CLASSIC AND MODIFIED BARR ’ S TECHNIQUE OF ANTERIOR TRANSFER OF THE TIBIALIS POSTERIOR TENDON IN IRREPARABLE PERONEAL PALSIES

Peroneal palsy with loss of active dorsal fl exion in foot can be surgically treated by anterior transfer of tibialis posterior tendon. Two techniques are available, classic and modifi ed Barr’s technique of the anterior transfer of tibialis posterior tendon, with diff erent place of tendon’s reinsertion. Th e aim of the study is evaluation of the degree of active dorsal fl exion in foot, and appearance of varus position and hipercorrection of the foot, by comparing the results of the two operative techniques. Th e study included  patients with peroneal irreparable palsies, divided into two equally sized groups. Th e fi rst group was treated by classic Barr’s technique. Th e other group of patients was treated by modifi ed Barr’s technique. Th e group treated by modifi ed Barr’s technique exhibited better functional results. Active dorsal fl exion achieved between o (in  cases) and o (in  cases), while varus position and hipercorrection of the foot were absent. In the second group of  patients, treated by classic Barr’s technique, o () and o () of active dorsal fl exion, indicated worse functional postoperative results. Active dorsal fl exion of o achieved by this method in two cases (), represents unsatisfactory functional result. Varus position of the foot was recorded in  cases () and hipercorrection in  cases (). Modifi ed Barr’s technique is surgical method with better functional and postoperative results in treatment of irreparable peroneal palsy.


Introduction
Irreparable peroneal palsies, without possibility of functional recovery, can be treated by anterior transfer of tibialis posterior tendon.Absence of innervation in neuromuscular junction, with loss of function, may be an indication for tendon transfer ().Functional recovery of injured nerve can be evaluated electromyographycaly, by interval tracking of Tinnel sign and by Hidget`s method of evaluation of postoperative results in the sense of motor and sensory recovery ().Electromyographic evaluation of reinnervation of neuromuscular junction is not a guarantee of functional recovery, because electomyography is rather functional than diagnostic test ().The aim of anterior transfer of tibialis posterior tendon, in the case of irreparable peroneal palsy, is reestablishment of lost active dorsal flexion in foot ().Anterior transfer of tibialis posterior tendon, which primary function is plantar flexion of the foot, with reinsertion on cuboid, or one of the cuneiform or metatarsal bones, is convenient type of tendon transfer in irreparable peroneal palsy ().Indications for tibialis posterior anterior transfer ():  ().Th e aim of the study is to compare success of classic and modifi ed Barr's techniques by evaluating the degree of active dorsal fl exion after anterior transfer of tibialis posterior tendon and by observing unfavorable postoperative results in the form of varus position and hipercorrection of the foot.

Material and Methods
The study included  patients with irreparable peroneal palsies.Th e fi rst group of  patients was treated by classic Barr's technique while the modified technique was applied in the other group of  patients.Criteria for inclusion in the study: -Patients of diff erent sex -Clinically and diagnostically verifi ed lesion of peroneal nerve -Patients treated by classic and modifi ed Barr`s technique Criteria for exclusion from the study: -Untreated peroneal palsies -Peroneal palsies treated by other operative techniques of tibialis posterior transposition Denervation of neuromuscular junction was verified electromyographycaly before the surgery.All the deforming changes in ankle joints were also corrected.Functional and full range of motions of joints before tendon transfer are essential for all types of tendon transfers.Postoperative results were evaluated by: -Clinical examination -Degree of active dorsal fl exion of the foot -Presence of varus position and hipercorrection of the foot

Results and Discussion
We have evaluated the results of operative treatment of  patients with irreparable peroneal palsies, loss of active dorsal flexion in foot and functional range of motion in the ankle joint.The patients were divided in two identically sized groups.Th e fi rst group was treated by classic Barr's technique and the second group was treated by modifi ed Barr`s technique.

Conclusion
Anterior transfer of tibialis posterior tendon in the cases of irreparable peroneal palsy removes dynamic deformity of the foot.Redirection of tendon in relation to medial malleolus diminishes the force of plantar fl exion of the foot.
Comparing the two methods of Barr's technique of tibialis posterior transfer, statistical signifi cance was found in diff erences in postoperative degree of active dorsal fl exion of the foot and in frequencies of varus position and hipercorrection.We found correlation between operative technique and postoperative results.Better functional results were obtained by modifi ed Barr's technique, with complete absence of varus position and hipercorrection of the foot, and higher degree of active dorsal fl exion.It implicates faster functional postoperative recovery and better walking stability.Tibialis posterior tendon has adequate length for reinsertion on cuboid bone, without angulation.According to our clinical experience, modifi ed Barr`s technique is the method of choice in the treatment of irreparable peroneal palsies.

CLASSIC BARR`S TECHNIQUE -reinsertion
of tibialis posterior tendon on either second or third cuneiform bone, or at the base of either second or third metatarsal bone, after desinsertion from the navicular bone, with passage of the tendon through the interosseus membrane of the leg .MODIFIED BARR`S TECHNIQUE-procedure identical to the classic Barr`s technique, but with reinsertion on cuboid bone (Th e technique developed at the Clinic for Plastic and Reconstructive Surgery The degree of active dorsal flexion, achieved by classic and modified Barr`s techniques is represented in Table.Comparison of these two techniques according to the achieved active dorsal flexion of the foot, is given inTable  and Figure .Varus position and hipercorrection of the foot, as unfavorable post-operative results, were observed only in the group of patients treated by classic Barr`s technique, as illustrated inTables  and  and Figures  and .Better functional results, with higher degree of active dorsal flexion of the foot -o () and o (), were found in the group of patients treated by modifi ed Barr's technique.Also, varus position and hipercorrection were completely absent.In the group of patients treated by classic Barr's technique, functional postoperative results were less successful.Active dorsal fl exion of o was not achieved.Th e highest degree of the achieved active dorsal fl exion was o () while o was achieved in certain cases ().Active dorsal fl exion of o was evaluated in  patients and is considered bed functional result.Varus position was found in  cases () and hipercorrection in  cases ().

TABLE 1 .
Parameter of active dorsal fl exion evaluated by maximal, minimal, median and standard deviation

TABLE 3 .
Absolute and relative frequencies of treated patients according to the varus position parameter

TABLE 2 .
Absolute and relative frequencies of the treated patients according to the parameter of active dorsal fl exion

TABLE 4 .
Absolute and relative frequencies of treated patients according to hypercorrection parameter