DROPFOOT TENDON SURCERY
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lames [. Bouchard, D.P.M.
Bradley D. Castellanq D.P.M.
PURPOSE
In this chapter we discuss the surgical indications and
techniques of tendon surgery for the correction of drop-
foot deform ity. A thorough u nderstand i ng of the pri nciples
of muscle-tendon surgery and tendon transfers is essen-
tial if optimal results are to be obtained surgically. Many
facto rs m u st be considered. These i ncl ude anatomy, physi-
ology, function and healingof musclesand tendons, proper
su rgical techn ique and tendon hand Iing, and many other
factors described previously in this book.
An understanding of the etiology and classification of
the dropfoot deformity is essential in the selection of the
appropriate su rgical proced u res. It is wise for the patient
and the surgeon to be realistic in determining the goals
and expectations of the proposedtendon transfersu rgery.
Definition And Classification
Dropfoot is a nonspecific term which refers to a condi-
tion involving the relationship of the foottothe leg in wh ich
there is paralysis or pronou nced weakness of the extensor
muscles. lt is a complicated deformitywhich may present
in varying degrees of severity depending on the etiology
and progressive nature of the underlying disease. Most
patients presentingwith d ropfootdeformitywill have clin i-
cal evidence of neuromuscular disease.
The dropfoot condition can be classified as flexible or
f ixed depend i ng on the severity and degree of contractu res
associated with the deformity. ln the early stages, deform ity
usually presents as paralysis of the extensor muscleswith-
outanysecondaryosseous or structu ral deformities. Such
soft ti ss u e d efo rm ity respo nd s we I I to vari ou s tend o n tran s-
fer procedures.
For atendon transferto be effective, the deformity must
be entirely flexible or non-osseous in nature or must be
made f lexible at su rgery. Flexibility is determ ined preoper-
atively by examination of range of motion. The clinician
should be able to demonstrate a reasonable range of pas-
sive motion to a corrected position or beyond.
The osseous or structural dropfoot is the most severe
type of deformity and is commonly referred to as talipes
equinus. lt presents as a fixed or structural deformity in
whichthere is inadequate rangeof motionto permitreturn
30
to a co rrected position. The rigid deform ity is q u ite recalci-
trantto treatment bytendon transfers. In some cases osse-
ous or fixed deformities can be altered by joint releases,
tendon lengthenings, osteotomies, and arthrodesis.
Not inf requentlythefixed dropfootdeformitywill require
apantalar or an kle arth rodesis i n order to obtai n an accept-
able fixed position of the foot to the leg.
Ti b i al i s Poste ri o r Tendo n Tran sfe r
lndications:
ln the presence of extensor muscle paralysis the tibialis
posterior provides potential for good restoration of dorsi-
flexory power bytransferthrough the interosseous mem-
brane to the dorsum of the foot. The normal function of
the tibialis posterior muscle is in stance phase and its
primary action is adduction and inversion of the foot.
Transfer of the tibialis posteror tendon to the dorsum of
the foot involves an out of phase muscle transfer in which
thefunction of the musclechangesfrom stance phasemus-
cle to swing phase.
ldeally in tendon transfer surgery it is best to transfer
muscles within phase. However, the out of phase muscle
transfer involvi ngthetibialis posteriortendon has provided
excellentf unctional results. It has been utilized at Doctors
Hospital for more than twenty-five years on a continuing
basis and is recommended for the following conditions:
1. Weak or paralyzed anterior muscle group
2. Non spastic equinovarus deformity
3. Recurrent clubfoot deformity
4. Dropfoot deformity
5. Charcot-Marie Tooth disease foot deformity
6. Permanent peroneal nerve palsy
Surgical Technique:
Review of the literature reveals three major techniques
which have been utilized for transferring the tibialis pos-
teriortendontothedorsum of thefoot in correction of the
dropfootdeformity. Oneof thefirst procedu res employed
uti I ized th ree separate incisions. The f i rst i ncision was made
medially over the insertion of the tibialis posterior at the
level of the navicular bone. Through this f irst incision, the
tendon is identified and released f rom its insertion intothe
navicular bone,with careto preserveas much Iength of the
tendon as possible.
The second incision is located on the anterior aspect of
the leg atthe level of the middle and distalthird just lateral
to the crest of the tibia. Through this second incision the
tibialis anterior muscle belly is identified and retracted f rom
the lateral aspect of thetibiato the level of the underlying
i nterosseous mem brane.

Dissection in the area of the anterior compartment of

the leg is relatively simple due to the well def ined tissue
layers. Exposure and separation of the anterior compart-
mentof the legtothe levelof the interosseous membrane
proximally and distally is essential in facilitating transfer
of the tibialis posterior through the interosseous mem-
brane. The use of Army-Navy retractors helps to facilitate
retraction of thetibialis anterior muscle bel lyand the neu ro-
vascu lar structu res f rom the anterior aspect of the interos-
seous membrane. With vital structures retracted, awindow
is made by incising the interosseous membrane.

Extreme care must be taken to avoid damageto a second

neurovascular bundle lying just posterior to the tibialis
posterior muscle belly (Fig. 1). With careful blunt dissec-
tion and the useof cu rved Kellyforceps and moistsponges/
thetendon and muscle bellyof thetibialis posteriorcan be
drawn through theopening in the interosseous membrane.
Fig. 2. Fixation of tibialis posterior to lateral cuneiform is
depicted. This method is not commonly used at Doctors
Hospital with tendon to tendon transfer being the currently
preferred method.

If resistance is encou ntered atthis pointthe su rgeon can
facilitate transfer by releasing any slips of tendon or mus-
cle that may be attached within the laciniate ligament or
just proximally. A curved forceps can be pushed gently
along the tendon and within the sheath to reflect loose
attachments. There are often small segments of muscle
fibers of origin distalto thewindowcreated in the interos-
lnterroseus
Tibialis Posterior
Tendon
Posterior Tibial
A.,V.,N'
Tendo
Fig. 1. Transfer of tibialis posterior requires careful dissection
proximally to avoid damage to the neurovascular bundle. Close
proximity of neurovascular structures is evidenced by this cross-
sectional view of the leg.
seous membrane and these must be gently pu I led f reewith-
out traumatizing the neurovascular supply to the tibialis
posterior tendon.
The third incision is located on the dorsum of the foot
at the level of the tendon to bone anastomosi s. At th is poi nt,
a forceps is inserted in a retrograde fashion through the
third incision on the dorsum of the foot up the extensor
sheath to the level of the second incision on the anterior
aspect of the leg. The ti bial is posterior tendon i s then d rawn
distally through the extensor sheath to its new insertion.
I n the origi nal tech niquethe transferred tibial is posterior
is fixated to the second or third cuneiform with the foot
held in a neutral subtalar position and with the ankle at a
right angle to the leg (Fig. 2).
Dependingon the severityof thedeformityand the pres-
ence of forefoot varu s or forefoot valgus, the su rgeon may
p refer to change the i n sertion of the transfer mo re med ial Iy
or laterally. One of the complications associated with a
mo re lateral i nse rtio n has been the develop m ent of exces-
sive pes valgus postoperatively.
Th e seco n d tec h n i q ue fo r ti b i al i s poste ri o r te ndon tra n s-
fer incorporates fou r separate incisions. The identicaltwo
proced u res for release and attachment of the tibial is pos-
teriortendon are performed butwith the add ition of a pos-
terior medial incision on the legtofacilitate passageof the
tendon through the interosseous membrane. This modif i-

31
cation helps to free the tibialis posterior f rom its attach-
ments to the tibia. The incision on the anterior aspect of
the leg is still necessary in orderto d rawthe tendon d istally
utilizing the extensor com partment for transfer to the dor-
sum of the foot as described previously.

At Doctors Hospital an alternative to bony insertion of

the tibialis posterior is used in most instances. The mod if i-
cation includes splittingthe posteriortibial tendon mem-
brane into medial and lateral halfs after transfer through
the interosseous membrane.The lateral half of thetendon
is passed down to the dorsu m of the foot and attached to
the peroneu s tertius tendon near its insertion. The medial
half is passed tothedorsu m of the footthrough the sheath
of the tibialis anterior and attached to it near its insertion.
(Fig.3)

S p I itti n g th e te n d o n fol owi n g t ran sfe r th ro u g h t h e i nte r-

I

osseous membrane resu lts in a more balanced suspension

with i nsertions med ial ly and lateral ly. Th is mod if ication has
provided gratifying results and has avoided some of the
postope rative com p I ications of excessive val gu s positio n
5th Metatarsal
which may be seen when the tibialis posterior tendon is
i nserted intotheth i rd cu neiform. Alsotendon anastomosis

following tendon su rgery has the advantage of decreased

postoperative care si nce tendon to tendon anastomosiswi ll
occur in5-6 weeks in contrast to tendon to bone anasto-
mosis which may require immobilization for 8-10 weeks.
Fig. 3. Split transfer of tibialis posterior tendon involves releas-
ing tendon from its insertion, retrograding tendon to proximal
Tendon anastomosis is also less trau matic to the patient
incision, passing tendon halves through tendon sheaths of
in that dissection and tissue handling is decreased in con- tibialis anterior and peroneus tertius, and tendon to tendon
trast to tendon to bone anastomosis. Many proven tech- anastomosis.
niques have been utilized at Doctors Hospital for f ixation
of transferred tendons.

The third technique for tibialis posterior tendon trans-

fer uses the same two incisions for the release and attach- te n do n tran sf e r to the pe ro n eu s te rti us tend o n late ra I ly an d
ment of the transferred tibialis posteriortendon. The major the tibialis anterior tendon medially.
difference in the third technique is that the tendon is not
transferred through the interosseous membrane but in- Results and Complications:
stead uti izes a posterior med ial approach wherethetendon
I

is slid mediallyaround the sideof the bonefrom the pos-
te rio r to the ante ri o r as pect of th e eg
I ju st ante rio
of the medial malleolus. Care is then taken in this instance
to drawthe tendon and muscle anteriorly in orderthatthe
muscle f ibers rather than the tendon are in direct contact
with the medial tibia. On the anterior aspect of the ankle
and foot, thetendon sheath of theextensortendons maybe
utilized for directing the path of transfer of the tendon.
Although this procedu re is tech nical lyeasierto perform
than the transfer of the tendon through the interosseous
membranetheoverall results have not been encouraging.
One of the major reasons for the rather disappointing re-
sults is the inabilityto preserve the gliding mechanism of
thetendon and the increased incidenceof adhesionswhich
restrictfunction and compromisethefinal surgical result.
Our preferred method istransferof thetibialis posterior
tendon through the i nterosseous membrane utilizing a split
Tran sfer of the ti bial is posterior tendon th rou gh the i nter-
r to marg i n osseous membrane for correction of dropfoot has been
an excellent proced u re forthe f lexible d ropfoot cond ition
in the absence of osseous deformity. Most of the compli-
cations and poor results have been seen in more severe
deformities involving structural or osseous deformity.
Proper patient selection and choice of procedure is es-
sential i n p reventi ng com p rom i sed resu lts. Tran sfer of the
ti bial is posteriortendon is not an acceptable p roced u re fo r
correction of spastic equ i novaru s si nce the ti bial is posterior
transfer in this deformitycan lead to secondarydeformities.
One of the feared complications following transfer of
the tibialis posteriortendon is a severe secondary pesvalgo
planus deformity. This complication is predictable in pa-
tientswith available rearfooteversion. lt is a rareoccu rrence
in the footwh ich can not be everted pastthe perpendicu Iar.
ln flexible feet the surgeon can prevent the complication

32
 B
,:r:,.

,'.,.i.i
'ia;ier::l

Fig. 4. Split peroneus longus tendon transfer is an alternative

muscle-tendon balancing procedure for dropfoot correction.
Incision planning and tendon to tendon anastomosis is
depicted.

tendon which can be palpated u nderthe skin and quickly

isolated.

The second incision is made along the calcaneocuboid

jointwherethe peroneus longus runs inferioron the lateral
by performing an ad ju nctive arthrodesisto stabilizethe sub-
aspect of the bone. The tendon can readily be identified
talar and m idtarsal joi nts agai nst pronation' Th i s may i nvolve
at the second incision on the lateral aspect of the foot by
talonavicu lar or triple arthrodesis.
placingthetendon undertraction atthefirst incision site.
Overall the results following transfer of the tibialis pos-
Following section of the peroneus longus tendon it is
teriortendon in thetreatment of the f lexible or nonosseous
withdrawn through thef irst incision fortransfertothe an-
d ropfoot cond ition have been very gratifying and pred ict-
terior compartmentth rough the anterolateral interm u scu-
able. Our surgicalapproach has remained essentially un-
lar septu m. Following the tech n iq ue described previou sly
changed for the past twenty-five years.
in transferof thetibialis posterior, the peroneus longusten-
don is routed down the extensor tendon sheath, beneath
Peroneus Longus Tendon Transfer
the cruciate retinaculum. The tendon may be attached to
the base of the third metatarsal, third cuneiform, or split
lnd ication s:
into medial and lateral portions for anastomosis the per-
The peroneu s longu s is a strong mu sclewhich often pro- oneus tertiu s and tibialis anteriortendons neartheir inser-
vides an effective tendon for transfer. Such transfers can tions (FiB.44 & B).
be quite adequate in the treatment of flexible dropfoot
At Doctors Hospital the preferred method of securing
deform The su rgicaltechnq iue for peroneus longus ten-
ity.
the tendons is by anastomosis to the tibialis anterior and
do n tran sfe r i s s i m i ar to th e tech n q u e d esc ri bed p revio u s ly
I i
peroneus tertius tendons. The split tendon anastomosis
for transfer of the tibialis posterior tendon.
helps to create a balanced suspension and in most cases
a better functional result postoperatively.
Technique:

Anatomicallythe peroneus Iongus tendon lies superficial
tothe peroneus brevison the lateralaspectof the lowerone
third of the leg. The peroneus longus tendon transfer is
usually performed through three separate incisions.
The first incision is placed over the lateral aspect of the
loweronethird of the Iegdirectlyoverthe peroneus longus
Resu lts and Complications:
The overall resu lts with transfer of the peroneu s longus
tendon have been gratifying in treatment of the dropfoot
deformity and other related anterior muscle group weak-
ness. It has been particu larly u sef u I in patients where the
tibialis posterior tendon is paralyzed or is of insuff icient

33
strength to be considered as an isolated sou rce of tendon
transfer.
Co m p I icati o n s fol owi
I n tendo n t ran s-
g pe ro ne u s I o ngus
fer are similar to those described previously in transfer of
the tibialis posterior tendon; though transfer of this ten-
don is unlikely to result in a valgus foot deformity.
Ankle Fusion
ln theosseous orf ixed dropfootcondition, tendon trans-
fers are ineffective in correctingthe deformity. In such in-
stances a more aggressive approach involving arth rodesis
is necessaryto provide adequate correction. Such correc-
tion often involves ankle fusion or pantalar arthrodesis
(Fig. s).
Surgical correction of fixed dropfoot condition can be
tech n icallyd iff icu It. ln contrasttotendon transferthe post-
operative course and rehabilitation may be prolonged.
The emphasis here is on surgical correction of the flex-
ibleor nonosseous dropfootcondition and adetailed dis-
cussion of ankle arthrodesis is beyond the scope of this
paper.
SUMMARY
Dropfoot deform ity presents an interesting challenge to
the podiatric surgeon. The surgeon undertakingtreatment
of the cond ition shou ld have a thorough u nderstand i ng of
the etiology of the deformity as well as being well versed
in the biomechanics of the involved part. Appropriate
choiceof technique is based on this knowledge. Of the pro-
cedures described, the tibialis posterior tendon transfer
Fig. 5. Pantalar arthrodesis was necessary in this patient with
Charcot-Marie Tooth disease due to extensive paralysis of leg
muscles. Tendon transfer would have been an insufficieni
means of stabilization in view of the extensive involvement.
34
through the interosseous membranewith splitanastomosis
to the medial and lateral aspects of the foot have provided
the most gratifying postoperative results.
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