Aims. To systematically review the efficacy of split tendon transfer surgery on gait-related outcomes for children and adolescents with cerebral palsy (CP) and spastic equinovarus foot deformity. Methods. Five databases (CENTRAL, CINAHL, PubMed, Embase, Web of Science) were systematically screened for studies investigating split tibialis anterior or split tibialis posterior tendon transfer for spastic equinovarus foot deformity, with gait-related outcomes (published pre-September 2022). Study quality and evidence were assessed using the Methodological Index for Non-Randomized Studies, the Risk of Bias In Non-Randomized Studies of Interventions, and the Grading of Recommendations Assessment, Development and Evaluation. Results. Overall, 17 studies (566 feet) were included: 13 studies used clinical grading criteria to report a postoperative ‘success’ of 87% (75% to 100%), 14 reported on orthotic use with 88% reduced postoperative use, and one study reported on ankle kinematics improvements. Ten studies reported post-surgical complications at a rate of 11/390 feet (2.8%), but 84 feet (14.8%) had recurrent varus (68 feet, 12%) or occurrence of valgus (16 feet, 2.8%). Only one study included a patient-reported outcome measure (pain). Conclusion. Split tendon transfers are an effective treatment for children and youth with CP and spastic equinovarus foot deformities. Clinical data presented can be used for future study designs; a more standardized functional and patient-focused approach to evaluating outcomes of surgical intervention of gait may be warranted. Cite this article: Bone Jt Open 2023;4(5):283–298

Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up. Methods:. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery. Results:. The evaluation parameters included VAS pain score, UCLA score, Constant score and AHES score, and X-rays of the shoulder. At follow-up of 25.3 ± 25.0 (range 22 to 63) months, the mean VAS pain score decreased from 9.3 ± 0.8 preoperatively to 1.7 ± 1.4 postoperatively (p < 0.001). All patients presented with significant improvements in pain and function of the shoulder for daily activities after surgery, however, only one patient achieved excellent results. There is no correlation of functional outcome with age, gender and body mass index. There was no infection or neurovascular complication. Discussion:. The biceps transfer provides soft tissue coverage of the humeral head, and restores the superior stability of the shoulder joint. The transferred biceps tendon also improves the mechanics and increases the compression force of the humeral head to the glenoid fossa. The results of the current study showed significant pain relief and improvement of shoulder function after biceps tendon transfer for irreparable rotator cuff tear. Conclusion:. Biceps tendon transfer is effective in the management of massive irreparable rotator cuff tear. The procedure is technically accessible with minimal surgical risks

Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle VAS pain was 6.73, and 3.13 respectively with a mean difference of 3.6 (p<0.001, 95% CI 2.6, 4.6). Mean pre and post-operative sinus tarsi VAS pain was 6.03 and 3.88, respectively with a mean difference of 2.1 (p<0.001, 95% CI 0.9, 3.4). Mean pre and post-operative EQ-5D Pain scores were 2.19 and 1.83 respectively with a mean difference of 0.4 (p=0.008, 95% CI 0.1, 0.6). Mean follow up time was 18.8 ± 18.4 months. Peroneus brevis to longus tendon transfer and gastrocnemius recession in the management of symptomatic progressive collapsing foot deformity significantly improved sinus tarsi and overall foot and ankle pain. Most EQ-5D scores improved, but did not reach statistically significant values with the exception of the pain score. This may have been limited by our cohort size. To our knowledge, this is the first report in the literature describing clinical results in the form of patient reported outcomes following treatment with this combination of isolated soft tissue procedures for the treatment of PCFD. For any figures or tables, please contact the authors directly

Introduction:. Peroneal muscle weakness is a common pathology in foot and ankle surgery. Polio, charcot marie tooth disease and spina bifida are associated with varying degrees of peroneal muscle paralysis. Tibialis Posterior, an antagonist of the peroneal muscles, becomes pathologically dominant, causing foot adduction and contributes to cavus foot posture. Refunctioning the peroneus muscles would enhance stability in toe off and resist the deforming force of tibialis posterior. This study determines the feasibility of a novel tendon transfer between peroneus longus and gastrocnemius, thus enabling gastrocnemius to power a paralysed peroneus tendon. Method:. 12 human disarticulated lower limbs were dissected to determine the safety and practicality of a tendon transfer between peroneus longus and gastrocnemius at the junction of the middle and distal thirds of the fibula. The following measurements were made and anatomical relationships quantified at the proposed site of the tendon transfer: The distance of the sural nerve to the palpable posterior border of the fibula; the angular relationship of the peroneus longus tendon to gastrocnemius and the achilles tendon; the surgical field for the proposed tendon transfer was explored to determine the presence of hazards which would prevent the tendon transfer. Results:. The mean angle between the tendons of peroneus longus and gastrocnemius/achilles tendon was 3°. The sural nerve lies on average 30 mm posterior to the palpable posterior border of the fibula. There were no significant intervening structures to prevent the proposed tendon transfer. Conclusion:. The line of action of peroneus longus and gastrocnemius are as near parallel as to be functionally collinear. The action of gastrocnemius may be harnessed to effectively power a paralysed peroneus longus tendon, without significant loss of force owing to revectoring of forces. The surgical approach to effect such a tendon transfer is both safe and practical

Purpose. This study aimed to objectively define gait derangements and changes before and after Tibialis Anterior Tendon Transfer surgery in a group of patients treated using the Ponseti method. Methods. 21 feet in 13 patients with Ponseti treated clubfoot who showed supination in swing on clinical examination, underwent gait analysis before, and approximately 12 months after, Tibialis Anterior Tendon transfer. 3–4 weekly casts were applied prior to the surgery, which was performed by transfer of the complete TA tendon to the lateral cuneiform. A parental satisfaction questionnaire was also completed. Results. In all but one patient, increased supination in swing phase was confirmed on pre-operative gait analysis, with EMG evidence of poor Tibialis Anterior modulation through-out the gait cycle. Post-operatively all patients showed improved positioning at initial contact, with heel strike and an absence of supination, and a decrease in swing phase supination. In all patients, knees were overly flexed at initial contact, some continuing through stance phase; there was no change seen postoperatively. All parents reported marked improvements in gait and activity level post-operatively. Conclusion. Gait analysis can be useful to confirm the need for tibialis anterior tendon transfer. Improved post-operative gait patterns seen by parents and clinicians can be related to objective improvements seen during gait analysis, confirming the benefit of tibialis anterior tendon transfer in appropriate patients

Although it is generally accepted that surgical treatment is the treatment of choice in chronic TA ruptures, therapeutic options are difficult. Traditional options include grafts (natural, allografts and synthetic grafts) and end to end repair. Natural grafts described include fascia lata and plantaris tendon. Synthetic materials such as Dacrongrafts, Marlex mesh and carbon fibers have been used. There are significant complications from graft and end to end repair. These include wound necrosis, delayed union, infection, foreign body reaction and devastating tissue loss. Also functional results are suboptimal after delayed reconstruction. Tendon transfer is another method that has been described for the treatment of these injuries. The tendons used were the flexor hallucis lomgus, flexor digitorum longus and the peronei . The FHL tendon transfer is considered advantageous to other tendon transfers because it is stronger, its axis of force is close to that of the TA and harvesting the tendon is easy and unlikely to cause any complications. We report excellent results following four operations in three patients treated with flexor hallucis longus tendon transfer for chronic Achilles tendon ruptures. All patients were on long term steroid treatment and an end to end repair would have been associated with a high complication rate. We believe that FHL transfer to replace the TA is a low morbidity alternative which gives good to excellent results in individuals with low to moderate demand

Objective: To assess the efficacy of split Tibialis Posterior tendon transfers for the treatment of spastic equino-varus feet. Materials and Methods: Fourteen patients with 14 spastic equino-varus feet underwent split Tibialis Posterior tendon transfers. The spasticity was due to cerebral palsy, ataxia telangiectasia and traumatic brain injury. All the patients had Ashworth 1–3 spasticity, and the forefoot was correctible in equinus. Evaluation of the results was by grading of the shape of the feet, ambulation, pain and brace tolerance. Results: One patient was lost to follow-up after an excellent primary result. Twelve patients had good or excellent results, and one patient had a fair result due to partial recurrence of the deformity. No complications were encountered. Conclusions: Split Tibialis Posterior tendon transfer is a safe and efficacious procedure for the treatment of spastic equino-varus feet. Good alignment of the treated feet allows comfortable brace and shoe wear. Patient selection is important in order to avoid over-correction or recurrence of the deformity

Common peroneal nerve (CPN) palsy has been reported to be the most frequent lower extremity palsy characterized by a supinated equinovarus foot deformity and foot drop. Dynamic tendon transposition represents the gold standard for surgical restoration of dorsiflexion of a permanently paralyzed foot. Between 1998 and 2005, we operated on 16 patients with traumatic complete CPN palsy. An osseous tunnel is drilled from anterior tibialis tendon (ATT) bony insertion through the cuneiform bones in the direction of the third cuneiform, through which the ATT is extracted and then pulled proximally under the extensor retinaculum. New ATT origin on the third cuneiform is therefore created. A double tendon transfer is then performed with a direct tendon-to-tendon suture at the distal third of the leg between the rerouted ATT and the posterior tibialis tendon (PTT) (transposed anteriorly through interosseous membrane) and between the flexor digitorum longus tendon (FDL), similarly transposed and sutured side-to-side with the extensor digitorum longus and extensor hallucis longus tendons. This second transfer strengthens ankle dorsiflexion and reanimates toe extension. All 16 patients were reviewed at a minimum followup of 24 months. Results were assessed using the Stanmore system questionnaire and were classified as excellent in eight, good in five, fair in two, and poor in one. In all cases, transosseous rerouting of the ATT provided a sufficient tendon length, which permitted tendon-to-tendon suturing between the ATT and PTT to be performed proximal to the extensor retinaculum eliminating tendon length-related problems. The new origin of the ATT at the third cuneiform was confirmed to be the optimal traction line to achieve maximum dorsiflexion with minimal imbalance in accompanying pronation and supination. Double tendon transfer also avoids not only drop of the toes, but also allows some extension of the hallucis. Postoperative static and dynamic baropodometric evaluations also were performed showing an overall satisfying progression of gait characterized by the absence of external overload in toe plantar flexion and by reduction of foot contact time with the ground with improvement of heel contact and pushoff phase with evidence of a longer step. The novelty of our proposed technique is that of moving the insertion of the recipient tendon (ATT) toward the donor transferred tendon (PTT) and not the contrary, providing an appropriate direction of pull with adequate length and fixation. For treatment of complete CPN palsy, transosseous rerouting to the third cuneiform of the ATT and dual transfer of the PTT and FDL tendons is a reliable method to restore balanced foot and toe dorsiflexion producing a normal gait without the need for orthoses

Introduction and Aims: The role of tendon transfer in progressive hereditary motor sensory neuropathy (CMT) is controversial. This paper examines a large single surgeon cohort and reviews the surgical outcome of tendon transfers against a large group of CMT patients represented by the Australian CMT Health Survey 2001. Method: A retrospective review was carried out in 19 patients (36 feet) with CMT, managed surgically by a single author (GW). Functional outcomes were measured using standard tools such as SF36, American Orthopaedic Foot and Ankle Score (AOFAS) rating scale, and a clinical review including a specially designed questionnaire. Quality of life and functional outcome has been compared with the Australian CMT Health Survey 2001 in 324 patients. Results: Nineteen patients were managed with tendon transfers, typically by flexor to extensor transfer of toes, combined with peroneus longus release and transfer, and tibialis posterior transfer. The Levitt classification of the objective results of surgery rates 79% of patients as having good-excellent outcomes. Eighty-nine percent of patients report an improvement overall with surgery, specifically 53% report improvement in pain, 79% feel their gait has benefited, and 58% report an improvement in the appearance of their foot deformity, as a direct result of their surgery. All patients reviewed would recommend similar surgery to others, and 95% of those surveyed wished they had their surgery much earlier (months to years). The AOFAS clinical rating system for ankle-hindfoot showed an average improvement of 39.7 points out of 100. In general patients treated by this method were improved when considered against a larger cohort both in quality of life measures and functional outcome. This combination was not always successful and a small number of disappointed patients were identified. Conclusion: Tendon transfer in the younger patient has a role in treating flexible deformity in CMT and improving quality of life. Traditionally surgery has been advised by means of arthrodesis in patients with more advanced fixed deformity and pain due to secondary osteoarthritis. This paper study shows that patients may benefit at an earlier stage in the progression of their disease by tendon transfer

Massive, irreparable rotator cuff tears occur in about 15% of patients with ruptures of the rotator cuff tendons. There is no consistently agreed management for irreparable rotator cuff tears, however, latissimus dorsi tendon transfer is a recognised technique. We aimed to review the functional outcome of patients undergoing this operation at a single tertiary referral centre. Fourteen latissimus dorsi transfer procedures in thirteen patients from May 2007 to May 2008 were retrospectively reviewed. The mean age of patients undergoing the procedure was fifty nine years. All patients were confirmed to have massive, irreparable (>5cm) rotator cuff tears as determined by MRI or ultrasound. Modified Constant scores (assessing shoulder pain, functional activity and movement) determined pre-operatively and post latissmus dorsi transfer were compared. The mean duration of follow up was 12 months. The mean Modified Constant Score (maximum = 75) improved from 23 points pre-operaively to 52 points post latissimus dorsi transfer (p < 0.05). All patients had improvement in shoulder pain following the operation. There was a trend for younger patients to have greater improvement in functional activity and shoulder movement. From our series, latissimus dorsi transfer is effective at improving functional outcomes in patients with massive, irreparable rotator cuff tears, especially in younger age groups

Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL) tendon transfer is considered advantageous over other tendon transfers. One disadvantage of FHL is it has limited excursion. There are no data to determine the optimal positioning of the FHL tendon to the calcaneum. Materials and Methods: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge® V19 were used to generate a human ankle joint model. This model is able to reproduce dorsi- and plantarflexion. Different attachment points of FHL tendon transfer to the calcaneum were investigated. Results: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355N. Plantarflexion increased for a more anterior attachment point. The maximal plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in these figures when the attachment point was moved to either a medial or lateral position. Clinical relevance: Optimal FHL tendon transfer positioning is a compromise between achieving plantarflexion for normal physiological function versus the force generating capacity and limited excursion of FHL. A more posterior attachment point is advantageous in terms of power. The range of motion is 10° less than when attachment is more anterior, the arc of motion (24.4°) is still physiological. We recommend that FHL is transferred to the calcaneum in a posterior position

Introduction. The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture. Materials and Methods. Fourteen patients with chronic tendo-Achilles rupture, presenting between April 2008 and December 2010, underwent surgical reconstruction and FHL transfer. Surgery was performed employing standard operative techniques, with shortening of the Achilles tendon and FHL transfer into the calcaneum with a Biotenodesis screw (Arthrex). VISA-A scores were performed preoperatively and six months postoperatively. Complication data was collected by review of the electronic patient record and direct patient questioning. Results. One patient died of an unrelated cause shortly before outcome scoring, and another patient was excluded because casting in the preoperative period prevented accurate scoring, although he achieved a good post-treatment score. Analysis was therefore carried out on twelve patients. Eleven of the twelve patients had significant improvement in their VISA-A score, with a mean improvement in score of 30 (p < 0.05). There were no significant complications in any of the patients. Conclusion. Our results show that FHL transfer in the management of chronic Achilles tendon rupture is a good, safe and reliable technique. There is excellent improvement in the mean VISA-A score, with no significant complications. Our results support the use of FHL tendon transfer for patients with chronic tendo-Achilles rupture

Introduction and Aims: While successful long-term results have been shown for ligament reconstruction–tendon interposition arthroplasty for treatment of thumb basal joint osteoarthritis, the need for invasive ligament reconstruction has not been established. In this study we describe long-term results utilising the technique of tendon interposition arthroplasty with dynamic tendon transfer and capsulorrhaphy. Method: Twenty-four thumbs (21 patients) were evaluated at an average of 7.1 years (1.8–19.5 years) post-procedure. Capsulorrhaphy was performed utilising APL tendon slips where tissue was insufficient. The APB origin was advanced via tendon transfer (FCR to APB), providing a stabilising abductor moment. Subjective assessment was performed using Visual Analogue Scores (VAS), Disabilities of Arm, Shoulder, Hand (DASH) scores, and patient satisfaction scales. Objective assessment included post-operative range of motion (ROM), grip/pinch strength, and radiographs for interposition arthroplasty height. Results: Twenty of 21 patients (95%) were satisfied and described results as either good or excellent. Twenty of 21 patients (95%) would undergo surgery again. Mean VAS was 8.7 at rest and 10.2 with activity (0, no pain; 100, maximum pain). Mean DASH score was 16.9 (range from 0, no difficulty performing daily tasks to 100, unable to perform daily tasks). ROM, grip, lateral and tip pinch strengths were comparable with those of the contralateral thumb. AP radiographs showed preservation in 12 of 12 patients (100%). Fourteen of 21 patients received the procedure on their dominant hand. Conclusion: Treatment of basal joint osteoarthritis with our technique provided stable and functional reconstructions, resulting in excellent pain relief. Results were comparable to, or better than, those previously cited in the literature for alternative procedures. These results suggest that dogma requiring static ligament reconstruction or suspension may need to be re-evaluated

Introduction: Tibialis anterior tendon transfer (TATT) is a common procedure for recurrence in clubfeet treated with the Ponseti method. Fixation usually includes passing the tendon through a drill hole in the lateral cuneiform using sutures brought out through the plantar aspect of the foot. Drilling of the tunnel and passing the sutures holds potential for neurovascular damage. We performed a cadaver study to evaluate plantar nerve structures at risk during TATT. Method: TATT was performed to the lateral cuneiform in fresh frozen adult cadaver limbs. In 3 feet, the drill hole was made perpendicular to the surface of the lateral cuneiform (group A), in 3 feet, the drill hole was perpendicular to the weight bearing surface of the foot (group B), in 3 feet, the drill was directed at 15 degrees in the frontal and sagital planes (group C) and in another 3 feet the drill was aimed at the middle of the foot (group D). The tendon sutures were pulled through the plantar aspect using two Keith needles aimed in the same direction as the drill hole. A layered dissection was performed. The distance from the drill hole to the nearest nerve or nerve branch was measured. Keith needles were passed 20 times per foot. With each pass, damage to nerve structures was noted. Results: In group A, the drill was in proximity to the medial plantar nerve at a mean distance of 1.7mm (1–3mm). The bifurcation of the nerve trunk was found more proximally at a mean distance of 5mm (2–9mm). In group B, the drill was found to be close to the lateral plantar nerve branches at a mean distance of 0.3mm (0–1mm) with a mean distance to the bifurcation of 25.3mm (16–37mm). The drill hole in group C was at a mean distance of 1.7mm (0–3mm) to the lateral plantar nerve bifurcation and at a distance of 1mm to the lateral nerve branch in one case. In group D, the drill exited in the middle of the plantar aspect at a mean distance of 7.7mm (5–11mm) from the medial nerve branch and 13mm (10–18mm) from the bifurcation of the medial nerve and at a mean distance of 4.3mm (3–6mm) from the lateral nerve branch and 14.7mm (11–19mm) from the lateral nerve bifurcation. Passing the Keith needles resulted in hitting a nerve structure 12 times in group A, 20 times in group B, 6 times in group C and once in group D. Conclusion: In TATT, the drill hole should be aimed at the middle of the foot in the transverse and longitudinal planes. This results in a maximum distance to both the lateral and medial nerve. A blunt Keith needle might allow a safer passing of the sutures to avoid damage to nerves and vessels

The “Knot of Henry” was dissected in 16 embalmed cadaveric feet to reveal the complex interconnections between flexor hallucis longus (FHL) and flexor digi-torum longus (FDL) tendons. Three distinct anatomical patterns were observed. Tension was applied manually to FHL or FDL proximal to the Knot. Digit movement was different depending on the anatomical pattern. FHL or FDL tendon transfer is an accepted technique to prevent progression of acquired plano-valgus deformity. In order to minimise donor deficit, we suggest the use of either FHL or FDL should be based on assessment of the anatomical pattern at the time of surgery

We reviewed 19 patients (30 feet) with congenital vertical talus treated surgically between 1987 and 1999, 22 of them by the same surgeon. The etiological diagnosis was idiopathic in seven patients. Six patients had associated congenital abnormalities (four arthrogryposis, two digitotalar dysmorphism) and six had associated neurological abnormalities (three microcephalic, three spinal dysraphism). Only two patients had surgery after the age of 18 months. The mean age at surgery was 14.7 months (6 to 51). In 15 feet a two-stage procedure was performed. Lengthening of the extensor tendons, notably tibialis anterior, was followed six weeks later by posterior release. In 15 feet a one-stage procedure was done, with no lengthening of the extensors or transfer of tibialis anterior. The Kidner procedure was done in seven feet, but the tibialis posterior was never found to be subluxed and the procedure was abandoned. The calcaneocuboid joint was opened and pinned in eight feet. The peroneal tendons required lengthening in eight feet. At a mean follow-up of 5.8 years (2 to 13.5), results were excellent in 17 feet (normal forefoot and hind-foot). Results were good in seven feet (normal radiographs, normal hindfoot, but pronated forefoot). In four feet the result was fair (valgus hindfoot with a plantarflexion angle of the talus more than 35(). In one patient, the results in both feet were poor (uncorrected). All seven good results followed a two-stage procedure. We concluded that this was due to relative weakening of the lengthened tibialis anterior to the peroneus longus. Where necessary, plantarflexion of the talus should be corrected at operation, and this should be correlated with intra-operative fluoroscopy. Adequate reduction of the navicula inferomedially on the talar head obviates the need for tendon transfer

The equinovarus hind foot deformity is one of the most common deformities in children with spastic paralysis and is usually secondary to cerebral palsy. Split posterior tibialis tendon transfer is performed to balance the flexible spastic varus foot and is preferable to posterior tibialis lengthening, as the muscle does not loose its power and therefore the possibility of a valgus or calcaneovalgus deformity is diminished. The cohort of the study consisted of 50 children with cerebral palsy who underwent split posterior tibial lengthening to manage spastic equinovarus hind foot deformity. Our inclusion criteria were: ambulatory patients with cerebral palsy, age less than 6 years at the time of the operation, varus deformity of the hind foot during gait, flexible varus hind foot deformity, and the follow-up at least 4 years. We retrospectively evaluated 33 ambulant patients with flexible spastic varus hind foot deformity. Twenty-eight patients presented unilateral and 5 bilateral involvement. The mean age at the time of the operation was 10,8 years (6–17) and the mean follow-up was 10 years (4–14). Eighteen feet presented also equinus hind foot deformity, requiring concomitant Achilles cord lengthening. Clinical evaluation was based on the inspection of the patients while standing and walking, the range of motion of the foot and ankle, callus formation and the foot appearance using the clinical criteria of Kling et al. Anteroposterior and lateral weight-bearing radiographs of the talo-first metatarsal angle were measured. The position of the hind foot was evaluated according to the criteria of Chang et al for the surgical outcome. 20 feet were graded excellent, 14 were graded good and 4 were graded poor. Feet with recurrent equinovarus deformity or overcorrection into valgus or calcaneovalgus deformity were considered as poor results. There were 23 feet presenting concomitant cavus foot component that underwent supplementary operations performed at the same time with the index operation. None of the feet presented mild or severe valgus postoperatively, while 4 feet presented severe varus deformity and underwent calcaneocuboid fusion sixteen and eighteen months after the index operation. On the anteroposterior and lateral weight-bearing radiographs the feet with severe varus had a negative talo-first metatarsal angle (mean −26,8 ± 18,4), those with mild varus had a mean of −14,5 ± 12,2. In feet with the hind foot in neutral position the mean value was 5.0 ± 7.4. The results of the feet in patients with hemiplegic pattern were better and significantly different than the diplegic and quadriplegic ones (p = 0.005). The results in our cases were in general satisfactory as 34 out of 38 feet were graded excellent and good. The feet with poor results presented a residual varus deformity due to intraoperative technical errors

Introduction:. Reverse total shoulder arthroplasty (RTSA) has become an accepted surgical treatment for patients with severe deficiency of the rotator cuff. Despite the utility of RTSA in managing difficult shoulder problems, humeral rotation does not reliably improve and may even worsen following RTSA. Several approaches to increase active external rotation (aER) postoperatively have been proposed including the use of concomitant latissimus dorsi tendon transfer (LDTT) or the use of an increased lateral-offset glenosphere (LG). We hypothesized that clinical outcome and range of motion after RTSA with a +4 mm or +6 mm LG would be comparable to RTSA with LDTT in patients with a lack of aER preoperatively. Methods:. An IRB-approved, prospective, single surgeon RTSA registry was reviewed for patients treated with LDTT or LG for preoperative aER deficiency with minimum 1-year follow-up. Patients qualified for aER deficiency if they had a positive ER lag sign or less than or equal to 10 degrees of aER preoperatively. Matched control groups with patients that did not have preoperative lack of aER and were not treated with LDTT or LG were included for comparison. Outcomes measures included Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), ASES Activities of Daily Living (ADL) score, Visual Analogue pain Scale (VAS), active forward elevation (aFE), active internal rotation (aIR), and aER. An independent, institutional biostatistician performed statistical analyses. Results:. The LDTT group had 21 patients (10 male, 11 female) and the LG group had 16 patients (5 male, 11 female). CMS, ASES, SSV, ADL, VAS, and aFE were significantly improved in case and control groups following RTSA (P < .05). There was no significant difference in the degree of improvement of CMS, ASES, SSV, ADL, VAS or aFE between the LDTT group and its control group or the LG group and its control group (P > .05). aER was significantly improved in the LDTT and LG groups (P < .001), but did not improve significantly in either control group (P > .05) (Figure 1). The LDTT group had a significantly lower postoperative aER than its control group (P = .001), whereas the LG group had similar postoperative aER to its control group (P = .376) (Figure 1). The LG group had significantly greater aER preoperatively and postoperatively than the LDTT group (P < .001 and P = .013). There was no significant difference in degree of improvement of aER between the LDTT and LG groups (P = .212). The LDTT group had a significantly lower postoperative aIR than its control group (P=.025), whereas the LG group had similar postoperative aIR to its control group (P = .234). The LG group had significantly greater improvement in aIR than the LDTT group (P=.009). Conclusion:. To our knowledge, this is the first series to compare outcomes of two common techniques used to improve aER following RTSA. In this series, we found overall similar improvements in outcomes between the groups. These results suggest that use of a LG may be preferable to LDTT given the relatively simplified surgical technique, similar improvement in aER, comparable clinical outcome scores, and the added benefit of improved aIR

Among the most popular techniques for the management of radial nerve palsy is the transfer of the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB), of the Flexor Carpi Radialis (FCR) to the Extensor Digitorum Communis (EDC) and of the Palmaris Longus (PL) to rerouted Extensor Pollicis Longus (EPL). This retrospective study was undertaken to assess the outcome of flexor carpi radialis transfer in the treatment of radial nerve palsy.

Twenty patients with a mean age of 36 years were included in this study. Surgical management, as described above, was decided since all patients had irreparable damage to the nerve. Parameters that were assessed included range of wrist motion, dynamic power of wrist flexion and extension, and radial and ulnar deviation and function.

The average follow-up was 4.5 years. Compared to a control group of 10 volunteers of similar characteristics, all patients achieved a functional range of motion and satisfactory power of wrist motion. All patients returned to their previous occupation.

Transfer of Flexor Carpi Radialis tendon for irreparable radial nerve palsy yields satisfactory results. Therefore, it can be expected that patients will obtain a functional range of motion as well as an adequate strength of motion.

Residual club foot (CTEV) is a challenging deformity which may require transfer of the tibialis anterior tendon to a more lateral position. The senior author has developed a modified SPLATT for residual forefoot supination in CTEV.

We describe the SPLATT procedure and evaluate clinical and radiological outcomes of 11 patients(14 feet) (mean follow up 6.6 years; range 5.5–8.9) (mean age 6.9 years; range 2.9–10.0). Two patients had cerebral palsy, 1 spina bifida and 1 juvenile rheumatoid arthritis, the remaining 7 patients were ideopathic.

Outcome measures based on patient centred assessment of function and foot appearance, by using the patient applied assessments of Chesney, Utukuri and Laaveg & Ponsetti (there is increasing recognition that doctor-centred or radiograph-based scoring systems do not tally well with patient satisfaction).

Objective assessment of outcome was provided by measurement of certain radiological parameters on the immediate pre-operative and the follow up weight-bearing radiographs (1st ray angle, talar-1st metatarsal angle, talar-2nd metatarsal angle, talo-calcaneal angle). The calcaneal line passing through the medial 1/3 of the cuboid or medial to the fourth metatarsal was also noted. The Blecks grade was recorded (pre-op 100% moderate-severe; post-op 88% mild-moderate). Parents assessed outcome based upon ‘best level of activity’, functional limitation and willingness to recommend treatment to others.

Mean Chesney score at the time of follow up was 12.3 (8 to 15); mean Utukuri score was 15.8 (10 to 24); Laaveg and Ponsetti score was 81.5 (67 to 95). The best activity level achievable was ‘unlimited’ in 4 patients, ‘football’ in 4 patients, ‘running’ in 1 and limited by an associated condition in 2 patients (1 juvenile rheumatoid arthritis; 1 cerebral palsy related spastic paraparesis). All patients/parents indicated that they would undergo the same procedure again. One patient had delayed wound healing treated successfully with dressings.

The 1st ray angle pre-operatively was 61.2°(range 50–70°), post-operatively it was 62.1°(range 50–81°). The talar-1st metatarsal angle was 28.8°(range 15–44°) pre-operatively and 19.1°(range 4–34°) post-operatively. The pre and post–operative talar-2nd metatarsal angles were 22.5°(range 0–35°) and 12.3(range 0–29°) respectively, the talo-calcaneal angle was 17.5°(range 10–35°) and 13.7(range 5–20°) respectively. The pre and postoperative lateral talo-calcaneal angles were 34.5°(range 25–40°) and 30.6(range 13–45°).

The recognition that patient orientated subjective assessment is gaining in acceptance, and confirm patient satisfaction with function, cosmesis and pain levels with the SPLATT procedure. More traditional radiological outcome measures also confirm that the modified SPLATT is a safe, effective and acceptable procedure.