A novel implantable mechanism-based tendon transfer surgery for adult acquired flatfoot deformity: Evaluating feasibility in biomechanical simulation

Adult acquired flatfoot deformity becomes permanent with stage III posterior tibialis tendon dysfunction and results in foot pain and difficulty walking and balancing. To prevent progression to stage III posterior tibialis tendon dysfunction when conservative treatment fails, a flexor digitorum longus to posterior tibialis tendon transfer is often conducted. However, since the flexor digitorum longus only has one-third the force-capability of the posterior tibialis, an osteotomy is typically also required. We propose the use of a novel implantable mechanism to replace the direct attachment of the tendon transfer with a sliding pulley to amplify the force transferred from the donor flexor digitorum longus to the foot arch. In this work, we created four OpenSim models of an arched foot, a flatfoot, a flatfoot with traditional tendon transfer, and a flatfoot with implant-modified tendon transfer. Paired with these models, we developed a forward dynamic simulation of the stance phase of gait that reproduces the medial/lateral distribution of vertical ground reaction forces. The simulation couples the use of a fixed tibia, moving ground plane methodology with simultaneous activation of nine extrinsic lower limb muscles. The arched foot and flatfoot models produced vertical ground reaction forces with the characteristic double-peak profile of gait, and the medial/lateral distribution of these forces compared well with the literature. The flatfoot model with implant-modified tendon transfer produced a 94.2% restoration of the medial/lateral distribution of vertical ground reaction forces generated by our arched foot model, which also represents a 2.1X improvement upon our tendon transfer model. This result demonstrates the feasibility of a pulley-like implant to improve functional outcomes for surgical treatment of adult acquired flatfoot deformity with ideal biomechanics in simulation. The real-world efficacy and feasibility of such a device will require further exploration of factors such as surgical variability, soft tissue interactions and healing response.