Comparative Study of Functional Outcome of Posterior Tibialis Tendon Transfer to Middle Cuneiform Bone and Anterior Tibialis Tendon with Other Techniques for Management of Foot Drop

Abstract

Background: Injury of the Common Peroneal Nerve leads to Foot Drop and causes disability in the gait of the patient. The common cause of Common Peroneal Nerve injury is trauma, which is either a penetrating injury at the line of its course or fracture of the upper part of fibula, and sometimes due to iatrogenic injury during orthopedic surgery. The disability of the patient includes loss of dorsiflexion, ankle eversion, and toes extension. During normal walking, the heel strikes the ground, so normally, the ankle remains in slight extension or natural position, and in the swing phase, an active extrusion of toes and ankle up to the ground, but in Foot Drop during heel strike, the patient slaps his foot on the ground and in the swing phase the patient drags it along the ground, so compensatory, the patient flexes hip more than the normal to lift the entire foot off the ground, i.e. the stepping gait. The target of our technique is to restore the dynamic dorsiflexion of the foot and normal toe-heel gait. There are various procedures and techniques used to correct Foot Drop; among them, tendon transfer is tendon or tendon-to-bone transfer. The Aim of the Study: In our study, we transferred the Posterior Tibialis Tendon to both the Middle Cuneiform bone and the Anterior Tibialis Tendon as an alternative technique for managing Foot Drop. The aim of this study is to compare the functional outcomes of Posterior Tibialis Tendon transfer to these two sites, using the criteria described by Carayon et al. Patients & Methods: The present study is prospective study conducted in the Department of Plastic and Reconstruction Surgery at Al-Wahda Teaching Hospital, Thamar-University, and the Plastic Surgery Department in the 48 Model Hospital. The patients included thirty patients from May 2015 to May 2024. All the patients were male, and their ages ranged from fifteen to forty years old. The patients were classified according to the techniques used for reconstruction into the following groups: Group (1): Transfer of Posterior Tibialis Tendon to Anterior Tibialis Tendon and Flexor Hallucis Longus Tendon by dividing the Posterior Tibialis Tendon longitudinal and tying by Pulvertaft weave method by non-absorbable suture. Group (2): The technique used for reconstruction of Foot Drop in this group is the transfer of Posterior Tibialis Tendon to the 2^nd Metatarsal bone by tying the tendon around the Metatarsal bone. Group (3): The Posterior Tibialis Tendon is inserted into the Middle Cuneiform bone by making a hole in the superior surface of the Cuneiform bone to the planter surface of the foot and tied by Prolen or Ethicon in the planter side of the same bone (tendinosis). The tendon elongation by tendon graft from the Plantaris muscle tendon or Palmaris Longus Tendon. The other side is inserted into both the Posterior Tibialis Tendon and Flexor Hallucis Longus. Results: The final record after post-operative follow-up for 24 months, we have noted that: In group (1), the results were excellent in two cases (20%), good in three cases (30%), moderate in two cases (20%), and finally poor results in two cases (20%). In the same group, two cases were complicated by surgical site infection and treated with antibiotic and observation, and the infection subsided. Regarding patient satisfaction, there were five cases out of ten patients (50%) who were unsatisfied, and all five cases underwent reoperation after one year by another technique. For group (2), after 24 months of follow-up, post-operatively, the majority of patients in group (2) were excellent and good according to the Carayon scale. Six patients out of ten had excellent results (60%). Also, there were two cases out of ten (20%) with good functional outcomes, only one patient out of ten patients had a moderate functional outcome (10%), and one case out of ten patients with poor outcomes (10%). Regarding post-operative infection of the same group, there was only one case complicated by surgical site infection. Eighteen cases out of ten patients were satisfied (80%). Regarding re-oparation, there were two patients out of ten patients (20%), redo the operation after two years. In group (3), there were seven patients out of ten patients with excellent results (70%). Also, there were two cases out of ten patients (20%) with good functional outcomes, no cases in moderate (0%), and one case had poor results (10%). There was only one case complicated by post-operative infection which was a surgical infection at the site of connection of the Posterior Tibialis Tendon with Anterior Tibialis and Flexor Hallucis Tendon, which we managed by debridement and redo the operation after six months by the same technique. Conclusion: In our study, group 3, most of the patients had excellent results (70%), and combination tendon to tendon and tendon to the bone have an advantage over the other techniques with a lower complication rate, such as the durability of restoring the function of dorsiflexion of the ankle and never recurrent, and also no need for further use of a splint with a good balanced foot. In the third group, all the patients were satisfied, and all the patients followed up for more than two years with excellent function outcomes with no drawbacks and only one case needed to re-operation in all the three groups.