Influence of Tendon Transfer Site on Moment Arms of the Flexor Digitorum Longus Muscle

Background: Adult acquired flatfoot is a common condition that leads to significant morbidity. Along with bony procedures to operatively treat this condition, transfer of the flexor digitorum longus (FDL) tendon to the medial cuneiform or navicular is routinely performed. The goal of this tendon transfer is to increase the capacity of the FDL to invert the hindfoot and control the transverse tarsal joints. However, it is not known whether this biomechanical goal is met or whether one transfer site produces a larger mechanical advantage compared to another site. The purpose of this study was to calculate FDL muscle moment arms at the hindfoot with two clinically relevant transfer locations to quantify the change in mechanical advantage of the FDL after tendon transfer. Methods: In seven cadaver specimens, muscle moment arms of the FDL with respect to hindfoot motion were measured using the tendon excursion method before and after the FDL was transferred to the plantar aspect of the navicular and medial cuneiform. The position and orientation of the foot and excursion of the FDL tendon were measured with an optoelectronic measurement system. Results: The FDL moment arm did not increase after tendon transfer to either the medial cuneiform or navicular when compared to its native site. There were significant decreases in FDL moment arm when transferred from its native site to the medial cuneiform (56% decrease, p = 0.018) and navicular (46% decrease, p = 0.026). Conclusions: In contrast to the clinical proposition that FDL transfer to the navicular or medial cuneiform increases this muscle's mechanical advantage to invert the hindfoot, this cadaver study suggests that, to the contrary, FDL muscle moment arms decrease after tendon transfer.