What is the role of tibialis anterior tendon transfer in the management of residual or recurrent foot deformities in patients with Congenital Talipes Equinovarus (CTEV)?

Tibialis Anterior Tendon Transfer for Recurrent CTEV

Tibialis anterior tendon transfer is an effective surgical intervention for managing dynamic supination deformity in patients with residual or recurrent clubfoot after Ponseti treatment, restoring muscle balance and preventing progression to fixed structural deformities. 1, 2

Indications for Surgery

The procedure is specifically indicated when:

• Dynamic supination deformity is present during the swing phase of gait, manifesting as hindfoot varus and forefoot supination 1, 3
• Muscle imbalance exists between a strong tibialis anterior and weak antagonist muscles (peroneals) 2
• The deformity is dynamic rather than fixed, meaning it occurs during movement but the foot can be passively corrected 1
• Patient has failed conservative management after initial Ponseti correction 1, 4

Important Clinical Caveat

Recent kinematic analysis reveals two distinct presentation patterns within this population: one subgroup demonstrates primarily hindfoot inversion (91% of gait cycle), while another shows predominantly hindfoot adduction (100% of gait cycle) 3. This heterogeneity suggests that visual assessment alone may be insufficient, though the procedure appears effective for both presentations based on current evidence.

Expected Outcomes and Effectiveness

Functional Restoration

The procedure effectively restores muscle balance in 87-88% of patients, with the following timeline 1, 2:

• At 3 months post-surgery: Eversion-to-inversion strength ratio normalizes and becomes comparable to children who never required the transfer 1
• At 12 months: Improvements in strength balance, plantar loading patterns, and functional satisfaction are maintained 1
• Long-term follow-up (mean 5.2 years): 87-88% achieve good restoration of muscle balance with no recurrences reported 2

Persistent Limitations

Despite successful muscle rebalancing, certain parameters remain different from unaffected feet 1:

• Range of motion remains somewhat restricted
• Foot alignment shows residual supination compared to controls
• These differences persist from baseline through 12-month follow-up

Surgical Technique Considerations

Modern bone anchor fixation techniques have demonstrated superior outcomes compared to traditional methods 4:

• 98.7% success rate with no recurrence of dynamic supination at mean 4.4-year follow-up 4
• Zero cases of anchor pullout 4
• No revision surgery required in the largest reported series (77 feet) 4
• Avoids the need for three skin incisions and plantar tissue breaching, reducing risk of pressure areas and neurovascular damage 4

Timing of Intervention

The mean age at surgery across studies is 4.3-5.6 years (range 1.4-10.7 years) 2, 4. This timing allows:

• Sufficient observation period to confirm dynamic (rather than fixed) deformity
• Adequate foot size for technical feasibility
• Intervention before secondary osseous changes develop 2

Role in Treatment Algorithm

Tibialis anterior tendon transfer should be positioned as the primary surgical intervention for dynamic supination after failed conservative management following Ponseti treatment 1, 2, 4. The procedure:

• Addresses the underlying muscle imbalance that perpetuates deformity 2
• Prevents progression to fixed structural deformities requiring more extensive surgery 2
• Can be performed even in the presence of other structural deformities (88% good outcomes in this subgroup) 2

When Structural Deformities Coexist

For patients presenting with both dynamic supination and structural deformities (such as equinus component), consider 5:

• Addressing bony factors (e.g., flat-top talus causing equinus) with guided growth techniques if present 5
• Tibialis anterior transfer remains effective even when structural components exist, with 88% achieving good muscle balance restoration 2

Quality of Life Impact

The procedure results in 1:

• Function and satisfaction scores that become indistinguishable from children who never required surgery by 3 months post-operatively
• Maintained improvements through 12-month follow-up
• No documented negative impact on quality of life measures

Key Clinical Pitfall

Do not delay surgery waiting for structural deformities to fully resolve 2. The presence of additional structural deformities does not contraindicate the procedure and outcomes remain excellent (88% good results) 2. Early intervention prevents secondary osseous changes and maintains foot function 2.