Tendon Transfer for Clubfoot: UK Surgery Guide

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Tendon Transfer for Clubfoot: A Complete UK Surgery Guide

If your child's clubfoot specialist has mentioned tendon transfer, you're likely feeling anxious about what this means. A tendon transfer for clubfoot — specifically the tibialis anterior tendon transfer (TATT) — is a well-established surgical procedure that forms part of the overall Ponseti treatment protocol in the UK. It's not a sign that treatment has failed; rather, it's a planned intervention to address a specific type of relapse and prevent further recurrence.

This guide covers everything UK parents need to know about tendon transfer surgery for clubfoot — why it's needed, what the procedure involves, NHS waiting times, recovery, and long-term outcomes. For broader information about the TATT procedure, see our detailed tibialis anterior tendon transfer guide.

Why Might My Child Need a Tendon Transfer?

Tendon transfer is typically recommended when a child experiences a specific type of clubfoot relapse called dynamic supination. This occurs when the tibialis anterior muscle — which runs along the front of the shin and attaches to the inner side of the foot — pulls the foot inward during walking. You may notice that your child:

  • Turns the foot inward when walking or running
  • Walks on the outer edge of the foot
  • Has the forefoot curving inward (adductus)
  • Shows increased signs of relapse despite reasonable bracing compliance

Dynamic supination is different from a full relapse — the foot may look normal at rest but turns inward during active movement. It occurs because the tibialis anterior muscle inserts on the medial (inner) side of the foot, creating an imbalanced pull. The tendon transfer moves the muscle's attachment to the centre or lateral (outer) side of the foot, rebalancing the forces and preventing further relapse.

When Is Tendon Transfer Performed?

TATT is typically performed on children aged 2 to 5 years, though it can be done in older children if needed. It is usually recommended after:

  • Initial Ponseti treatment (casting, tenotomy, and bracing) has been completed
  • A dynamic supination relapse has been identified
  • Repeat Ponseti casting has been performed to restore the foot's position (usually 2–4 casts)
  • An Achilles tenotomy may also have been repeated if the tendon has re-tightened

The Procedure: What Happens During Tendon Transfer Surgery

Before Surgery

Your child will have a pre-operative assessment at the hospital, which typically includes:

  • A full clinical examination of the foot
  • Discussion of the procedure, risks, and expected outcomes
  • Consent process — you'll sign a consent form after all your questions have been answered
  • Fasting instructions (no food or drink for a specified period before the anaesthetic)

The Surgery

The operation is performed under general anaesthetic and typically takes 45–90 minutes. The procedure involves:

  1. Incision: A small incision is made on the inner side of the foot to detach the tibialis anterior tendon from its original insertion point on the medial cuneiform bone
  2. Tunnel creation: A pathway is created through the foot to the new attachment site
  3. Tendon rerouting: The detached tendon is threaded through the tunnel to a new insertion point — typically the lateral cuneiform or the third cuneiform bone (in the centre of the foot)
  4. Reattachment: The tendon is securely fixed in its new position, often using sutures through a bone tunnel or an anchor
  5. Cast application: A full-leg plaster cast is applied with the foot in the corrected position

Some surgeons may also perform an Achilles tenotomy or lengthening at the same time if the tendon has re-tightened, and a capsulotomy (release of tight joint structures) if needed.

After Surgery: In Hospital

Most children stay in hospital for one night (day surgery is sometimes possible). After the operation:

  • Your child will wake from the anaesthetic, which can cause temporary grogginess and sometimes nausea
  • Pain relief is provided — usually paracetamol and ibuprofen, sometimes with a nerve block that lasts several hours
  • The cast will be in place and must be kept dry
  • You'll be given discharge instructions including how to manage pain, keep the cast dry, and when to return for follow-up

Recovery Timeline

Weeks 1–2: Immediate Recovery

  • Your child will be in a full-leg cast
  • Most children need pain relief for the first 3–5 days, then settle quickly
  • Mobility: Your child can move around using a pushchair, buggy, or being carried. Older children may use crutches
  • School-age children will typically need 1–2 weeks off school

Weeks 2–6: Cast Period

  • The cast remains in place for approximately 6 weeks in total
  • A cast change may occur at around 3 weeks (from a full-leg to a below-knee cast in some centres)
  • Keep the cast dry — use waterproof covers for bathing
  • Your child can attend nursery or school once comfortable, using a pushchair or wheelchair for mobility

Weeks 6–8: Cast Removal and Rehabilitation

  • The cast is removed at approximately 6 weeks
  • The foot may look swollen and pale initially — this is normal
  • Your child will begin walking again, initially with caution
  • Some children return to normal mobility within days; others take a few weeks
  • Physiotherapy may be recommended to restore strength and range of motion — see our physiotherapy exercises guide

Months 2–6: Return to Full Activity

  • Most children are walking normally within 2–3 months of cast removal
  • Running and sports typically resume within 3–6 months
  • The foot continues to improve in strength and flexibility over the following months
  • The boots and bar bracing protocol continues (or is restarted) after surgery, typically for 1–2 years

NHS Pathway for Tendon Transfer

Referral and Waiting Times

Tendon transfer for clubfoot is performed at specialist paediatric orthopaedic centres across the UK. The pathway typically involves:

  1. Your clubfoot specialist identifies the need for tendon transfer at a routine follow-up appointment
  2. Repeat Ponseti casting is usually performed first (2–4 casts over 2–4 weeks)
  3. A surgical referral is made (if not already under the surgeon)
  4. Pre-operative assessment
  5. Surgery date

NHS waiting times for this procedure vary by region but typically range from 6–18 weeks from decision to operate. If there is a clinical urgency (e.g., rapid relapse), the team may expedite the process.

Cost

All tendon transfer surgery for clubfoot is fully funded by the NHS. There is no cost to the family for the surgery, hospital stay, casting, follow-up appointments, or physiotherapy. Some families may be eligible for disability benefits to help with the additional care needs during the recovery period.

Risks and Complications

As with any surgery, there are potential risks, though serious complications are uncommon:

  • Infection: Risk of wound infection is approximately 1–2%. Treated with antibiotics
  • Overcorrection: The foot may develop a valgus (outward-turning) position if the tendon is transferred too far laterally. This is rare and usually mild
  • Undercorrection: The dynamic supination may persist if the transfer doesn't fully rebalance the foot. Further procedures may be needed
  • Tendon pull-out: The transferred tendon may detach from its new insertion point. This is rare with modern surgical techniques
  • Stiffness: Some reduction in foot flexibility is expected but usually doesn't affect function
  • Anaesthetic risks: Standard risks associated with general anaesthesia in children, which are very low

Overall, the complication rate is low, and the procedure has an excellent track record. Studies report success rates of 85–95% in preventing further relapse after TATT.

Success Rates

Tendon transfer for clubfoot has been extensively studied and has a strong evidence base:

  • Relapse prevention: Approximately 85–95% of children do not require further surgery after TATT
  • Foot function: Long-term studies show excellent functional outcomes, with the vast majority of children achieving normal or near-normal foot function
  • Patient satisfaction: Studies consistently report high satisfaction rates among parents and older patients
  • Long-term durability: The results of TATT are typically long-lasting, with correction maintained into adulthood

For broader success rate data, see our Ponseti method success rate article.

UK Specialist Centres

Tendon transfer for clubfoot is performed at numerous paediatric orthopaedic centres across the UK. Major centres include:

  • Great Ormond Street Hospital (GOSH), London
  • Alder Hey Children's Hospital, Liverpool
  • Sheffield Children's Hospital
  • Birmingham Children's Hospital
  • Royal Hospital for Sick Children, Edinburgh
  • Noah's Ark Children's Hospital, Cardiff
  • Royal Manchester Children's Hospital

Your local clubfoot team will refer you to the most appropriate centre. If you're unsure about your NHS referral pathway, speak to your specialist or GP.

Frequently Asked Questions

Q: Is tendon transfer major surgery?

A: TATT is considered a moderate surgical procedure. It requires general anaesthetic and involves operating on tendons and bone, but it is well-established with predictable outcomes. Most children go home the same day or after one night, and recovery is relatively straightforward. It is considerably less invasive than the extensive soft tissue releases that were common before the Ponseti method.

Q: Will my child need to wear the boots and bar again after surgery?

A: Yes, in most cases. The boots and bar bracing protocol is typically continued or restarted after surgery, usually for 1–2 years of night-time wear. This helps maintain the correction and supports the healing process.

Q: Can the tendon transfer be done at the same time as other procedures?

A: Yes. It's common for TATT to be combined with an Achilles tenotomy or lengthening, and sometimes with a capsulotomy (release of tight joint structures). Combining procedures reduces the number of anaesthetics and overall recovery time.

Q: What happens if the tendon transfer doesn't work?

A: In the small percentage of cases where TATT doesn't fully correct the problem, further options include repeat tendon transfer, additional soft tissue procedures, or bony surgery (osteotomy) in older children. Your specialist will discuss the most appropriate approach based on your child's specific situation.

Q: How do I manage my child's pain after surgery?

A: The surgical team will prescribe appropriate pain relief, typically paracetamol and ibuprofen. A nerve block performed during surgery often provides excellent pain relief for the first 12–24 hours. Most children need regular pain relief for 3–5 days, after which they settle. Keeping the leg elevated and distraction activities (books, screens, toys) help during the initial recovery. For more about managing discomfort, see our pain management guide.

Q: Will my child have a scar?

A: Yes, there will be a small surgical scar, typically on the inner side of the foot. In children, scars tend to heal very well and fade significantly over time. The scar is usually small and not noticeable in normal footwear. For more about surgical scars, see our clubfoot surgery scars guide.

Summary

Tendon transfer (TATT) is a well-established, effective surgical procedure for managing dynamic supination relapse in children with clubfoot. It is considered part of the overall Ponseti treatment protocol rather than a failure of treatment. The procedure has success rates of 85–95%, is performed under general anaesthetic, and requires approximately 6 weeks in a cast. All treatment is fully funded by the NHS. With proper post-operative bracing and follow-up, the vast majority of children achieve excellent, long-lasting foot function.