What Is a Tibialis Anterior Transfer?
A Tibialis Anterior Transfer — commonly abbreviated to TAT — is a surgical procedure used to treat a specific type of clubfoot (talipes) relapse called dynamic supination. It's one of the most common surgical procedures in clubfoot management, and if your child's consultant has recommended it, this guide explains what's involved.
In simple terms: the tibialis anterior is a muscle that runs down the front of the shin and attaches to the inner side of the foot. Its job is to pull the foot upward (dorsiflexion). In a normally aligned foot, this is fine. But in a relapsing clubfoot, this muscle's pull on the inner side of the foot causes the foot to turn inward when walking — this is the dynamic supination your consultant has identified.
The TAT procedure moves (transfers) the tendon of this muscle from the inner side of the foot to the outer side (or the middle). This rebalances the muscle pull so it lifts the foot straight up rather than pulling it inward.
When Is TAT Needed?
TAT is typically recommended when:
- Dynamic supination is present: You can see the foot turning inward during walking. The foot may look fine at rest but turns in with each step. Your consultant will confirm this by watching your child walk.
- The child is usually between 2.5 and 5 years old: This is the most common age range, though it can be performed in older children and occasionally adults.
- Re-casting alone hasn't resolved the relapse: Some relapses respond to a further course of Ponseti casts. If the foot corrects with casting but the dynamic supination returns when the child walks, TAT addresses the underlying muscle imbalance that casting can't fix.
- The foot is passively correctable: The surgeon needs to be able to move the foot into the correct position during examination. If the foot is rigid and can't be corrected passively, additional procedures may be needed alongside the TAT.
The Surgery: What Happens
Before the Operation
- Your child will have a pre-operative assessment at your NHS hospital, including blood tests and a general health check.
- The procedure is done under general anaesthetic — your child will be fully asleep.
- Most TAT procedures are done as a day case or with one overnight stay.
- Your child needs to fast before the anaesthetic (your hospital will give you specific instructions).
During the Operation
The surgery typically takes 45-90 minutes:
- Small incision on the top of the foot (inner side) to detach the tibialis anterior tendon from its current attachment point.
- The tendon is tunnelled under the skin to the outer side of the foot (or the middle, to the third cuneiform bone — the exact location varies by surgeon preference).
- A small incision on the receiving side allows the tendon to be reattached to the bone, usually through a small hole drilled in the bone and secured with a suture or button.
- Additional procedures may be performed at the same time if needed — for example, an Achilles tendon lengthening if equinus is present, or a re-tenotomy.
- A plaster cast is applied with the foot in the corrected position.
After the Operation
The immediate post-operative period:
- Your child will wake up from the anaesthetic in a recovery room. They'll likely be groggy and may be upset — this is the anaesthetic wearing off, not pain.
- Pain is managed with paracetamol and ibuprofen (sometimes stronger medication initially).
- They'll go home the same day or the next morning, depending on the hospital and how your child recovers from the anaesthetic.
- They'll be in a below-knee cast.
Recovery Timeline
| Timeframe | What Happens |
|---|---|
| Week 1-2 | In cast, non-weight-bearing. Elevated foot, pain management, rest. Some children adapt to moving around on their bottom or with a walker. |
| Week 3-6 | Still in cast. Some centres allow protected weight-bearing in a cast shoe. Cast changed at 3 weeks to check the wound. |
| Week 6 | Cast removed. Fitted with boots and bar (worn at night/nap time). May be given a daytime ankle brace (AFO) initially. |
| Week 6-12 | Gradual return to normal walking. Physiotherapy begins — gentle exercises to strengthen the transferred tendon in its new position. |
| Month 3-6 | Full recovery. Walking normally, running, playing. The transferred tendon has strengthened in its new position. |
Success Rates and Outcomes
TAT has excellent outcomes when performed at the right time for the right indication:
- Success rate: 85-95% of children achieve good correction of the dynamic supination.
- Relapse after TAT: About 10-15% may have some recurrence. This is usually manageable with continued bracing and monitoring.
- Long-term function: Most children return to completely normal activity levels, including sports, within 3-6 months of surgery.
- Donor site: Moving the tendon doesn't cause a significant functional deficit — the other muscles (tibialis posterior, peroneal muscles) compensate effectively.
Risks and Complications
Like any surgery, TAT carries risks:
- Infection: Small risk (1-2%) of wound infection. Usually manageable with antibiotics.
- Overcorrection: Rarely, the foot can be corrected too far in the other direction. This is uncommon with experienced surgeons.
- Undercorrection: The dynamic supination may not be fully corrected. Further procedures may be needed.
- Stiffness: Some temporary stiffness in the ankle after cast removal. Physiotherapy addresses this.
- Anaesthetic risks: Standard risks of general anaesthetic in children (very small).
Discuss these risks with your surgeon before consent. The overall complication rate is low, and serious complications are rare.
Preparing Your Child for Surgery
- Explain in age-appropriate terms: "The doctor is going to fix the muscle in your foot so it works better. You'll have a sleep medicine so you won't feel anything, and you'll wear a cast for a few weeks, just like when you were a baby."
- Prepare entertainment: Six weeks in a cast with a toddler requires activities. Stock up on colouring books, puzzles, building blocks, and tablet shows.
- Arrange childcare for siblings: Surgery day can be long. If you have other children, arrange care for them.
- Plan the home setup: You'll need a pushchair or wheelchair for outings, a way to keep the cast dry during baths, and a sleeping arrangement that works with the cast.
Frequently Asked Questions
Is TAT a big operation?
It's a moderate procedure — not as minor as a tenotomy, but not as major as a full surgical release or bony surgery. Most children go home the same day or the next morning, and recovery is straightforward.
Will my child need boots and bar again after TAT?
Usually yes — most consultants recommend returning to night-time boots and bar for a period after TAT (often until age 4-5, or for 1-2 years post-surgery). This helps maintain the correction while the transferred tendon strengthens.
Can TAT be done at any age?
It's most commonly performed between ages 2.5 and 5, but it can be done in older children and even adults. The technique is slightly different for older patients (the tendon may be split rather than fully transferred).
What if TAT doesn't work?
If dynamic supination persists after TAT, your surgeon may recommend repeat casting, a revision of the transfer, or alternative procedures. This is uncommon — TAT has a high success rate.
My consultant says my child needs TAT — does this mean the Ponseti method failed?
No. TAT is a recognised part of the Ponseti protocol for managing relapse. Dr Ponseti himself described TAT as the standard procedure for dynamic supination. It's not a failure of the method — it's a planned tool within it.
We cover this in more detail here: Tendon Transfer for Clubfoot: UK Surgery Guide.