Archives of Orthopaedic and Trauma Surgery

, Volume 131, Issue 7, pp 903–910 | Cite as

Tendon transfers for drop foot correction: long-term results including quality of life assessment, and dynamometric and pedobarographic measurements

  • Hans-Ulrich SteinauEmail author
  • Alexandra Tofaute
  • Kathrin Huellmann
  • Ole Goertz
  • Marcus Lehnhardt
  • Jessica Kammler
  • Lars Steinstraesser
  • Adrien Daigeler
Orthopaedic Surgery



Drop foot deformity is a common problem with severe restrictions in quality of life and impairment of daily activities. A technique of posterior tibial tendon transfer through the interosseus membrane and fixation to the anterior tibial and the long peroneal tendon “Bridle procedure” (stirrup-plasty) offers a physiological alternative to surgical correction.


Data of 53 consecutive patients treated by stirrup-plasty were acquired from patient’s charts; 31 were interviewed with standardized questionnaires; 20 were examined physically; 19 received pedobarography, and 8 underwent dynamometric muscle function tests. Follow-up time averaged 6.5 years.


The mean range of motion (ROM) in the ankle joint was 8° dorsiflexion and 15° plantar flexion. Most patients achieved plantigrade foot position and the majority developed gait without orthotic devices. As expected, maximum dorsiflexion torque averaged a third of the non-operated leg, according to reduced muscle diameter and strength of the transferred muscle. Pressure distribution of the sole during gait was not relevantly altered by the tendon transfer compared to the non-operated leg. Most patients were satisfied with the operative results and reported a significant increase in quality of life.


Fusion of the transposed posterior tibial, anterior tibial and the peroneus longus tendon prevents drop foot deformity sufficiently. The stirrup mechanism, in combination with tenodesis of the toe extensors, provides a balanced foot and avoids equinovarus and cavus deformity without immobilizing the ankle joint. Improvements in quality of life parameters justify the risk of the operative procedure for the patient.


Tendon transfer Stirrup-plasty Bridle procedure Drop foot Peroneal palsy 



We thank Petra Ostheide who was very helpful in performing the dynamometer measurements, the Department of Biometry and Epidemiology, Ruhr-University, Bochum, R. Klaaßen-Mielke for assistance with statistical analysis, and Amanda Daigeler for her formal English revision of the manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Biesalski K, Mayer L (1916) Die Physiologische Sehnenverpflanzung. Julius Springer, BerlinGoogle Scholar
  2. 2.
    Brand PW (1974) Biomechanics of tendon transfer. Orthop Clin North Am 5(2):205–230PubMedGoogle Scholar
  3. 3.
    Campbell DE, Glenn W (1979) Foot-pounds of torque of the normal knee and the rehabilitated postmeniscectomy knee. Phys Ther 59(4):418–421PubMedGoogle Scholar
  4. 4.
    Carayon A, Bourrel P, Bourges M, Touze M (1967) Dual transfer of the posterior tibial and flexor digitorum longus tendons for drop foot. Report of thirty-one cases. J Bone Joint Surg Am 49(1):144–148PubMedGoogle Scholar
  5. 5.
    Daum WJ, Brinker MR, Nash DB (2000) Quality and outcome determination in health care and orthopaedics: evolution and current structure. J Am Acad Orthop Surg 8(2):133–139PubMedGoogle Scholar
  6. 6.
    Goh JC, Lee PY, Lee EH, Bose K (1995) Biomechanical study on tibialis posterior tendon transfers. Clin Orthop Relat Res 319:297–302Google Scholar
  7. 7.
    Green NE, Griffin PP, Shiavi R (1983) Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 65(6):748–754PubMedGoogle Scholar
  8. 8.
    Gunn DR, Molesworth BD (1957) The use of tibialis posterior as a dorsiflexor. J Bone Joint Surg Br 39-B(4):674–678PubMedGoogle Scholar
  9. 9.
    Herndon CH (1961) Tendon transplantation at the knee and foot. Instr Course Lect 18:145–168PubMedGoogle Scholar
  10. 10.
    Hove LM, Nilsen PT (1998) Posterior tibial tendon transfer for drop-foot. 20 cases followed for 1–5 years. Acta Orthop Scand 69(6):608–610PubMedCrossRefGoogle Scholar
  11. 11.
    Hsu JD, Hoffer MM (1978) Posterior tibial tendon transfer anteriorly through the interosseous membrane: a modification of the technique. Clin Orthop Relat Res 131:202–204Google Scholar
  12. 12.
    Ivanic GM, Hofstaetter SG, Trnka HJ (2006) The acquired flatfoot: mid-term results of the medial displacement calcaneal-osteotomy with flexor digitorum longus transfer. Z Orthop Ihre Grenzgeb 144(6):619–625PubMedCrossRefGoogle Scholar
  13. 13.
    Johnson KA, Strom DE (1989) Tibialis posterior tendon dysfunction. Clin Orthop Relat Res 239:196–206Google Scholar
  14. 14.
    Mann RA, Thompson FM (1985) Rupture of the posterior tibial tendon causing flat foot. Surgical treatment. J Bone Joint Surg Am 67(4):556–561PubMedGoogle Scholar
  15. 15.
    Mayer L (1937) The physiological method of tendon transplantation in the treatment of paralytic drop-foot. J Bone Joint Surg 19:389–394Google Scholar
  16. 16.
    McCall RE, Frederick HA, McCluskey GM, Riordan DC (1991) The Bridle procedure: a new treatment for equinus and equinovarus deformities in children. J Pediatr Orthop 11(1):83–89PubMedCrossRefGoogle Scholar
  17. 17.
    Miller GM, Hsu JD, Hoffer MM, Rentfro R (1982) Posterior tibial tendon transfer: a review of the literature and analysis of 74 procedures. J Pediatr Orthop 2(4):363–370PubMedCrossRefGoogle Scholar
  18. 18.
    Mizel MS, Temple HT, Scranton PE Jr et al (1999) Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency. Foot Ankle Int 20(5):285–289PubMedGoogle Scholar
  19. 19.
    Ober FR (1933) Tendon transplantation in the lower extremity. N Engl J Med 209:52–59Google Scholar
  20. 20.
    Omer GE Jr (1982) Reconstructive procedures for extremities with peripheral nerve defects. Clin Orthop Relat Res 163:80–91PubMedGoogle Scholar
  21. 21.
    Pinzur MS, Kett N, Trilla M (1988) Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy. Foot Ankle 8(5):271–275PubMedGoogle Scholar
  22. 22.
    Pinzur MS, Sherman R, DiMonte-Levine P, Kett N, Trimble J (1986) Adult-onset hemiplegia: changes in gait after muscle-balancing procedures to correct the equinus deformity. J Bone Joint Surg Am 68(8):1249–1257PubMedGoogle Scholar
  23. 23.
    Prahinski JR, McHale KA, Temple HT, Jackson JP (1996) Bridle transfer for paresis of the anterior and lateral compartment musculature. Foot Ankle Int 17(10):615–619PubMedGoogle Scholar
  24. 24.
    Rodriguez RP (1992) The Bridle procedure in the treatment of paralysis of the foot. Foot Ankle 13(2):63–69PubMedGoogle Scholar
  25. 25.
    Root L, Miller SR, Kirz P (1987) Posterior tibial-tendon transfer in patients with cerebral palsy. J Bone Joint Surg Am 69(8):1133–1139PubMedGoogle Scholar
  26. 26.
    Silver RL, de la Garza J, Rang M (1985) The myth of muscle balance. A study of relative strengths and excursions of normal muscles about the foot and ankle. J Bone Joint Surg Br 67(3):432–437PubMedGoogle Scholar
  27. 27.
    Srinivasan H, Mukherjee SM, Subramaniam RA (1968) Two-tailed transfer of tibialis posterior for correction of drop-foot in leprosy. J Bone Joint Surg Br 50(3):623–628PubMedGoogle Scholar
  28. 28.
    Steinau HU (1986) Microvascular latissimus dorsi transfer. Clinical use including management of the site of tissue removal. Chirurg 57(3):126–133PubMedGoogle Scholar
  29. 29.
    Steinau HU, Biemer E (1985) Possibilities of plastic surgical reconstruction in limb-sparing resection of malignant soft tissue tumors of the extremities. Chirurg 56(11):741–745PubMedGoogle Scholar
  30. 30.
    Turner JW, Cooper RR (1972) Anterior transfer of the tibialis posterior through the interosseus membrane. Clin Orthop Relat Res 83:241–244PubMedCrossRefGoogle Scholar
  31. 31.
    Ulrich HW, Blauth W (1993) Die Verpflanzung des Musculus tibialis posterior zur Behandlung von Peroneuslähmungen. Operat Orthop Traumatol 5(3):203–212CrossRefGoogle Scholar
  32. 32.
    Urbach D, Nebelung W, Weiler HT, Awiszus F (1999) Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear. Med Sci Sports Exerc 31(12):1691–1696PubMedCrossRefGoogle Scholar
  33. 33.
    Vertullo CJ, Nunley JA (2002) Acquired flatfoot deformity following posterior tibial tendon transfer for peroneal nerve injury: a case report. J Bone Joint Surg Am 84-A(7):1214–1217PubMedGoogle Scholar
  34. 34.
    Warren AG (1968) The correction of foot drop in leprosy. J Bone Joint Surg Br 50(3):629–634PubMedGoogle Scholar
  35. 35.
    Watkins MB, Jones JB, Ryder CT Jr, Brown TH Jr (1954) Transplantation of the posterior tibial tendon. J Bone Joint Surg Am 36-A(6):1181–1189PubMedGoogle Scholar
  36. 36.
    Westin GW (1965) Tendon transfers about the foot, ankle, and hip in the paralyzed lower extremity. J Bone Joint Surg Am 47(7):1430–1443PubMedGoogle Scholar
  37. 37.
    Wiesseman GJ (1981) Tendon transfers for peripheral nerve injuries of the lower extremity. Orthop Clin North Am 12(2):459–467PubMedGoogle Scholar
  38. 38.
    Williams PF (1976) Restoration of muscle balance of the foot by transfer of the tibialis posterior. J Bone Joint Surg Br 58(2):217–219PubMedGoogle Scholar
  39. 39.
    Yeap JS, Birch R, Singh D (2001) Long-term results of tibialis posterior tendon transfer for drop-foot. Int Orthop 25(2):114–118PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Hans-Ulrich Steinau
    • 1
    Email author
  • Alexandra Tofaute
    • 1
  • Kathrin Huellmann
    • 1
  • Ole Goertz
    • 1
  • Marcus Lehnhardt
    • 1
  • Jessica Kammler
    • 1
  • Lars Steinstraesser
    • 1
  • Adrien Daigeler
    • 1
    • 2
  1. 1.Department of Plastic Surgery, Burn Center, Hand Center, Sarcoma Reference Center, BG-University Hospital BergmannsheilRuhr-University BochumBochumGermany
  2. 2.Department of Hand, Plastic and Reconstructive Surgery, Burn CenterBG-Unfallklinik LudwigshafenLudwigshafenGermany

Personalised recommendations