The Role of Anterior Tibial Muscle Tendon Transfer as a Miniinvasive Surgical Step in Primary Relapse of Clubfoot Deformity, Following Ponseti Method

Introduction. Ponseti protocol is widely accepted contemporary method for treatment ideopatic clubfoot deformity and provides up to 95 % success. I corrects heel varus and equinus and forefoot adductus when is early started and properly applied. The optimal correction should be acquired by a gentle manipulations, followed by several plaster casts. Usually mininvasive procedure achilotenotomy provides final correction of the heel equinus. In spite of following this protocol strictly, first relapse evidences may appear at the age of 2 year. There are many studies, proving the disastrous late results after the classic surgical procedure, like open posterior or posteromedial release, applied in relaps cases. The early assessed successful results primary aligned foot further are followed by high grade displaced tarsal bones with total talocalcaneal and midtarsal rigidity in adolescent age. The miniinvasive approach of anterior tibial tendon (ATT) transfer provides constant correction and interruption of the clubfoot relapse with a minimal rate of any side deformities. Materials. ATT is applied in 21 from a total of 165 patients ( 228 feet) with ideopatic clubfoot for a period of 10 years. The mean follow up period is 5 years with assessment of the growing plantigrade foot, as measurements of talocalcaneal angle in anterior- posterior and lateral X-ray projections. Results. The followed treated club feet present constant correction of the elements of plantigradidity in a period of 1 year. Talocalcaneal angle improves as follows Anteroposterior projection varies before operation - 6 - 22 (mean 13, 7), post op - 13 to 29 (mean 20, 7). Lateral projection varies before operation - 16 - 31 (mean 20, 1), post op - 15 - 41 (mean 31, 6). Conclusions The principle of miniinvasive surgery, as a step in treatment of relapses after Ponseti clubfoot protocol, presents a new attitude and prevents the growing foot from many of the late disastrous results, that usually occur after aggressive early surgery. It is based on the main Ponseti postulate les surgery better results in equinovarus treatment and has to be accepted as general principle.