November 2012

TATT in relapsed clubfeet can affect plantar flexion

By Jordana Bieze Foster

Tibialis anterior tendon transfer (TATT) is known to be associated with limited ankle dorsiflexion, but practitioners should be aware that plantar flexion also can be negatively affected, according to research presented in October at the International Clubfoot Symposium.

TATT has been shown to improve a number of ankle kinematic variables in relapsed clubfoot patients with overactive tibialis anterior muscles, but weakening of the ankle dorsiflexors can decrease dorsiflexion range of motion. For this reason, surgeons often perform TATT with the foot in a maximally dorsiflexed position, according to John Herzenberg, MD, director of pediatric orthopedics at Sinai Hospital in Baltimore. But Herzenberg and colleagues found that this technique, in some patients, appears to have an effect on passive plantar flexion.

The Baltimore researchers analyzed 17 clubfeet in 12 patients treated with TATT at a mean age of 5 years. Overall, ankle plantar flexion at follow up (at least nine months after surgery) did differ significantly from preoperative levels. But while plantar flexion was the same or better in eight feet, nine feet demonstrated reduced plantar flexion.

“While achieving dorsiflexion is emphasized as an important goal, it is equally important to maintain plantar flexion,” Herzenberg said.

In a separate symposium presentation, researchers from the UK reported findings that suggest patients are less likely to need a TATT procedure if their clubfoot management has been centralized at a single institution than if they have been shuttled between locations.

In 156 children (271 clubfeet) treated at a single center and 116 children (201 clubfeet) treated at multiple centers, investigators from Chelsea and Westminster Hospital in London found that the percentages of feet and patients undergoing TATT were significantly higher for those treated at multiple centers.

“A higher proportion of poor responders were referred to us by other centers,” said Alison Hulme, MBBS, a consultant pediatric orthopedic surgeon at Chelsea and Westminster Hospital.

Demographics in both groups were similar, including Pirani scores, Hulme said. But multicenter cases were more likely to be associated with prolonged casting, poorer compliance, and a later age at both presentation and correction.

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