Updated: 10/4/2016

Split Anterior Tibial Tendon Transfer

Review Topic

Preoperative Patient Care


Intermediate Evaluation and Management


Obtains focused history and physical

  • history
  • varus foot position or forefoot supination, either static or dynamic in patients with cerebral palsy.
  • overpull of the anterior tibial tendon that causes dynamic foot deformity in children with other neurologic problems.
  • residual forefoot supination, adduction, or varus deformity either static or dynamic, with overpowering of anterior tibial tendon function after initial clubfoot treatment.
  • loss of eversion power of foot secondary to trauma or disorders such as Charcot-Marie-Tooth disease
  • symptoms
  • intoeing, tripping
  • callusing under 5th metatarsal
  • difficulty with shoe wear and brace wear
  • physical exam
  • observational gait analysis shows excessive supination in swing phase of gait, intoeing
  • alignment of foot noted with weight bearing and non-weight bearing
  • range of motion ankle and subtalar joint documented
  • strength of anterior tibialis tendon noted should be at least grade 4/5
  • recognizes factors that could predict complications or poor outcome
  • rigid foot deformity preventing the foot from being manipulated into a neutral position
  • weak anterior tibialis tendon grade 3 or less
  • progressive neurologic disease that will result in weakness of the anterior tibialis in the future


Orders and interprets required diagnostic studies

  • AP and lateral weight bearing foot radiographs
  • oblique foot radiographs


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • mitchell shoe and bar wear, orthotics
  • physical therapy
  • serial casting
  • describes accepted indications and contraindications for surgical intervention
  • indications
  • residual forefoot supination, adduction, or varus deformity either static or dynamic, with overpowering of anterior tibial tendon function after initial clubfoot treatment or with a neurologic condition such as cerebral palsy.
  • loss of eversion power of foot secondary to trauma
  • contraindications
  • rigid foot deformity preventing the foot from being manipulated into a neutral position
  • weak anterior tibialis tendon grade 3 or less
  • progressive neurologic disease that will result in weakness of the anterior tibialis in the future


Postop: 3-4 Week Postopereative visit

  • evaluate for signs or symptoms of infection
  • evaluate for signs or symptoms of neurovascular injury
  • cast change and wound check
  • any orthotics, if needed, are measured before the new cast is placed


Postop: 6 Week Postoperative Visit

  • wound check
  • diagnose and management of early complications
  • infection
  • wound complications
  • remove the walking cast
  • remove the plantar anchoring button
  • measure for articulating AFO with plantarflexion stop to be worn for for 6 months in the clubfoot patient maybe lifetime wear in the neurologic patient depending on condition
  • place in weight bearing cast while waiting for brace

Advanced Evaluation and Management


Modifies post-operative plan based on response to treatment

  • patient fails to improve post-operatively
  • evaluate tension on tendon transfer, ensure it hasn't ruptured
  • asses strength of transferred tendon
  • physical therapy for strengthening and gait training
  • return to OR as needed

Preoperative H & P


Obtains history and performs basic physical exam

  • check range of motion
  • asses motion of subtalar joint
  • asses dorsifexion of ankle
  • asses the ability of the hindfoot to be placed in a neutral position


Screen medical studies to identify and contraindications for surgery


Orders appropriate initial imaging and laboratory studies

  • standing ap lateral xrays of the foot
  • oblique xray foot


Perform operative consent

  • describe complications of surgery including
  • death, loss of limb, neurovascular damage
  • rupture of the transferred tendon
  • pressure sores
  • insufficient tension of the transferred tendon
  • wound complications

Operative Techniques


Preoperative Plan


Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • Sterile button
  • felt pad
  • Keith needles
  • right angle retractor
  • Ober tendon passer


Room setup and equipment

  • standard OR table
  • tourniquet
  • c-arm fluoroscopy if transfer is to the cuboid


Patient positioning

  • supine
  • place a bump under the ipsilateral hip for internal rotation of the foot

First Skin Incision


Mark and make an oblique incision

  • make a 1.5 cm oblique incision at the insertion of the anterior tibialis tendon at the medial cuneiform and first metatarsal


Expose the anterior tibialis tendon

  • incise the tendon sheath to expose the tendon with a 15 blade


Dissect and detach the tendon

  • dissect the tendon to the insertion at the cuneiform and first metatarsal
  • detach the medial/plantar half of the tendon with sharp dissection
  • use an 0 or 2-0 vicryl to place a Bunnel suture in the cut end of the tendon

Second Incision


Make a second incision

  • make a second 1 cm incision at the anterior distal tibia directly over the anterior tibial tendon just lateral to the crest
  • the location of the tendon can be easily identified by pulling on the distal tendon while palpating over tibia
  • incise the tendon sheath to expose the tendon


Transfer the tendon

  • use a hemostat or Ober tendon passer to pull the tendon until the tendon's distal end is pulled into the proximal incision (take care to stay under the retinaculum and in the tendon sheath while retrieving and transporting the tendon)
  • protect the tendon with a wet sponge wrap

Third Incision


Make a third incision

  • this incision should be 1 cm long at the dorsum of the foot directly over the lateral cuneiform, found at the base of the third metatarsal
  • alternatively this incision is overlying the peroneus tertius which is found just lateral to the lesser toe extensor tendons


Expose the cuboid

  • retract the extensor tendons of the toes to expose the lateral cuneiform
  • incise periosteum at the center of the lateral cuneiform
  • can use c-arm to confirm the location of the cuboid


OR Exposure of Peroneus Tertius

  • open sheath overlying peroneus tertius tendon
  • The peroneus tertius is immediately lateral to the toe extensors
  • confirm it is the tertius tendon. The foot should evert and dorsiflex when the tendon is pulled and the toes do not extend
  • 10% of people do not have a peroneus tertius


Create a subcutaneous tunnel

  • use a large curved hemostat or dissecting scissors to make a subcutaneous tunnel from the distal wound to the lower leg wound
  • use the hemostat or a tendon passer to grasp the sutures in the tendon stump


Transfer the tendon to the third incision

  • using the hemostat or tendon passer, pull the tendon distally and laterally into the third incision

Tendon Passage and Fixation


Fixation through the cuboid

  • drill a hole in the cuboid
  • use a drill bit that is slightly larger than the transferred tendon to make a drill hole through the lateral cuneiform in a dorsal to plantar direction
  • keep a finger on the plantar area to prevent penetration of the drill bit through the skin
  • prepare the tendons for passage through the drill holes
  • attach the two ends of the suture in the anterior tibial tendon to separate long straight Keith needles
  • push the Keith needles through the drill holes from the dorsal to plantar surface
  • the exits of the 2 Keith needles should be 3 to 5 mm apart
  • attach the sterile button
  • with the needles attached to the two sutures, pierce through a small square of felt pad and a sterile button
  • pass the tendons
  • gently pull the tendon into the drill hole in the lateral cuneiform


Transfer to the peroneus tertius

  • pull distally on the split anterior tibial tendon transfer
  • place a right angle clamp under the split tendon transfer and the peroneus tertius
  • complete the side-to-side transfer with a 2-0 non-absorbable suture

Suture Tying


Tie the sutures

  • hold the foot in neutral or mild dorsiflexion and eversion as the sutures are tied on top of the button which overlies a thick piece of felt to protect the skin
  • alternatively the foot is held in neutral or mild dorsiflexion and eversion as the sutures are ties in a figure-8 fashion side by side to the peroneus tertius tendon

Wound Closure


Deep closure

  • 2-0 or 3-0 absorbable suture for subcutaneous tissue


Superficial closure

  • 3-0 running monofilament for skin


Dressings and immobilization

  • steri-strips
  • place in a non weight bearing short leg cast if there is a button on the foot as they can develop a pressure sore with weight bearing
  • place in a weight bearing short leg cast if the split anterior tibialis tendon was transferred to the peroneus tertius tendon

Postoperative Patient Care


Perioperative Inpatient Management


Write comprehensive admission orders

  • advance diet as tolerated
  • IV fluids
  • pain control
  • neurovascular checks
  • physical therapy
  • strict non-weight bearing on operative foot if patient has a button
  • may weight bear as tolerated in cast if tendon transferred to peroneus tertius
  • cast management
  • cast elevation, keep heel off of bed


Discharges patient appropriately

  • pain control
  • pt should be discharged with prescriptions for oral narcotics and diazepam to be taken as needed for two weeks for pain and spasm
  • schedule follow-up at 3-4 weeks and 6 weeks
  • cast care instructions
  • keep heel off of bed, do not get cast wet, do not put anything inside cast

Complex Patient Care


Develops unique, complex post-operative management plans

  • Rupture of Tendon transfer
  • Return to OR for reconstruction
  • pressure sore from button
  • wound care initiated in clinic

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