The purpose of this paper is to report on the use of a tendon transfer (anterior tibial to midfoot) to correct dynamic foot and ankle varus deformity. Anterior tibial tendon transfer to mid-foot is useful to consider in planning treatment where there is a need to rebalance a foot in which the unopposed or weakly opposed anterior tibial causes the abnormal varus position of the foot and ankle. 12 patients, 22 feet had anterior tibial tendon transfers performed. 10 were bilateral. 10 patients had neuromuscular disease as the underlying cause for the foot imbalance, 1 patient had idiopathic clubfoot with residual, recalcitrant varus after earlier posteromedial release and 1 patient was hemiplegic secondary to stroke caused by encephalopathy. Age of the patients at the time of their initial procedure(s) ranged from 2 to 34. There was at least 1 year follow-up after each procedure for the patient to be entered into this study. A 1-grade functional loss was encountered following tendon transfer of anterior tibial muscles grading between 4–5. (4=good, 5=being normal). The transferred muscles allowed the dynamic varus deformity to be removed and the foot to become plantigrade. In its transferred position, it functioned to actively contract and contributed to give support of the ankle. After an initial period of cast use post-operatively and bracing for 6 months to support the transfer, continued use of AFO was no longer necessary. Anterior tibial tendon transfer to mid-foot, originally described by Garceau continues to be an useful method for rebalancing a foot in which the abnormal pull of the normal or almost normal functioning anterior tibial muscle. This muscle is unopposed or weakly opposed because of the underlying neuromuscular disorder or previous surgery. Thus, it causes the foot and ankle to turn into varus. The technique used is straightforward and simple. It is a useful procedure to consider when rebalancing a foot may be needed.

An anterior skin flap taken from the instep can be used to cover the bone ends in disarticulation of the ankle when ulceration or necrosis of the heel prevents the use of the heel flap for a conventional Syme’s amputation. From 1995 to 2003 December, we performed ankle disarticulation by using anterior flap after primary radical debridement in 42 cases with traumatic foot amputation injured by antipersonnel land mines. In all our cases, we observed wound healing in 2 weeks without any problems. The patients were advised to use a cylindrical bootee for indoor walking in third week. After 1–1.5 month, we put plastazote pad on stump end for prosthesis fitting, and for ourdoor walking the patients used prosthesis which would combine partial end-bearing and partial weight bearing on the patellar tendon. Ground contacting and standing without a prosthesis were also acceptable. We observed the advantages of prosthesis fitting. For instance, there is no need to open a window on the prosthesis socket for fitting and it is easier to fit the slender stump into the prosthesis. In early fitting we did not come across any problems about the slipping of the flap from stump as seen in conventional Syme’s amputation. In short and long term follow-ups, we found that the patients did not complain much about their prosthesis. For all these reasons, we think that ankle disarticulation with anterior flap rather than transtibial amputation should be preferred in patients with traumatic foot amputation since conventional Syme’s amputation can not be performed in heel injuries.