Comparative Analysis of 3 Anterior Tibialis Tendon Transfer Techniques in Idiopathic Clubfoot: Traditional Pull-through Button Technique, Pull-through Interference Screw Technique, and Anchor Technique

Abstract

BACKGROUND: Recurrence in clubfoot after the Ponseti technique is a well-recognized phenomenon. The use of the anterior tibial tendon transfer (ATTT), is a well-documented technique for addressing dynamic supination following treatment. Despite its widespread use, there is a lack of comparative studies evaluating different fixation techniques for ATTT. We conducted a multicenter study to assess and compare the outcomes of 3 techniques. METHODS: Three centers collaborated in this comparative analysis. Children with dynamic supination after initial Ponseti treatment who underwent ATTT between 2008 and 2023 were included. A pull-through technique with suture over a button (group A) was employed in 52 patients (72 feet), a pull-through technique using an interference screw fixation (group B) was employed in 23 patients (26 feet), and a suture anchor technique (group C) was employed in 55 patients (65 feet). A retrospective review included demographics, surgical procedures, and outcomes. The comparison between the 3 groups was made with ANOVA and Kruskal-Wallis tests. P values of <0.05 were considered statistically significant. RESULTS: A total of 130 children (163 feet), were included. There were no statistically significant differences in age, sex, side, isolated ATTT, and additional surgery between groups. At final follow-up (mean 42.0 mo), 28 patients (38 feet) experienced some form of relapse: group A, 27.8% (20/72 feet); group B, 30.8% (8/26 feet); and group C, 15.4% (10/65), P=0.56. There were 5 postoperative complications directly related to the ATTT, comprising 4 cases in group A (5.6%) and one in group B (1.5%), P=0.165. Of these complications only one case from group A included pull out of the transferred tendon. There were no cases of overcorrection. CONCLUSIONS: All 3 fixation techniques effectively secured the tibialis anterior tendon transfer in this pediatric population following recurrent clubfoot. While the suture anchor technique may offer certain advantages, the decision on fixation method should be individualized, taking into account patient anatomy and the surgeon's experience. LEVEL OF EVIDENCE: Level III-retrospective comparative study.