Point-Counterpoint: Is The Flexor Digitorum Longus Tendon Transfer Effective For Stage 2 Adult-Acquired Flatfoot?

William T. DeCarbo, DPM, AACFAS; Lawrence A. DiDomenico, DPM, FACFAS, Ramy Fahim, DPM, AACFAS, and Zachary Thomas, DPM

1. Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res. 1989; (239):196-206.
2. Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect. 1997; 46:393-405.
3 Aronow MS. Triceps surae contractures associated with posterior tibial tendon dysfunction. Tech Orthop. 2000; 15:164-73.
4. Johnson JE, Cohen BE, DiGiovanni BF, et al. Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency. Foot Ankle Int. 2000; 21(9):722-9.
5. Den Hartog BD. Flexor digitorum longus transfer with medial displacment calcaneal osteotomy. Foot Ankle Clin. 2001; 6(1):67-76.
6. LeVeau B. Static Equilibrium. In: Biomechanics of Human Motion. WB Saunders, Philadelphia, 1997, pp. 36-68.
7. Haddad SL, Mann RA. Flatfoot in Adults. In: Coughlin MJ, Mann RA, Saltzman C (eds.) Surgery of the Foot and Ankle. Eighth edition. Mosby, St. Louis, 2011, pp. 1007-86.
8. Aronow MS. Tendon transfer options in managing the adult flexible flatfoot. Foot Ankle Clin N Am. 2012; 17(2):205-226.
9. Inman V, Ralston H, Todd F. Muscles. In Human Walking. Williams & Wilkins, Baltimore, 1981, p. 103.
10. Plattner P, Mann R. Disorders of Tendons. In: Ryan JD (ed.). Surgery of the Foot and Ankle. Sixth edition, Mosby, St. Louis, 1993, pp. 805-35.
11. Silver T, DeLa Garza J, Rang M. 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. 1985; 67(3):432-37.
12. Myerson M. Adult acquired flatfoot deformity. J Bone Joint Surg Am. 1996; 78(4):780-792.
13. Myerson M, Corrigan J, Thompson F. et al. Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation. Foot Ankle Int. 1995;16(11):712-718.
14. Saltzman C. The acquired adult flatfoot. Presentation at the AAOS Comprehensive Foot and Ankle Course, Current Concepts and Practical Solutions, Tyson Corner, VA, 1999.
15. Trevino S, Gould N, Korson R. Surgical treatment of stenosing tenosynovitis at the ankle. Foot Ankle Int. 1981; 2(1):37-45.
16. Moseir SM, Lucas DR, Pomeroy G, et al. Pathology of the posterior tibial tendon in posterior tibial tendon insufficiency. Foot Ankle Int. 1998; 19(8):520-524.
17. Mosier SM, Pomeroy G, Manoli A 2nd. Pathoanatomy and etiology of posterior tibial tendon dysfunction. Clin Orthop Relat Res. 1999; 365:12-22.
18. LaRue BG, Anctil EP. Distal anatomical relationship of the flexor hallucis longus and flexor digitorum longus tendons. Foot Ankle Int. 2006; 27(7):528-32.
19. Mulier T, Rummens E, Dereymaeker G. Risk of neurovascular injuries in flexor hallucis longus tendon transfers: an anatomic cadaver study. Foot Ankle Int. 2007; 28(8):910-5.
20. O’Sullivan E, Carare-Nnadi R, Greenslade J, et al. Clinical significance of variations in the interconnections between flexor digitorium longus and flexor hallucis longus in the region of the knot of Henry. Clin Anat. 2005; 18(2):121-5.
21. Wacker J, Calder JD, Engstrom CM, et al. MR morphometry of posterior tibialis muscle in adult acquired flat foot. Foot Ankle Int. 2003; 24(4):354-357.
22. Rosenfeld PF, Dick J, Saxby TS. The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction. Foot Ankle Int. 2005; 26(9):671-674.
23. Kou JX, Balasubramaniam M, Kippe M, Fortin PT. Functional results of posterior tibial tendon reconstruction, calcaneal osteotomy and gastrocnumius recession. Foot Ankle Int. 2012; 33(7):602-11.


These authors say performing the flexor digitorum longus tendon transfer is unnecessary in most cases and this tendon lacks the long-term mechanical advantage to stabilize the midfoot in patients with stage 2 adult-acquired flatfoot.

By Lawrence A. DiDomenico, DPM, FACFAS, Ramy Fahim, DPM, AACFAS,
and Zachary Thomas, DPM

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