Posterior Tibial Tendon Transfer to the Dorsum of the Foot

What is the posterior tibial tendon?

The posterior tibial tendon (PTT) runs on the inside of the ankle and foot and works to pull the foot inward. Sometimes a

View of foot from the inside with first two incisions marked out
 person loses the ability to pull up the ankle, which is called foot drop. Patients that have a foot drop can have difficulty walking. If you cannot adequately pull up your foot when you walk, you can trip and potentially fall. Patients with foot drop who are not treated will often walk strangely. 
A first line of treatment for foot drop is an ankle-foot orthosis (AFO). An AFO is a brace that pushes the ankle up so that the foot doesn’t “drop” as it swings. The orthosis is made of plastic and goes under the foot and up the back of the ankle and leg. The AFO is usually attached to the leg with a Velcro strap just below the knee. These devices often make walking much easier for people with this problem.

What is a posterior tibial tendon transfer?

Patients who do not want to walk with an AFO can have surgery. The surgery involves a transfer of the PTT to top of the foot. The goal of the procedure is for the patient to walk barefoot without an AFO. In some patients this transfer can also help to straighten out the foot.

What signs indicate surgery can be done?

Anyone with foot drop who wants to walk without a brace can consider this procedure.

When should I avoid surgery?

Patients should not have this surgery if the PTT is not working properly. Also, a flatfoot deformity may get worse if this tendon is transferred.

General Details of the Procedure

Four incisions are necessary for this procedure. These are used to prepare, pass and anchor the tendon to its new location.

View of foot from outside with third and fourth incisions marked out
  The tendon is secured either by a screw or by pulling the sutures holding the tendon to the bottom of the foot and tying them outside of the skin. The tendon is secured with some tension so that it can function well once healed.

What happens after surgery?

A well-padded splint will be needed for two weeks after surgery. The splint and sutures are removed after two weeks. At that point, you will be placed in a boot brace, but you must not put weight on the foot for an additional four weeks. At six weeks you can begin weight-bearing, and usually you can stop using the boot between nine and 12 weeks after surgery. Physical therapy is often started at this time to help the tendon to pull up the ankle. Therapy can take months.

Potential complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Rarely, the tendon can pull out of the bone after it has been transferred, although the surgeon is careful to test the strength of the tendon’s attachment to the bone prior to leaving the operating room. If the tendon is placed with not enough tension, then the transfer doesn’t work appropriately, and the patient still has some degree of a foot drop. If the tendon is placed too tightly, then the patient can actually lack some ability to pull the ankle down, or plantarflex. These complications are rare.
If the tendon is put into bone in such a way that it pulls the foot into a high or low arched position, it can create some deformity in the foot. The surgeon is careful to take these things into account and this complication can largely be avoided.

Frequently Asked Questions

Do I have to have this surgery?
No, this surgery is elective. Many patients can function at a high level with an AFO. However, for some, the brace is not well tolerated, and they choose surgery.
How long do I have to be off my foot after surgery?
Patients need six weeks of non-weightbearing after this surgery for the tendon to heal.
Is this surgery all I need?
That is decided on a case-by-case basis. For some patients, a single tendon transfer is all that is needed. In other patients, further surgery may be necessary.
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