, compartment syndrome, muscular dystrophy, and amyotrophic lateral sclerosis are some of the muscular causes. In a multi centric study done in Italy, the aetiology and predisposing factors of mutual peroneal nerve mono-neuropathy were studied. Information technology was establish that in 16% of patients, the cause of peroneal mono-neuropathy was idiopathic, xx.3% patients had developed neuropathy after surgery effectually the knee joint and trauma was the cause in eleven.vi% patients, surprisingly weight loss contributed to peroneal mono-neuropathy in fourteen.v% in their serial. 3 In 1959 working in Polambakkam leprosy center in Bharat, Hemerijckx iv reported an incidence of iii bilateral and 59 unilateral foot drib deformity in two,337 leprosy patients with overall incidence of 2.5% in the 8 associated leprosy centers covered past the Belgian leprosy centre in India.
Management
Bourgeois Management
Bourgeois management is indicated for patients with foot drop secondary to leprosy of less than 12 months' duration considering 50% of these patients recover spontaneously during the beginning 12 months. 5 Fritschi and Brand working in the Karigiri leprosy unit of measurement have recorded that they would wait for upwardly to a year earlier considering surgery. 6 In idiopathic conditions too, waiting for a year later on the onset is recommended.
All patients with foot drop of more than 12 months duration will ultimately require surgery to prevent contractures and pes ulceration. vii The aim of conservative direction is to preclude evolution of contractures and foot ulcers while the involved nervus is immune to spontaneously recover. Bourgeois direction involves placing the patient nether a closely supervised program of physiotherapy and splinting. The foot is splinted in a foot and ankle orthosis to prevent stretching of the paralyzed inductive grouping of muscles and to prevent contracture of the tendo Achilles. seven 8 Office of steroids in patients with foot driblet in leprosy is still controversial. A multicenter, randomized, double-blind, placebo-controlled trial conducted in Nepal and Bangladesh did not reveal any differences between the treatment and placebo groups; however, there was reduced deterioration of nervus part in the prednisolone group. 5 The efficacy of steroid therapy seems to depend upon the elapsing of nerve involvement and the caste of impairment. The earlier corticosteroids were given afterward the onset of nervus damage, it was likelier to prevent permanent nerve function impairment. nine x A Cochrane Review in 2016 stated that further randomized controlled trials (RCTs) are needed to establish optimal corticosteroid regimens and to examine the efficacy and prophylactic of adjuvant or new therapies for treating nervus damage in leprosy. 11
Nerve Surgery
Primary nerve surgery for patients with foot driblet includes neurolysis or decompression, main repair, nerve grafting, or nerve transfer. Nerve decompression aims to relieve mechanical compression due to edema secondary to neuritis. Surgical decompression is indicated in leprosy patients with obvious evidence of nervus compression, nerve abscess, nerve pain, or nerve role impairment that is refractory to medical handling. 7 12 13 Outcomes following nerve decompression are highly varied with good outcomes reported by Chaise and Roger. 14 Still, Boucher et al in a moderate size RCT stated that combined treatment with steroids and decompression showed an improvement in sensory and motor deficits simply statistically meaning results were observed but in patients with incomplete paralysis and patients with neuritic pain lone. xv In patients with peroneal nerve neuropathy due to other causes, neurolysis is indicated in patients with intact nerve activeness potentials. Kim et al reported good outcomes in 88% of such patients. 16 As per a Japanese written report, early on decompression is recommended in patients with foot drop caused by lumbar degenerative affliction accompanied by severe motor disturbance, especially in older patients. 17 In patients with peroneal nerve compression secondary to nervus tumors especially schwannomas, excision of tumor while preserving nerve continuity is possible with intraoperative monitoring of nervus action potentials. Kim and Kline reported fourscore% of patients with nervus tumors had excision of nerve tumors with complete preservation of part. sixteen
Nerve repair or grafting is indicated in patients in whom nerve continuity is non preserved following tumor excision or when the nerve is transected. Primary nerve repair with epineural stitches under magnification is platonic merely a nerve gap of more three cm will require nerve grafting. Kim and Kline analyzing 318 patients with peroneal nerve pathology of varied etiology ended that timely surgical exploration and nervus repair or grafting achieved good results; however, in their series the look for spontaneous recovery in trauma was merely four months which we feel is inadequate. sixteen In their series, patients who had nerve grafts less than 6 cm had better outcomes when compared with patients with longer grafts.
Nervus transfers are indicated in patients with foot drop of less than i year duration. This involves transfer of functional fascicles of either the superficial peroneal nerve or of the tibial nervus to the deep peroneal nervus or motor branch of tibialis anterior muscle. Nath and colleagues reported success using this technique with xi out of 14 patients recovering grade iii+ or more muscle power. 18 nineteen
Secondary Procedures
When direct surgical repair is non possible and bourgeois management or nerve surgeries have failed, so secondary procedures are required. The primary aim of the surgery is restoring agile dorsiflexion of the foot and correcting the inversion deformity when the peronei are also paralyzed along with the inductive group. This is achieved using tendon transfers, and when tendon transfer is not feasible or has failed, and then bony procedures like triple arthrodesis with tenodesis or ankle arthrodesis may take to be considered to achieve a stable foot. Due to uncertain outcomes after principal nervus procedures, secondary procedures like tendon transfers ofttimes end upwards as the definitive treatment in these patients. 7
Tendon Transfer
Preoperative Assessment : Preoperative evaluation of the involved muscles and potential donor muscles play a major role in determining the choice of procedure. The muscles of the anterior and lateral compartment are evaluated in terms of muscle power. Tibialis anterior is tested by keeping the patient in sitting position and asking the patient to dorsiflex the talocrural joint and invert the human foot without extending the toes. The extensor hallucis longus (EHL) and extensor digitorum longus (EDL) are tested past asking the patient to extend the dandy toe and 2nd to 5th toes, respectively, at the metatarsophalangeal joint. 20 It is essential to assess the strength of the peroneal muscles before contemplating tendon transfer. The correct style of testing the peroneus longus and brevis is to brand the patient sit, place the affected limb over the opposite knee with the hip internally rotated and knee flexed, and take the patient lift the human foot (evert) ( Fig. 2 ). The patient will not exist able to do and then if the peronei are paralyzed. If this is the instance, tibialis posterior is the ideal selection as motor for the transfer. In one case tibialis posterior is chosen equally the motor, preoperative training of tibialis posterior is to exist started by making the patient sit down, place the affected foot over the opposite knee with the hip externally rotated, genu flexed, and have the patient lift the foot (invert). This is connected for few weeks and strengthening of the tibialis is achieved by suspending a sand bag over the foot while performing the same maneuver.
Testing the peroneus longus and brevis.
Before proceeding with tendon transfer surgery, it must be ascertained that at that place is no contracture of tendo Achilles. If contracture is nowadays, it needs to be stretched or released before the actual transfer is performed. Tendo Achilles release and tendon transfer tin can be performed in the same sitting. In leprosy, ulcers in human foot are common and they must be healed before taking up for transfers.
Disorganization of the tarsal bones is often seen in patients with foot drib secondary to leprosy and in diabetes every bit involvement of the tibial nervus is also nowadays in virtually of the patients leading to neuropathic os disintegration. seven Radiological imaging of the foot is required to determine whether there are whatsoever disorganization of the tarsal bones. Radiological show of disorganization is a relative contraindication for tendon transfer. When the disorganization is significant to the extent that the passive range of movement of the ankle is less than 10 degrees or with the presence of instability, information technology may be worthwhile to opt for bony procedures rather than tendon transfer. Ten-rays of the foot, with the pes in full forced varus and valgus will aid determine whether the instability is principally in the subtalar or ankle articulation. If the instability is in the ankle joint, or if the tibialis posterior muscle is not interim, then the patient will exist required to undergo talocrural joint arthrodesis or pantalar fusion. 7
We tin can analyze the tendon transfer procedures under various components, viz. selection of motor, the route it takes to reach its site of insert, and various insertions.
Motor
As discussed earlier when both the anterior and lateral groups of muscle are involved, the option of motor is the tibialis posterior muscle. This not only removes the unopposed inversion force just also helps to restore dorsiflexion when it is inserted on to the back of the foot. Tibialis posterior transfer for foot drop in leprosy is credited to Paul Brand who worked in CMC Vellore in the twelvemonth 1955. 21 Other choices for motor are flexor digitorum longus (FDL) used along with the tibialis posterior to power the extensor digitorum and hallucis tendons equally a double transfer. 22 Leclère et al reported inductive transposition of the lateral gastrocnemius muscle forth with neurotization of the peroneal nerve. 23
In patients with isolated deep peroneal nerve interest, where the peroneus longus and brevis are spared and then it is better non to transfer the tibialis posterior. 24 Removal of the tibialis posterior will eliminate the balancing inversion force against the peroneal evertors of the foot which are not paralyzed. Rerouting the peroneus longus is a better process in such conditions.
Route
Since the peroneus longus lies adjacent to the inductive group of muscles separated simply past a septum, it can be shifted anteriorly without difficulty from the lateral side. Tibialis posterior on the other hand lies posterior to the bones and interosseous membrane, and requires taking a different route to reach the anterior compartment.
The ii normally followed routes are the interosseous route and circumtibial route ( Fig. 3 ). As reported by Watkins et al, 25 Codivilla 26 and Putti 27 are considered the pioneers of the inductive transposition of the tibialis posterior tendon to the dorsum of the foot through the interosseous membrane. Gunn and Molesworth 28 reported 56 cases of driblet pes (54 of them acquired by leprosy) in which the tibialis posterior tendon was inserted into the tarsus after being brought forward through the interosseous membrane of the leg.
Tibialis posterior transfer—routes of tendon transfer (Courtesy: Srinivasan H. Atlas of corrective surgical procedures unremarkably used in leprosy).
In circumtibial road described past Ober, 29 the posterior tibial tendon is brought around the medial attribute of the tibia. The divergence in functional issue betwixt the two routes is negligible with marginal increase in range of movement of ankle in the circumtibial route xxx but there is as well a likelihood of more inversion deformity than in the interosseous route. 31
The Insert
Fixation of tendon tin be done to bone, periosteum or tendons on the dorsum of human foot.
Barr originally inserted the tendon to the intermediate or lateral cuneiform bone or base of the second or tertiary metatarsal bone bringing the tendon through the interosseous route. 32 Modification of Barr'due south procedure, fixing the tendon to the cuboid bone, according to Salihagić et al produced much improve consequence than the classic Barr'southward procedure. 33 Ober stock-still the tendon to the base of the third metatarsal bringing it circumtibially. 29 Stable fixation to the bone requires pull-out wire sutures, staples, or bone anchor. Many of united states of america feel that fixing the transferred tendon to the tendons on the dorsum of the foot is easy and the balancing of forces can be achieved to right both inversion and plantar flexion deformity. Combining a bony anchorage with tendon suturing was suggested by Vigasio et al. 22 The tibialis inductive tendon was divided proximally and the distal tendon was rerouted tunneling through the cuneiform bones and sutured to the tibialis posterior tendon brought through the interosseous route, along with FDL tendon motorizing the EHL and EDL tendons. Classical Bridle insert 34 is to the tendons of the tibialis anterior and peroneus longus balancing the inversion and eversion of the human foot. In 1966, Thangaraj reported over 50 operations in which the tibialis posterior tendon, brought anteriorly through the interosseous membrane, was inserted into the tendons of the EDL and EHL in the anterior compartment of the leg. 30 Srinivasan et al described his 2-tail procedure of tibialis posterior transfer which is beingness followed by many treating leprosy patients worldwide. He inserts the split tibialis posterior tendon brought circumtibially and sutures one slip to the EHL and the other to the EDL and peroneus tertius tendons. 35 In his series of 39 cases, 34 cases had ninety degrees or more than of dorsiflexion. Out of these 34 patients, 30 had range of movement of more than fifteen degrees. 35 We prefer to include the tibialis inductive along with the EHL in 1 slip and the other to the EDL. Insertion into the EHL, EDL, and peroneus tertius balances the foot well and produces expert range of move.
Process
Tibialis Posterior Transfer
The two-tail tibialis posterior procedure is given below. 36
Either full general anesthesia or spinal/epidural anesthesia is given. A pneumatic tourniquet is practical. The tendon of the tibialis posterior at its insertion is identified through an oblique incision fabricated over the tuberosity of the navicular bone along one of the creases ( Figs. 4 5 6 ). A suture is applied to the tendon close to its insertion and left long. This suture steadies the tendon and helps to call up it dorsum if information technology gets stuck while delivering information technology into the leg. The tendon is then discrete from its insertion and its synovial attachments are divided. Sometimes if the cease looks bulbus it must be trimmed ( Fig. 7 ). A five-cm curvilinear incision is made in the lower part of the leg close to the medial border of the tibia, nearly 10 cm in a higher place the medial malleolus. The tendon of the tibialis posterior is identified and pulled out ( Fig. viii ). The lowest muscle fibers inserting into the tibialis posterior tendon may accept to exist shaved off from the tendon if it comes in the fashion of polish gliding. The tendon is split into two tails upwardly to where it volition cross the tibia proximally ( Fig. 9 ). Past keeping the split up tendon over the skin circumtibially, we can assess where exactly the tendons will accomplish ultimately when tunneled. At this place, two transverse incisions are fabricated on the dorsum of the human foot, one over the EHL tendon and the other over the tendons of the EDL ( Figs. 10 11 ). Through these incisions, the tendons of the EHL and the EDL and peroneus tertius are identified and isolated. A tendon tunneler is passed from each of these wounds in the dorsum of the pes to the wound in the leg making 2 separate tunnels for each slip. The tunnels are made subcutaneously ( Fig. 12 ). The motor slips are pulled through. The recipient tendon of the EHL is lifted with a hook and pulled proximally to keep it taut. A slit is made in it and the skid of the tibialis posterior tendon is passed through it. Another slit is made distally in another plane and once again it is passed through it ( Figs. thirteen 14 15 ). The tendon is fixed with three or four 2/0 nonabsorbable suture material. The next sideslip is passed similarly through the EDL and peroneus tertius keeping the tension to balance the foot in neutral position without inversion or eversion. During this stage, the knee is held in flexion of approximately xxx degrees and the ankle in dorsiflexion beyond xc degrees to the maximum possible extent ( Fig. 16 ). We can utilise a tension adjustment splint as shown or held in identify by placing towels as shown ( Fig. 17 ). The motor tendons are kept in moderate tension. The final position is as shown in Fig. xviii .
Tibialis posterior transfer: exposure and sectionalization of the tibialis posterior in the foot (Courtesy: Srinivasan H. Atlas of corrective surgical procedures commonly used in leprosy).
Incision over the tuberosity of navicular to expose the tibialis posterior tendon insertion.
Identification and isolating the tibialis posterior tendon.
Division of the tibialis posterior tendon and synovium (note the bulbous distal end of the tendon).
Retrieval of the tibialis posterior tendon into the leg wound.
Tibialis posterior transfer—exposure in leg, retrieval of the tendon, and partition into two slips (Courtesy: Srinivasan H. Atlas of corrective surgical procedures commonly used in leprosy).
Tibialis posterior transfer—incision in foot and exposure of the recipient tendons (Courtesy: Srinivasan H. Atlas of cosmetic surgical procedures commonly used in leprosy).
Division of the tibialis posterior tendon into two slips, which is placed over the lower 3rd of the leg to assess their reach. It is also used to determine the orientation of the subcutaneous tunnels.
Tibialis posterior transfer—tunneling of tendon slips (Courtesy: Srinivasan H. Atlas of corrective surgical procedures ordinarily used in leprosy).
Tibialis posterior transfer—suturing of slips (Courtesy: Srinivasan H. Atlas of corrective surgical procedures commonly used in leprosy).
Passing and suturing of the slip of the tibialis posterior tendon through slits fabricated in the extensor hallucis longus tendon.
Passing and suturing of the slip of the tibialis posterior tendon through slits made in the extensor digitorum longus tendon and peroneus tertius tendons.
The position to exist maintained during tenorrhaphy, genu in flexion and the ankle in maximum dorsiflexion (beyond 90 degrees).
Tibialis posterior transfer—tension aligning splint (Courtesy: Srinivasan H. Atlas of corrective surgical procedures normally used in leprosy).
The final resting tension after completion of the transfer.
Peroneus Longus Transfer
An oblique incision is made over the lateral aspect of the foot from base of the 5th metatarsal to approximately one cm below the lateral malleolus to expose the insertion of the peroneus longus and brevis. Srinivasan divides the brevis tendon distally and longus more distally and sutures the proximal brevis tendon to the distal longus tendon making the brevis act as a longus. Many do not use this step. The longus which is divided distally is delivered in the leg through a five-cm-long incision made anterolaterally approximately v cm above the lateral malleolus. The tendon is then split as in tibialis posterior transfer. Like the tibialis posterior procedure, tunnels are made and suturing done as before. The only difference beingness the tendon slips attain the human foot from the lateral side instead of the medial side in the tibialis posterior transfer.
Postoperative Period
A below-articulatio genus plaster is practical. The plaster is bi-valved after iii weeks. Physiotherapy is started with reeducation equally discussed earlier. Initially later 3 weeks, training is done to contract the tibialis muscle. Afterward 4 week, the patient is made to stand with back up. Between periods of practice, the leg and foot are kept in the plaster slab. After half dozen weeks, the patient is allowed to walk betwixt parallel bars with minimal weight bearing. From eight weeks onwards, full weight bearing is allowed.
Complications
The reported complications following tendon transfers of the foot and ankle include persistent deformity, hurting and rigidity, wound infections and abscesses, tarsal tunnel syndrome, sural nervus injuries, and other causes of paresthesias, and neuropathic pain. 37 Postoperative surgical site infections are rare. Adhesions giving rise to reduced range of movements are noticed especially in interosseous route transfers which can be avoided if the window in the interosseous membrane is large enough. Insufficient tension gives rise to reduced dorsiflexion or persistent equinus deformity. In circumtibial transfers excessive inversion may exist noticed. This can be avoided by tunneling showtime vertically from the EHL site proximally and and then curving it around the tibia facilitating vertical pull. Interosseous route transfers do non produce this. Similarly, eversion tin can occur if excess tension is given while the EDL slip is tightened more than. Rarely in leprosy the tibialis posterior may become paralyzed later and may not work. Dehiscence is rare.
Arthrodesis
As discussed earlier, if there is disorganization of the tarsal bones and in cases where the tibialis posterior is also involved, it may be worthwhile arthrodesing the ankle and subtalar joints.
In conclusion, when there is no recovery subsequently main procedures for foot drop, in leprosy and other causes of peroneal neuropathy, dynamic transfers yield very skilful results. There is not much difference between circumtibial and interosseous routes. Tendon fixations are much easier to perform than bony fixation and can give excellent results. In our experience, 2-tail tibialis posterior process gives expert results.
Footnotes
Conflict of Interest None
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