Young’s Keyhole Teno-Suspension

Primarily designed for pes planus (flexible flat-foot) that is driven by a sagittal-plane collapse of the medial longitudinal arch.
- Especially useful when a navicular–cuneiform fault (plantar break in the medial column) is present.
Age criterion: Children ≥ 10 years old.
- Rationale: younger children still remodel spontaneously; older children have a more stable deformity and a tendon strong enough to transfer.

Name cues
- “Young” → procedure originator & mnemonic of a young child in the visual memory aid.
- “Keyhole” → literal key-hole drilled through the navicular bone.
- “Teno-suspension” → tendons are re-routed and suspended to bolster the arch.

Harvest the distal tibialis anterior tendon.
Reroute it plantarly through the drilled keyhole in the navicular.
- Anchors the tendon more proximally and plantarly than its native insertion on the medial cuneiform/1st met.
Biomechanical outcome
- Converts the TA from a pure dorsiflexor/ inverter of the forefoot to a dynamic sling supporting the medial arch.
- Continues to act in the sagittal plane (dorsiflexion force) but now adds an anti-planus support.

Advance the posterior tibialis tendon to the plantar aspect of the navicular.
Generates a “soft-tissue cradle” with TA—both tendons wrap under & around the navicular, counteracting arch collapse.

Frequently combined because an equinus contracture can perpetuate flat-foot.
ATL lowers forefoot pressure and facilitates the plantar-flexory effect on the 1st ray.

Sagittal plane dominance
- Both transferred tendons are primary dorsiflexors, so the correction they impart aligns with sagittal motion.
Plantar-flexion of the 1st ray
- By shifting the TA insertion plantarly/proximally, its vector gains a plantar-flexory component on the medial column, stabilising the forefoot in the same plane.

Flat-foot deformity is often a tri-planar problem; here the focus is purely sagittal for cases where collapse occurs mainly in that plane.
Repositioning a strong tendon (TA) closer to the lever arm of the arch yields immediate dynamic support every time the patient dorsiflexes the ankle.
PT advancement provides synergistic inversion & midfoot stabilization, supplementing the weakened spring ligament complex.

Evans calcaneal lengthening → primarily frontal/transverse. Young’s addresses sagittal.
Subtalar arthroereisis → acts as a block to pronation; Young’s provides active muscular support.
Cotton opening-wedge osteotomy → dorsal opening at medial cuneiform (also sagittal) but osseous, not tendon-based.

Ensure the navicular drill-hole is large enough to avoid tendon strangulation but small enough for snug fixation.
Suture or interference screw fixation secures the rerouted TA.
Check for full ankle dorsiflexion after ATL (≥ 10° with knee extended).

Non-weight-bearing short-leg cast for 6 weeks.
Transition to CAM boot and begin physical therapy focusing on dorsiflexion strength & proprioception.

Over-pulling TA → may create cavus; balanced tensioning is key.
Neurovascular risk near the navicular—careful dissection.
Recurrent deformity if ATL insufficient; always address equinus when present.

Success rates reported > 85 % for pain relief & arch restoration in properly selected patients.
Better outcomes when combined with ATL in presence of equinus.

Pediatric consent: involve both patient and guardians, emphasizing expected growth, rehab commitment, and possibility of staged procedures in future.
Long-term follow-up necessary to observe skeletal maturation and ensure maintained correction through adolescence.