Review Question - QID 692

In the surgical treatment of dynamic supination following Ponseti treatment, the accepted sites of insertion for anterior tibial tendon transfer are the lateral cuneiform (more common) and cuboid. The anterior tibial tendon is harvested from its insertion at the medial and under surface of the first cuneiform bone (Point C on Figure A), and the base of the first metatarsal bone. The AAOS COR review book states that either split anterior tibial tendon or whole anterior tibial tendon may be used, but the 2007 OITE question #31 preferred whole tendon transfer over split tendon transfer and whole tendon is the most common choice among surgeons. The dynamic swing phase supination deformity may develop as a result of medial overpull of the anterior tibialis tendon. Incomplete reduction of the navicular onto the talar head results in changing the anterior tibialis muscle from predominately a strong dorsiflexing to a strong supinating force. If uncorrected, this can lead to recurrence of hindfoot varus.

The review article by Ponseti reviews the closed manipulation and casting method he developed along with stating that the presence of vimentin and myofibroblast-like cells in the thick, tight, and shortened medial and posterior tarsal ligaments are probably involved in clubfoot pathogenesis in-utero.

The Level 5 article by Noonan and Richards reviews the Kite method(serial manipulation and casting), Ponseti method (serial manipulation and casting), and French method(requires daily PT and taping) for nonoperative clubfoot management.

The Level 5 article by Cummings et al states that after several decades of operative treatment of clubfoot it was found that the complications of such surgery, including recurrence, overcorrection, stiffness, and pain have led to a renewed interest in nonoperative treatments.