The posterior tibial transfer procedure

The posterior tibial transfer procedure can either involve transfer of the posterior tibial tendon alone or transfer with attachment to two other tendons, the peroneus longus and the anterior tibialis. When all three tendons are used it is called a Bridle procedure because the three tendons are attached in a bridle configuration.

Multiple incisions are needed to move the tendon from one position to another. The posterior tibial tendon is taken off its insertion on the navicular bone on the inner side of the foot. This is the first incision. A second incision is made above the ankle and the tendon and muscle are identified. The tendon is pulled into this second incision and then transferred in between the tibia and fibula bones to the front of the ankle.

Another incision is made on the top of the foot at the bone to which the tendon is going to be transferred. The tendon is routed under the skin to this bone and fixed into a tunnel in the bone.

If a Bridle procedure is performed, a second tendon, the peroneus longus, is cut above the level of the ankle on the outer side of the leg. This tendon is then routed to the front of the ankle and the free end is attached to the posterior tibial tendon and the anterior tibial tendon in a bridle configuration. With this construct the posterior tibial muscle pulls on all three tendons to pull the foot up. The posterior tibial tendon is routed to the top of the foot as described above.

Occasionally, the ankle can be very stiff from long-standing weakness. If it is not possible to pull the ankle up for attachment of the tendon transfer, the Achilles tendon is lengthened to help bring the foot and ankle up. This is done either through an incision on the calf or an incision right over the Achilles tendon. The location of the incision is based on the tightness of the ankle.