Congenital metatarsus varus is a common deformity that usually responds to conservative treatment. In fifteen feet operated on for resistant deformity, an anomalous insertion of the tibialis posterior tendon was found in fourteen. Six cadaveric infant feet were dissected to confirm the normal insertion. The dynamic component of the deformity is stressed

Flat foot due to rupture of the tibialis posterior tendon has not previously been described in children. We present three young patients who developed unilateral pes planus after old undiagnosed lacerations of the tendon. Transfer of the flexor hallucis longus to the distal stump of the tibialis posterior tendon achieved good results in all three cases

The December 2022 Foot & Ankle Roundup. 360. looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle

Aims. The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD. Methods. The study was conducted on 40 adult embalmed cadaveric lower limbs. Chopart joint complexes were dissected, and the structures supporting the joint inferiorly were observed and noted. Results. The articulating bones exhibit features like a cuboid shelf and navicular beak, which appear to offer inferior support to the joint. The expanse of the spring ligament complex is more medial than inferior, while the superomedial part is more extensive than the intermediate and inferoplantar parts. The spring ligament is reinforced by the tendons in the superomedial part (the main tendon of tibialis posterior), the inferomedial part (the plantar slip of tibialis posterior), and the master knot of Henry positioned just inferior to the gap between the inferomedial and inferoplantar bundles. Conclusion. This study highlights that the medial aspect of the talonavicular articulation has more extensive reinforcement in the form of superomedial part of spring ligament and tibialis posterior tendon. The findings are expected to prompt further research in weightbearing settings on the pathogenesis of flatfoot. Cite this article: Bone Jt Open 2024;5(4):335–342

Background. Weightbearing computed tomography scans allow for better understanding of foot alignment in patients with Progressive Collapsing Foot Deformity. However, soft tissue integrity cannot be assessed via WBCT. As performing both WBCT and magnetic resonance imaging is not cost effective, we aimed to assess whether there is an association between specific WBCT and MRI findings. Methods. A cohort of 24 patients of various stages of PCFD (mean age 51±18 years) underwent WBCT scans and MRI. In addition to signs of sinus tarsi impingement, four three-dimensional measurements (talo-calcaneal overlap, talo-navicular coverage, Meary's angle axial/lateral) were obtained using a post processing software (DISIOR 2.1, Finland) on the WBCT datasets. Sinus tarsi obliteration, spring ligament complex and tibiospring ligament integrity, as well as tibialis posterior tendon degeneration were evaluated with MRI. Statistical analysis was performed for significant (P<0.05) correlation between findings. Results. None of the assessed 3D measurements correlated with spring ligament complex or tibiospring ligament tears. Age, body mass index, and TCO were associated with tibialis posterior tendon tears. 75% of patients with sinus tarsi impingement on WBCT also showed signs of sinus tarsi obliteration on MRI. Of the assessed parameters, only age and BMI were associated with sinus tarsi obliteration diagnosed on MRI, while the assessed WBCT based 3D measurements were, with the exception of MA axial, associated with sinus tarsi impingement. Conclusion. While WBCT reflects foot alignment and indicates signs of osseous impingement in PCFD patients, the association between WBCT based 3D measurements and ligament or tendon tears in MRI is limited. Partial or complete tears of the tibialis posterior tendon were only detectable in comparably older and overweight PCFD patients with an increased TCO. WBCT does not replace MRI in diagnostic value. Both imaging options add important information and may impact decision-making in the treatment of PCFD patients

Aims: Valgus pes planus deformities in patients with RA are similar to those seen with TPTD. The valgus pes planus deformities that derive from RA and TPTD do not necessarily have the same etiology, however. With this in mind, we studied TPTD in patients with RA using plain radiographs and MRI scanning. Methods: We studied 12 feet from 10 patients with RA, with 1 male and 10 female subjects. Plain radiographs were taken using the method of Yokokura, and the L, N, C, R and T values were determined for the longitudinal arch. MRI þndings were then classiþed as Type I, II or III, based on the classiþcation of Conti et al. The radiological þndings were also correlated with the clinical þndings. Results: The mean values for the longitudinal arch parameters were: L 21.2±4.0%; N 26.5±6.2%; C 30.5±4.5%; R 48.9±5.8%; and T 30.8±4.3%. MRI scanning revealed 4 feet of Type I, 3 Type II, and no Type III, with no abnormality detected in 5 feet. Conclusions: We examined the relationship between foot deformities and the tibialis posterior tendon in patients with RA, using plain radiographs and MRI scanning. In RA a condition corresponding to TPTD may lead to a valgus pes planus deformity, but this deformity may also arise from a high degree of joint destruction unrelated to the tibialis posterior tendon. We therefore concluded that the valgus pes planus deformity in patients with RA is not necessarily caused by disorders of the tibialis posterior tendon. We also concluded that degeneration of the tibialis posterior tendon in patients with RA is related to joint inßammation

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

Aim. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressures. Progressive hindfoot equinus from contraction of gastrocnemius-soleus-tendo-Achilles complex and progressive plantar flexed metatarsal heads secondary to claw toe deformity results callus at the metatarsal heads which break down to ulceration. The aim is to describe 2-stage treatment pathway for managing these ulcers. Methods. Consecutive patients, who presented with forefoot ulcers since February 2019 were treated with a 2-stage treatment pathway. The first stage of this is an out-patient tendo-Achilles lengthening (TAL). The second stage is surgical proximal dorsal closing wedge metatarsal osteotomy for patients with persistent or recurrent ulcers. Patients were followed for a minimum of 12 months. Results. 112 patients (146 feet) underwent TAL by 3 consultants. Of these, 96 patients were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 patients (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with 1. st. metatarsal and 5. th. metatarsal head ulcers respectively. In 12 patients (10%), the ulcer failed to heal or recurred. MRI scan in these patients showed plantar flexed metatarsals from progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy of the metatarsal/s, with no recurrence at a minimum 12months of follow-up. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after the first stage out-patient percutaneous TAL

Introduction: Tibialis posterior tendon dysfunction is a common cause of foot pain and dysfunction in the middle aged patients. Initially, it presents as medial ankle pain and swelling, with or without a flexible flat foot, later progressing on to a fixed deformity. Operative management for the early stages of tendon dysfunction poses a significant workload on hospitals and physical burden on patients. We have evaluated non-operative management of early tibialis posterior tendon dysfunction (. 1. ). Methods: This is a prospective study on patients with stage I and II tibialis posterior tendon dysfunction treated with a structured physiotherapy protocol. Twelve consecutive patients referred to a foot and ankle consultant with early tibialis posterior dysfunction from July 2008 were included in the study. The physiotherapy regime includes repetitive resisted active dorsiflexion, inversion, eversion, heel rise, and tip toe walking. The intensity of physiotherapy is progressively increased over the period of four months in four phases. Criteria for successful rehabilitation are ability to perform greater than ten single stance heel rises and tip toe walking for more than 100 yards. Patients who cannot achieve the expected progression were re-referred for surgical intervention. All the patients were referred for support with orthoses, however, only a few received the orthoses during the treatment period. The outcome was assessed using the validated outcome score Foot Function Index (FFI) before and after physiotherapy regimen. Results: The study group consisted of 10 females and two males with 10 unilateral and two bilateral cases. The mean age was 59 years (48 to 79). The average number of physiotherapy visits was five. Prior to treatment the mean number of single stance tip toes performed by the patients was four. Out of 12 patients, ten successfully completed the rehabilitation. The mean FFI before rehabilitation was 55, which improved to 19 at the end of four months rehabilitation. On analysis using a paired t test 95% CI for mean difference: (25.07, 46.93) P < 0.0001. The improvement was consistent with all the three components of FFI (pain, activity and function) (p< 0.0001). Conclusion: This study suggests early tibialis posterior tendon dysfunction can be treated effectively with structured physiotherapy

Aim. To describe a 2-stage treatment pathway for managing neuropathic forefoot ulcers and the safety and efficacy of percutaneous tendo-Achilles lengthening (TAL) in out-patient clinics. Methods. Forefoot ulcers in patients with diabetic neuropathy are a result of factors that result in increased forefoot plantar pressure. Plantar flexed metatarsal heads secondary to progressive claw toe deformity and hindfoot equinus from changes within the gastrocnemius-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus, secondary to motor neuropathy results in progressive increase in forefoot plantar pressures. Consecutive patients, who presented to our Diabetic Foot clinic since February 2019 with forefoot ulcers or recurrent forefoot callosity were treated with TAL in the first instance, and in patients with recurrent or non-healing ulcers, by proximal dorsal closing wedge osteotomy; a 2-stage treatment pathway. Patients were followed up at 3, 6, and 12 months to assess ulcer healing and recurrence. Results. One hundred and twelve patients (146 feet) underwent TAL by 3 consultants in the out-patient clinics. Of these, 96 feet were followed for a minimum of 12 months (range 12–36 months). None had infection or wound related problems at the tenotomy sites; complete transection of the tendon was noted in 4 patients (4%) and one-patient developed heel callosity suggestive of over-lengthening. In 92 feet (96%), the ulcers healed within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. In 12 feet (10%), the ulcer failed to heal or recurred, the MRI scan in these patients showed plantar flexed metatarsals secondary to progressive claw toe deformity. The ulcer in this group healed after surgical offloading with proximal dorsal closing wedge osteotomy. In patients with osteomyelitis, the intramedullary canal was curetted and filled with local antibiotic eluting agents such as Cerament G. ®. The osteotomy site was stabilised with a percutaneous 1.6mm k-wire. Conclusion. The described 2-stage treatment pathway results in long-term healing of neuropathic forefoot ulcers, and in 96% of patients, the ulcer healed after out-patient percutaneous TAL alone. TAL is a safe and effective initial out-patient procedure with improved patient outcomes

Aim. The aim of this paper is to analyse the cause of neuropathic diabetic foot ulcers and discuss their preventive measures. Methods. Review of patients with foot ulcers managed in our diabetic MDT clinics since Feb 2018 were analysed. Based on this observation and review of pertinent literature, following observations were made. Results. Forefoot. Progressive hindfoot equinus from contraction of gastroc-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus muscles and, progressive plantar flexed metatarsal heads secondary to claw toe deformity results in increased forefoot plantar pressures. In patients with insensate feet, this result in ulcer formation under the metatarsal heads from shear stress when walking. Callosity under the metatarsal heads is the earliest clinical sign. Most patients by this time have fixed tightness of the muscle groups as assessed by negative Silfverskiold test. Percutaneous tendo-Achilles lengthening (TAL) has shown to reduce the mid-forefoot plantar pressures by 32% and ulcer healing in 96% of patients within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. Proximal metatarsal osteotomies further reduce the forefoot pressures to near normality. Midfoot. Midfoot ulcers are secondary to rocker-bottom deformity a consequence of Charcot neuroarthropathy (CN). Hindfoot equinus as described and relative osteopenia from neurally mediated increased blood flow (neurovascular theory) and repeated micro-trauma (neurotraumatic theory) result in failure of medial column osseo-ligamentous structures. As the disease progress to the lateral column, the cuboid height drops resulting in a progressive rocker bottom deformity. The skin under this deformity gradually breaks down to ulceration. In the pre-ulcerative stages of midfoot CN, TAL has shown to stabilise the disease progression and in some patents’ regression of the disease process was noted. The lump can excised electively and the foot accommodated in surgical shoes. Hindfoot. These develop commonly at the pressure areas and bony exostosis in non-ambulatory patients. In ambulatory patients, the most common cause are factors that result in over lengthening of tendo-Achilles such as after TAL, spontaneous tears, or tongue-type fractures. Conclusions. Early identification of factors that result in plantar skin callosity and treating the deforming forces prevent progression to ulceration. Total contact cast without treatment of these deforming forces results in progression of these callosities to ulceration while in the cast or soon after completion of cast treatment

Aims. Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis. Methods. The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently. Results. Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications. Conclusion. TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity. Cite this article: Bone Jt Open 2024;5(3):252–259

Purpose: The use of allografts for anterior cruciate ligament (ACL) reconstruction has gained increased popularity. The major benefits of allograft for ACL replacement include decreased morbidity, easier patient rehabilitation and include ease of surgical procedure, decreased harvest site morbidity and easier patient rehabilitation. Further, allografts have improved appeal because of better sterilization techniques, improve graft availability and decreased hospital costs.|The objective of this study was to perform mechanical testing on various types of allograft. Specimens for allograft reconstruction of the anterior cruciate ligament included tibialis anterior tendon, tibialis posterior tendon, Achilles tendon and bone patella tendon tissues. Methods: The allografts tested were used for deployment in patients suffering with anterior cruciate ligament disruptions. A total of fifty grafts were analyzed. The breakdown of graft types included 15 tibialis anterior tendon, 15 tibialis posterior tendon, 10 Achilles tendon and 10 bone patella tendon tissues. The test techniques included: cutting the tendons to a set thickness and length. The tendons were then mounted in a cryogrip and frozen with liquid Nitrogen to below zero. They were mounted into a servo-hydraulic testing machine and pre-loaded and pre-conditioned. The specimens were then stretched to failure at a set strain rate. Results: No difference was found between the mechanical/material properties of the various tendon allografts – these included tensile strength and a high stress linear modulus assessments. The mechanical (structural properties) of the allografts were more dependant on the cross sectional area of the allograft than the type of allograft tissue.The greater the cross-sectional area of the allograft, the greater the strength and stiffness of the graft. Conclusions: These findings have considerable clinical applicability in choosing an allograft for anterior cruciate ligament reconstruction

Tibialis posterior tendon (TPT) dysfunction is a disorder of unknown aetiology. Trauma, inflammatory processes, anatomical abnormalities and iatrogenic factors have all been implicated as causative mechanisms. The condition presents with pain and swelling around the medial malleolus. The pain is characteristically worse on exercise and relieved by elevation. The disorder has been classified by Johnson and Strom (1989); stage I is characterized by pain around the medial malleolus and mild weakness of single heel raising. Without treatment the condition may progress to a fixed valgus deformity along with pes planus. Aim. To assess the outcome of surgical decompression of stage I TPT dysfunction. Method. Ten cases were identified, operated on by a single surgeon over a three-year period. The patients were assessed in a dedicated clinic by administration of a questionnaire and by clinical examination. Results. Nine patients with an average age of 30 years (13–51) agreed to participate in the study. Six of the nine patients recalled a sporting injury to the ankle prior to onset of symptoms. Eight of these of patients underwent a course of physiotherapy prior to surgery. After decompression all patients reported reduction of pain as measured using a visual analogue scale, with five patients reporting complete resolution of pain. Patients experienced relief of pain on average four weeks (1.5–6) after surgery. All patients were able to return to work and normal leisure activities after appropriate rehabilitation. Conclusions. Decompression of the tibialis posterior tendon in stage I dysfunction leads to pain relief and enables an early return to normal activities. Therefore surgical decompression of the tibialis posterior tendon may be considered in cases of stage I dysfunction which are refractory to conservative measures, particularly in young and active patients

Introduction: Intra-operative visualisation of talonavicular reduction does not exclude the possibility of persistent navicular rotatory subluxation as cause of persistent cavus or adductus deformity. Open perinavicular arthrography accurately defines navicular rotatory status. Similarly, inferior navicular insertion of the tibialis posterior tendon is a reliable predictor of correction of navicular rotation. Methods: Six operated clubfeet, aged six to ten months and operated on from March 2001 to September 2001, were included in this study. Correction was obtained using a sequential release and reduction was held with talonavicular and calcaneocuboid pinning. Simultaneous perinavicular arthrography was done using contrast soaked surgical patties inserted into the opened talonavicular and naviculocuneiform joints. Naviculocuneiform status and navicular insertion of the tibialis posterior were observed and conventional intra-operative clinical- and radiographic assessment of clubfoot correction was compared with perinavicular arthrographic findings. Results: Naviculocuneiform displacement was not observed. Visual and arthrographic assessment of talonavicular reduction showed a correlation of 100%, but such reduction often necessitated joint incongruence. Arthrography showed persistent navicular rotatory subluxation after adequate release and talonavicular reduction in 2 cases. Anteroposterior and lateral talar-first metatarsal angles fail to identify inadequate plantar fascia release, failure of talonavicular reduction or persistent navicular rotation as cause of persistent deformity. After adequate plantar fascia release, visual confirmation of talonavicular reduction and arthrographic confirmation of navicular rotatory reduction successfully corrected persistent midfoot deformities. Medial navicular insertion of the tibialis posterior tendon was observed in all cases of navicular rotatory subluxation, while restored inferior navicular insertion of this tendon was confirmed in all cases where navicular rotation was corrected. Recurrent navicular rotation after confirmed correction was observed in one case after single pinning of both talonavicular and calcaneocuboid joints. Conclusions: The naviculocuneiform joint should not be addressed at clubfoot surgery. Inferior navicular tibialis posterior insertion confirms correction of navicular rotation as cause of persistent midfoot deformity and should be routinely assessed. Recurrent navicular rotatory subluxation suggests double pinning of the talonavicular joint

1. A case of traumatic forward dislocation of the tibialis posterior tendon at the ankle is described. 2. A possible mechanism of the injury is suggested

The accessory navicular (AN) is a separate ossification center for the tuberosity of the navicular that is present in approximately 5–14% of the general population. It produces a firm prominence on the plantar-medial aspect of the midfoot. There may be a co-existent flexible flatfoot, but there is no conclusive evidence of a cause-and-effect relationship between the two conditions. It is usually not symptomatic, and few cases necessitate operative intervention. When symptoms require surgical treatment, excision of the AN, with or without advancement of the posterior tibial tendon, usually is considered. To describe new technique of AN excision and tibialis posterior tendon advancement (TPTA) using a bio-absorbable tenodesis screw and to investigate the outcome of this cohort in comparison to conventional simple excision. Retrospective 2 Cohort study. Single surgeon series from single institution. All patients younger than 18 years from Jan 2000 to Aug 2012 undergoing simple excision (SE) or excision with TPTA were identified from the prospectively collected database. Case notes were reviewed and data regarding demographics, indications for surgery, presence of Pes Planus, time from presentation to surgery, length of follow-up, patient satisfaction and complications were recorded. Pain and functional outcome were measured using Visual Analogue Score (VAS) and patient reported outcome measure- Oxford Ankle Foot Questionnaire- Child and Teenager Version. There were 6 patients in SE group. There were 3 males and 3 females. Mean age at surgery was 13.9 years. Surgical indication was painful swelling in all patients and in addition 1 had pes planus. There were 7 in SE & TPTA group. There were 3 males and 4 females. The mean age at surgery was 13.1 years. Surgical indication was painful swelling in all patients and in addition 1 had hind foot rigidity and 3 had pes planus. Postoperative protocol involved weight bearing with or without cast in SE group and non-weight bearing in cast for 6 weeks in TPA group. All patients reported excellent to good outcome. There were no complications and no reoperations after tendon advancement. In conclusion, based on our study findings, we think AN excision and TP advancement is a safe and effective technique for symptomatic pain relief. It is a novel technique which achieved excellent to good outcome in our series

Background. The adult acquired flat foot is caused by a complete or partial tear of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medializing calcaneal osteotomy for recontruction of the deformity. Material & Methods. Twenty-six patients (31 feet) with an average age of 58 years (36–75) were operated for an acquired flat foot deformity. The patients were seen before surgery, one year after surgery and an average of 85 months after surgery to assess the following parameters: AOFAS Score, VAS Score for pain (0–10). Foot x-rays in full weightbearing position (dorsoplantar and lateral) were done at every visit in order to assess the following parameters: tarsometatarsale angle on the dorsoplantar and lateral x-ray, talocalcaneal angle on the lateral x-ray, calcaneal pitch angle and medial cuneiforme height on the lateral x-ray. Results. The AOFAS hindfoot score improved from 46.4 to 89.5 (max.: 100) points 1 year postoperatively und decreased to 87.8 points at the last follow-up. VAS for pain decreased from 6.6 to 1.1 at the one year follow-up and increased to 1.5 at the last follow-up. All radiologic parameters improved and stayed without significant changes over time. Following complications were seen: one recurrence, two patients with irritation of the sural nerve, one patient with hypesthesia of the big toe. In six patients the screws had to be removed. Apart from that no other revision surgery had to be done. Conclusion. Flexor digitorum longus transfer together with medializing calcaneal osteotomy provides excellent results for the therapy of acquired flat foot deformity. The results did not change significantly over time

The interosseous route remains popular for tibialis posterior tendon transfer for drop-foot. It leaves a smaller range of movement than the circumtibial route, but lengthening the calcaneal tendon may improve this. The results of this present series indicate that, in order to predict a good functional result, the ankle must be held in at least 20 degrees of dorsiflexion at the time of tendon transfer

1. The tibialis posterior tendon was transferred in twenty-eight congenital club feet to maintain the correction obtained by serial wedge plasters. 2. There has been no relapse in twenty-seven of the twenty-eight feet in the period under review–namely, one to three years from operation. 3. The technique of the operation is described. 4. It appears that this operation should not be attempted when a soft-tissue correction has been done previously