Outcome of tibialis anterior tendon transfer in recurrent relapsed clubfoot deformity with concomitant peroneal nerve dysfunction

Objectives: To assess the clinical and functional outcome of Tibialis Anterior Tendon Transfer in Recurrent Relapsed Idiopathic Clubfoot Deformity associated with peroneal nerve dysfunction. Methodology: This observational study included 16 (2.11%) of 756 Idiopathic Clubfoot Deformity (CFD) patients with recurrent and relapse deformity following Ponseti management, treated during January 1, 2011 to December 31, 2023 at Ziauddin Hospital Clifton, Karachi, Pakistan. Included patients had evertors and toe extensors weakness associated with concomitant Peroneal Neuropathy. Following an initial Ponseti re-casting, Extended Posterior Release (EPR) and Tibialis Anterior Tendon Transfer (TATT) was performed. Clinical and functional outcomes were assessed on Nogueira and Songs satisfaction protocols. Results: All 16 patients had bilateral idiopathic Clubfoot deformity at initial treatment, who developed Iatrogenic Complex Clubfoot deformity with concomitant Peroneal nerve dysfunction, four of these had recurrent relapse on left side only. Their muscle charting revealed peroneal and toe extensor muscles weakness, while Tibialis Anterior strength was grade IV. Five patients had flexible deformity, while 11 patients had fixed severe deformities. Thirteen patients underwent EPR and TATT, while three had Posterio-Medial Release and TATT. At 3-10 years of follow-up, six patients improved from Nogueira Poor to good Nogueira outcome and Satisfied on Song’s Scale. While three patients achieved Nogueira’s “Poor” and “Very dissatisfied” on Song’s criteria. Conclusion: A small and rare sub-set of iatrogenic complex clubfoot deformity with peroneal nerve dysfunction, is undoubtedly difficult to treat. Early diagnosis and treatment prevents extensive surgical interventions, which is required mostly in late presenting, rigid deformities. The association between peroneal neuropathy and preserved tibialis anterior muscle strength in these patients remains poorly understood.