A new method of functional tendon transfer for the dysfunction of extensor hallucis longus

A surgical technique of functional tendon transfer for the treatment of extensor hallucis longus (EHL) rupture is described. By using the extensor digitorum longus tendon of the second toe, the patient regains active dorsiflexion of the big toe and the deformity of the toe is corrected.     

Auf die Spannung kommt es an – Matrix-verstärkte turn-down-Plastik einer chronischen Ruptur der Extensor hallucis longus-Sehne am wachen Patienten

BackgroundReconstruction of a chronic rupture of extensor hallucis longus tendon can be very challenging for various reasons. Direct tendon repair is often not possible due to retraction or degeneration. In addition, the choice of adequate tension of tendon during surgery may be difficult.Material and MethodsWe report a case of a 24-year-old patient in which various problems could be avoided by combining a turn-down-reconstruction and membrane augmentation. A selective nerve block was used to enable active movements of the toe during surgery to confirm adequate tension of the reconstructed tendon.ResultThe procedure was performed succesfully. After 6 months the patient presented without any complaints. He performed a good range of motion with full power.ConclusionThis technique shows up an elegant way for reconstruction of a chronic rupture of extensor hallucis longus tendon.     

Autogenous graft repair using semitendinous tendon for a chronic multifocal rupture of the extensor hallucis longus tendon: a case report

Chronic multifocal closed rupture of the extensor hallucis longus tendon is an extremely rare injury. Previously, chronic multifocal partial rupture of the extensor hallucis longus tendon had not been reported. This case study reports one case of autogenous graft repair of a chronic multifocal rupture of the extensor hallucis longus tendon using a semitendinous tendon autograft.     

Subcutaneous rupture of the flexor hallucis longus tendon: a case report

It is well known that rupture of the flexor hallucis longus tendon can be associated with open injuries and that closed rupture of the flexor hallucis longus tendon is rare. Tendon injuries of the foot can occur secondary to direct, indirect, or repetitive injury. Repetitive tendon injuries can cause tendinitis or stenosing tenosynovitis. Tendinitis is associated with internal tendon injury that can present with tendon thickening, mucinoid degeneration, nodule development, or in situ partial tears. Stenosing tenosynovitis is the development of tendon adhesions within the tendon sheath that interfere with tendon gliding, known as trigger toe. The flexor hallucis longus tendon is susceptible to injury along its entire course. A total of 35 cases of complete or partial closed ruptures of the flexor hallucis longus tendon have been reported. We present the case of complete subcutaneous rupture of the flexor hallucis longus tendon associated with trauma at the proximal phalangeal head.     

A Combined Surgical Approach for Extensor Hallucis Longus Reconstruction: Two Case Reports

The surgical management of foot tendon injuries is not well-represented in literature. To achieve excellent functional recovery of the extensor hallucis longus (EHL) tendon, we aimed at developing a reliable and feasible reconstructive technique.A surgical technique for delayed reconstruction of the EHL tendon, combining an elongation procedure with second toe extensor tendon transfer, is described in this article.The results of this combined approach for EHL tendon reconstruction were remarkable, since the patients of the two clinical cases reported regained active extension of the hallux after 6 months without any associated complication.This study represents a step forward in foot surgery, since it describes an alternative technique to manage EHL tendon lesions.     

Optimizing independent finger flexion with zone V flexor repairs using the Massachusetts General Hospital flexor tenorrhaphy and early protected active motion

PURPOSE: Independent FDS action has been cited to be problematic with repair of multiple tendons in zone V owing to adhesion formation between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Of the several described flexor repair techniques the ideal tendon repair should be strong enough to allow for early active motion to minimize adhesion formation and maximize tendon healing. Biomechanical studies have proven the Massachusetts General Hospital (MGH) repair to be strong enough to allow for early active motion. The purpose of this study was to examine the use of the MGH technique for zone V flexor tendon injuries to allow for early protected active motion to achieve independent finger flexion through better differential gliding of the tendons. METHODS: We performed a retrospective review 168 zone V finger flexor tendon repairs for 29 patients performed consecutively over 4 years when early active motion was not contraindicated. The same early protected active motion protocol was used for all of these patients. We reviewed total active motion, independent flexion, rupture, and need for tenolysis. These injuries involved 103 FDS and 65 FDP tendons to 103 fingers. The median follow-up period was 24 weeks. Of these 29 patients 19 were men and 10 were women. The average patient age was 28 years. RESULTS: The total active motion for these zone V repairs was 236 degrees +/- 5 degrees Overall 97 of 103 digits attained good to excellent function and 88 of 103 developed some differential glide. One of these patients required a tenolysis. Three repairs ruptured in 1 patient owing to suture breakage that was associated with noncompliance with the dorsal extension block splint. CONCLUSIONS: Our retrospective review of 168 consecutive flexor tendon repairs showed that the MGH technique allowed for early protected active motion, which provided good to excellent functional outcomes with 88 of 103 developing independent finger flexion at an acceptably low complication risk.     

Lacerations and ruptures of the flexor or extensor hallucis longus tendons

Lacerations and ruptures of the flexor hallucis longus or extensor hallucis longus tendon are frequently managed with operative repair. Tendon injuries of the hallux are not all alike; careful consideration should be given to the mechanism and site of injury, the timing of presentation, and the presence of other injuries. Not all tendon injuries of the hallux require repair. The effectiveness of a repair will depend on the goals of surgery, which may include pain relief, active joint motion, or correction of deformity. When goals are clearly defined, a satisfactory result can be expected in most patients.     

Local Autograft and Strong Pulvertaft Fixation Technique for Reconstruction of a Rerupture of the Extensor Hallucis Longus Tendon: A Case Report

There are different treatment options for extensor hallucis longus injuries. For primary repair, the end-to-end suture is recommended. The treatment of reruptures or tendon defects is challenging, and a wide range of procedures have been used in this regard, including primary and secondary repairs with and without auto- and allografts. To overcome the disadvantages of second-site morbidity and to achieve high primary stability, we demonstrate a technique using a local tendon graft in combination with a strong Pulvertaft suture technique in a case of rerupture of the extensor hallucis longus tendon.     

Surgical treatment and results in 17 cases of open lacerations of the extensor hallucis longus tendon.

There is a scarcity of information on extensor hallucis longus tendon injuries and published studies frequently offer conflicting treatment recommendations and results. PATIENTS AND METHODS: This paper reports on the treatment and results of open lacerations of the extensor hallucis longus tendon in 17 patients treated by a plastic surgeon over a period of 12 years. All injuries occurred due to industrial accidents. All patients were males with a mean age of 30 years (range=21-49 years). All zones of tendon injury were represented except zones 2 and 5. Sixteen patients underwent surgical exploration within 24h of injury and one patient had a delayed repair using a tendon graft. The laceration of the tendon was complete in 15 patients, and in these patients, the tendon repair was protected for 6 weeks using k-wires to the big toe and short-leg walking cast. The remaining two patients had partial tendon lacerations and were treated conservatively (without tendon suturing) and immediate unrestricted mobilisation. One patient had significant soft tissue loss requiring reverse sural artery flap cover. At final follow-up (mean=3 months), the results of tendon repair were assessed as per the grading system of Lipscomb and Kelly, and the AOFAS hallux score for pain (maximum score of 40 points indicating no pain) and for functional capability (maximum score of 45 points). RESULTS: All patients healed with no infections or painful neuromas. Two patients experienced prolonged mild aching pain in the foot on walking, but the pain eventually resolved in both patients. All patients returned back to work 2.5-5 months after surgery. As per Lipscomb and Kelly's grading system, the result was graded as good in four patients and fair in the remaining 13 patients. No poor results were seen. The AOFAS hallux pain score was 40 points in all patients and the mean functional capability score was 42.1 points (range=40-45 points). CONCLUSION: A large series of extensor hallucis longus tendon lacerations is reported. Treatment and the methods of immobilisation are given for various zone and injury types. Although it is difficult to obtain a completely normal range of motion of the big toe after surgery, all patients are expected to recover good active extension and return back to work pain-free.     

Acute, traumatic rupture of a flexor hallucis longus tendon: a case report

A previously undescribed lesion--complete, acute traumatic rupture of the flexor hallucis longus--is reported in a 34-year-old man to demonstrate the location of lesion, possibility of misdiagnosis, mechanism of rupture, and the surgical technique. The results of surgical repair were excellent. The literature regarding other injuries to the flexor hallucis longus tendon is also remarkably limited.     

The Use of Ultrasonography to Identify the Intersection of the Dorsomedial Cutaneous Nerve of the Hallux and the Extensor Hallucis Longus Tendon: A Cadaveric Study

Terminal branches of the superficial fibular nerve are at risk of iatrogenic damage during foot surgery, including hallux valgus rigidus correction, bunionectomy, cheilectomy, and extensor hallucis longus tendon transfer. One terminal branch, the dorsomedial cutaneous nerve of the hallux, is particularly at risk of injury at its intersection with the extensor hallucis longus tendon. Iatrogenic injuries of the dorsomedial cutaneous nerve of the hallux can result in sensory loss, neuroma formation, and/or debilitating causalgia. Therefore, preoperative identification of the nerve is of great clinical importance. The present study used ultrasonography to identify the intersection between the dorsomedial cutaneous nerve of the hallux and the extensor hallucis longus tendon in cadavers. On ultrasound identification of the intersection, dissection was performed to assess the accuracy of the ultrasound screening. The method successfully pinpointed the nerve in 21 of 28 feet (75%). The sensitivity, positive likelihood ratio, and positive and negative predictive values of ultrasound identification of the junction of the dorsomedial cutaneous nerve and the extensor hallucis longus tendon were 75%, 75%, 100%, and 0%, respectively. We have described an ultrasound protocol that allows for the preoperative identification of the dorsomedial cutaneous nerve of the hallux as it crosses the extensor hallucis longus tendon. The technique could potentially be used to prevent the debilitating iatrogenic injuries known to occur in association with many common foot surgeries.     

Delayed Rupture of the Extensor Hallucis Longus and Extensor Digitorum Communis Tendons After Breaching the Anterior Capsule with a Radiofrequency Probe During Ankle Arthroscopy: A Case Report

A 40-year-old man with early arthritis, loose bodies, and anterolateral joint impingement symptoms in his left ankle, which was refractory to noninvasive therapeutic modalities for 1 year, underwent ankle arthroscopy and radiofrequency thermal ablation. The anterior capsule of the ankle joint was breached by the radiofrequency probe while the loose bodies were removed from the anterior recess, exposing the extensor tendons and resulting in a delayed spontaneous rupture of the extensor hallucis longus tendon and extensor tendons to the second and third toes. The extensor hallucis longus tendon was repaired with a semitendinosus tendon graft, and extensor digitorum tendons underwent primary repair. The patient regained full function and was symptom free 1 year after surgery.     

Reconstruction of Neglected Flexor Hallucis Longus Tendon Rupture: A Case Report

Isolated rupture of the flexor hallucis longus tendon is an unusual injury. We present the case of a neglected flexor hallucis longus tendon closed traumatic rupture at the plantar aspect of the first phalangeal head of the great toe in a middle-age male. The injury occurred while he was dancing. Because end-to-end tendon suture was impossible, the ensuing gap was repaired using a free plantaris tendon graft. We present the operative repair benefit of the flexor hallucis longus tendon rupture to regain the function and strength of the interphalangeal joint of the hallux, avoid extension of the distal phalanx, and maintain the longitudinal arch of the foot.     

Combined rupture of the tibialis anterior and the extensor hallucis longus tendons—functional reconstruction

Background Traumatic rupture of the tibialis anterior (TA) tendon represents a very rare foot injury. A combined injury of both the TA and the extensor hallucis longus (EHL) tendons has not yet been reported. Within the scope of this work we will prove that tendon transfers in cases of combined tendon injuries are a reasonable course of action in order to achieve the aim of a functional reconstruction.Methods A combined rupture of the tibialis anterior (TA) and the extensor hallucis longus (EHL) tendons was treated by suturing the EHL tendon to the distal TA tendon stump. The TA insertion was secured and the distal portion of the EHL tendon attached to an extensor digitorum slip. The TA muscle was proximally attached to the tendinous EHL segment.Results A 1 year follow-up verified very good results, showing the patient without complaints in regard to the trauma. Compared with the contralateral non-affected side, the repaired foot showed very satisfactory results in reference to range of motion, strength and gait.Conclusion With this work we proved that tendon transfers in cases of combined tendon injuries make sense in order to achieve functional reconstruction. This approach preserves function and strength and avoids the problems and risks of alternate treatment techniques, including tendon grafting.     

Autogenous graft repair of an extensor hallucis longus laceration

The author presents an overview of tendon healing with particular attention to the principles of tendon graft repair. A clinical case of a patient who experienced an extensor hallucis longus laceration 8 weeks prior to the graft repair is reviewed. The extensor hallucis longus tendon was repaired using an autogenous graft taken from the extensor hallucis brevis.     

Die Rückversetzung der Sehne des Musculus extensor hallucis longus in der modifizierten Technik nach Robert Jones

Zusammenfassung Operationsziel Korrektur einer Klauenzehenfehlstellung der Großzehe durch Rückversetzung des Musculus extensor hallucis longus und damit Ausschaltung der pathologischen Wirkung der extrinsischen Zehenmuskulatur sowie Schaffung einer aktiven Elevationswirkung auf das Os metatarsale I durch Rückversetzung des Musculus extensor hallucis longus auf das Os metatarsale I. Indikationen Funktionelle Beschwerden durch eine Klauenzehenfehlstellung der ersten Zehe infolge einer Überaktivität oder eines Übergewichts der extrinsischen über die intrinsische Muskulatur. Voraussetzung für die Operation ist ein normaler oder fast normaler Kraftgrad des Musculus extensor hallucis longus. Die alleinige Operation nach Robert Jones ist nur bei flexibler Flexionsstellung des Os metatarsale I wirksam; bei fixierter Stellung sollte sie mit einer extendierenden Osteotomie der Basis des Os metatarsale I kombiniert werden. Kontraindikationen Fehlende Kraft des Musculus extensor hallucis longus. Operationstechnik Ansatznahes Ablösen der Sehne des Musculus extensor hallucis longus und transossäre Rückversetzung auf das Os metatarsale I. Ergebnisse 65 Patienten wurden von 06/1990 bis 07/1997 in einer modifizierten Technik nach Robert Jones operiert. 51 von ihnen (19 Frauen, 32 Männer) mit 81 Rückversetzungen der Sehne des Musculus extensor hallucis longus konnten nach durchschnittlich 42 Monaten (neun bis 88 Monate) kontrolliert werden. Nach den Bewertungskriterien von Tynan und Klenerman waren die Patienten mit dem Ergebnis 36-mal sehr zufrieden, 38-mal bedingt zufrieden und sieben mal unzufrieden. Die Zehenfehlstellung wurde bei allen Füßen beseitigt. Summary Objectives Transfer of the extensor hallucis longus tendon to the neck of the first metatarsal to correct a claw toe deformity of the great toe. This transfer counteracts the pathologic action of the extrinsic toe muscles and produced an active elevation of the first metatarsal. Indications Activity-related complaints due to a claw deformity of the great toe secondary to a hyperactivity of the extrinsic muscles or a predominance of the extrinsic over the intrinsic muscles. Prerequisite: normal or near normal power of the extensor hallucis longus. This procedure is only indicated in instances of a flexible malposition of the first metatarsal. It must be combined with an extension osteotomy of the first metatarsal for a fixed deformity. Contraindications Insufficient power of the extensor hallucis longus. State after compartment syndrome or after posttraumatic malalignment. Surgical Technique Detachment of the tendon of the extensor hallucis longus close to its insertion and transfer to the neck of the first metatarsal. Results Between June 1990 and July 1997, the modified Jones technique was used in 65 patients. In 51 patients (19 women, 32 men) with 81 transfers, a follow-up examination was done after an average of 42 months (9 to 88 months). Using the assessment criteria of Tynan and Klenerman, the patients regarded the result as excellent in 36 cases, as satisfactory in 38 and as unsatisfactory in 7. The malposition of the toe was corrected in all feet.     

Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation

Chronic disorders of the Achilles tendon are commonly seen by the orthopaedic surgeon. In cases that are resistant to conservative treatment, a variety of surgical procedures have been utilized in the past. The indications for a previously described technique of flexor hallucis longus tendon transfer for reconstruction of chronic Achilles tendon rupture have been expanded to include further subsets of chronic Achilles tendinopathy, including rupture and tendinosis. We evaluated 20 patients (mean age 61) who underwent flexor hallucis longus transfer for treatment of chronic Achilles tendinopathy at a mean of 14 months following surgery. Our results were measured with the SF-36 survey, AOFAS Ankle-Hindfoot Scale, and Cybex strength and range of motion testing. Wound complications, tip-toe stance, and calf circumference were also assessed. There were no postoperative reruptures, tendinopathy recurrences, or wound complications. Despite a small loss of calf circumference, range of motion, and plantarflexion strength, 90% of patients scored 70 or higher on the AOFAS scale. SF-36 testing revealed significantly lower scores in the physical function category when compared with United States norms. Flexor hallucis longus tendon transfer/augmentation is a reasonable option for treatment of chronic Achilles tendinosis and rupture.     

A Practical Correction of Great Toe Claw Deformity

Ischemic contracture of the leg causing clawing of the toes is a known complication of compartment syndrome of the leg. Although a substantial amount of published data are available on the prevention and acute management of compartment syndrome, a relative paucity of data has been published on the optimal management of the resultant claw toe deformity. In the present case report, the operative management of a patient with left great toe clawing secondary to ischemia is described. Surgical management included lengthening of the extensor hallucis longus tendon and transfer of the extensor hallucis brevis tendon to the extensor hallucis capsularis, with percutaneous pinning of the great toe.     

Early active mobilization after primary repair of the flexor pollicis longus tendon

BackgroundThere have been few studies regarding primary flexor tendon repair of the thumb following early active mobilization, whereas there have been multiple such studies of the finger. This study examined the outcomes of patients who underwent early active mobilization after primary repair of the flexor pollicis longus tendon.MethodsThis study was a retrospective case series. Between 1993 and 2019, 17 thumbs of 17 consecutive patients with complete flexor pollicis longus tendon lacerations were treated using the Yoshizu #1 technique, followed by early active mobilization. The mean time between injury and primary flexor tendon repair was 2 days. Two thumbs had zone T1 injuries and 15 had zone T2 injuries. Mobilization of the thumb began on the first postoperative day with a combination of active extension and passive and active flexion. The mean follow-up period was 8 months. The percentage of total active motion of the thumb was regarded as the sum of the active motion of the two joints, divided by 140°. Functional outcomes were graded in accordance with the Strickland criteria.ResultsThree repair ruptures occurred in thumbs treated by inexperienced surgeons. Excluding tendon ruptures, the mean percentage of total active motion of the thumb was 83%. The mean active flexion of the interphalangeal and metacarpophalangeal joints was 62° and 64°. The mean extension deficit was 8.8° at the interphalangeal joint and 7.5° at the metacarpophalangeal joint. According to Strickland's criteria, repairs to eight thumbs were ranked excellent, three were good, one was fair, and five were poor.ConclusionsOur results are not inferior to the findings of previous reports regarding early postoperative mobilization after primary flexor pollicis longus tendon repair, in terms of the acquisition of active thumb motion. Poor outcomes result from repair rupture and increased extension deficits of the interphalangeal and metacarpophalangeal joints.     

Repair and rehabilitation of extensor hallucis longus and brevis tendon lacerations in a professional dancer

STUDY DESIGN: Case report. BACKGROUND: Tendon lacerations of the hallux are potentially devastating to a dancer. Strength of the hallux musculature is necessary to attain and maintain balance, push-off in multiple turns, and decelerate in jumps and hops. The purpose of this paper is to report on the repair and rehabilitation of extensor hallucis longus and extensor hallucis brevis tendon lacerations in a professional dancer. CASE DESCRIPTION: A 30-year-old dancer sustained complete laceration of her extensor hallucis longus and extensor hallucis brevis tendons, and partial laceration of the dorsal aspect of the hallux metatarsophalangeal (MTP) joint capsule. Following primary repair, at 9 weeks postsurgery, hallux MTP joint active dorsiflexion was limited to 5 degrees and passive dorsiflexion to 70 degrees . First toe dorsiflexion and plantar flexion strength was 4/5 at the MTP and 3+/5 at the interphalangeal joint. Rehabilitation included functional electrical stimulation to address considerable calf atrophy, strengthening exercises, functional retraining, and progressive return to dance. OUTCOME: The dancer returned to her previous level of dancing in 18 weeks, with 73 degrees and 85 degrees of hallux MTP joint active and passive dorsiflexion, and 30 degrees and 35 degrees of active and passive plantar flexion, respectively. Hallux MTP and interphalangeal joint muscle strength were 5/5 and 4+/5, respectively. Improvement, manifested in her SF-36 and Dance Functional Outcome System scores, accompanied her full functional recovery. DISCUSSION: Hallux stability provided by coactivation of the great toe extensors and flexors is crucial to accomplish the demands of bipedal and unipedal balances and activities in dance. This report demonstrates the success of primary surgical repair and rehabilitation in a dancer/athlete experiencing this injury.