Checkrein deformity due to extensor hallucis longus hypotrophy treated with extensor digitorum longus tendon transfer

Checkrein deformity is a relatively rare condition caused by hypotrophy or adhesion of a tendon after a lower leg injury. The occurrence of this condition due to the dysfunction of the extensor hallucis longus (EHL) is extremely rare. Only a few related case reports have been published, and Z-lengthening of the EHL tendon was performed for almost all patients.We report a case of checkrein deformity due to EHL hypotrophy. The patient was involved in a traffic accident 7 years ago. He sustained left tibial and fibular closed diaphyseal fractures and underwent minimally invasive plate osteosynthesis. He continued to have left great toe symptoms characterized by dorsiflexion of the great toe during ankle plantarflexion. The EHL had become an insufficient power source because of considerable hypotrophy. Therefore, a tendon transfer using the extensor digitorum longus to the second toe was performed as a primary treatment.     

Reconstructive measures for the foot after compartment syndrome]

Following severe indirect and/or direct trauma to the foot, compartment syndrome can easily develop in this foot. Untreated, the compartment syndrome results in a complex post-traumatic deformity--the "short foot syndrome." This may manifest itself as a contracted pes equinovarus foot with clawing of the toes. Isolated compartment syndrome of the foot due to local injury may result in the formation of hammer toes. During childhood and adolescence, severe soft tissue injuries to the lower leg or foot, with subsequent compartment syndrome of the foot or a neurovascular injury to the lower limb, may result in an alteration in growth of the affected region or may involve the foot. Radiological assessment of this contracted "short foot" using sonography or MRI demonstrates scarred, necrotic musculature mainly involving the muscles of the posterior tibia, the flexor hallucis and the flexor digitum. Muscular imbalance due to long-standing muscle palsies, or chronic post-traumatic osteitis of the tibia contribute to the development of rigid equinus foot and ankle. Treatment of the contracted foot includes complex soft tissue release, muscle and tendon transfer, tendon-lengthening procedures, and intrinsic releases to correct the toe deformities. In the adult with a severe post-traumatic pes equino-varus deformity, triple arthrodesis is recommended.     

Extensor hallucis longus tenorrhaphy by using the Massachusetts General Hospital repair

Extensor hallucis longus tendon injury and surgical treatment recommendations are infrequently reported. In contrast to long extensor tendon injuries to the foot, flexor and extensor tendon injuries of the hand have been extensively studied and surgical treatment protocols have been delineated. In biomechanical studies, the Massachusetts General Hospital technique has been shown to have superior strength to other tenorrhaphies and to allow for early active mobilization. The purpose of this study was to examine the use of this technique for repair of extensor hallucis longus tendon injuries to allow for early active motion with minimal risk of rupture. We performed a retrospective review of 6 extensor hallucis longus tendon repairs at the toe level. These patients all regained active motion of the great toe. None had loss of extension. There were no tendon ruptures with this technique of tendon repair. The Massachusetts General Hospital technique can be used to repair the extensor hallucis longus tendon with good functional outcome and minimal risk of tendon rupture.     

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.     

Extensor hallucis longus tendon contracture following triplane fracture of the tibia

Tendon contractures are a well-known sequele to compartment syndrome. It is most often seen in the upper limb [Santi MD, Botte MJ. Volkmann's ischaemic contracture of foot and ankle: evaluation and treatment of established deformity. Foot Ankle Int 1995;16(6):368–77] but have been infrequently described in the foot [Botte MJ, Santi MD, Prestianni CA, Abrams RA. Ischaemic contracture of foot and ankle: principle of management and prevention. Orthopedics 1996;19(3):235–44]. This case report describes an unusual case of isolated extensor hallucis longus (EHL) tendon contracture following a triplane fracture of distal tibial epiphysis with no evidence of compartment syndrome of either the leg or the foot. In addition, it demonstrates a successful outcome following ‘Z’ lengthening in the management of this condition.     

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.     

Transfer of extensor hallucis longus tendon (modified robert jones procedure)

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 produces an active elevation of the first metatarsal.     

Selective lengthening of the proximal flexor tendon in the management of acquired claw toes

We report the management of the acquired claw-toe deformity in ten adults. Each patient developed a varying number of claw toes at a mean interval of six months after the time of injury. There was clinical evidence of an acute compartment syndrome in one case. The clawing occurred at the start of heel-rise in the stance phase of gait. At this stage the patients complained of increasing pain and pressure on the tips of the toes. The deformities were corrected by lengthening flexor hallucis longus and flexor digitorum longus alone or in combination. The presence of variable intertendinous digitations between the tendons of flexor hallucis longus and flexor digitorum longus means that in some cases release of flexor hallucis longus alone may correct clawing of lesser toes.     

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.     

Tendon transfer for dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy – A case report

Introduction and importanceIrreparable sciatic nerve palsy is a cause of foot drop and resulting in absent or weak most of the muscles in leg. There may be dysfunctions of all tendons in the leg excepting Achilles tendon and plantaris tendon. The treatment of this atypical neurologic injury has not been defined.Case presentationI reported a case of foot drop following irreparable sciatic nerve palsy in which there was a dysfunction of all tendons in leg excepting Achilles tendon and plantaris tendon. The medial gastrocnemius tendon and plantaris tendon were transferred into the anterior tibialis tendon, the extensor digitorum longus tendon and extensor hallucis longus tendon. The lateral gastrocnemius tendon was transferred into the peroneus brevis. Four months post-operative, he reported no pain and became capable of walking without the assistance of an orthosis or a crutch and without steppage gait.Clinical discussionAnterior transfer of the tibialis posterior tendon was the preferred procedure. If no posterior tibial tendon function was presented, then in order of preference, the extensor hallucis longus, extensor digitorum longus, peroneal, flexor hallucis longus tendon, medial gastrocnemius, lateral gastrocnemius and plantaris tendon would be used.ConclusionThe atypical dysfunction of all tendons in the leg excepting Achilles tendon and plantaris tendon following irreparable sciatic nerve palsy was presented. Tendon transfer using medial gastrocnemius tendon, lateral gastrocnemius tendon and plantaris tendon seemed to be a good choice for treatment of this injury. It allowed reconstruction of a stable, painless, plantigrade foot.Level of evidenceCase report.     

Arthroscopic Release of First Metatarsophalangeal Arthrofibrosis

Various degrees of first metatarsophalangeal joint arthrofibrosis frequently occur in patients with bunion surgery or big toe trauma. In those patients with functional limitation who fail to respond to conservative treatment, surgery is indicated. We describe here an arthroscopic approach to first metatarsophalangeal release that is designed to improve functional results. Dorsomedial and dorsolateral portals are established at the medial and lateral sides of the extensor hallucis longus tendon. Through these 2 portals, the dorsal capsule is released and the medial and lateral joint gutters can be cleared up. The metatarsosesamoid compartment is approached through the straight medial portal and the working portal, the latter of which is located 4 cm proximal to the joint line between the abductor hallucis tendon and the medial head of the flexor hallucis brevis. Under visualization through the medial portal, adhesions around the sesamoid apparatus can be debrided with a shaver through the working portal. This completes the release of joint circumference and improves the motion range of the joint.     

Arthroscopically assisted Z-lengthening of extensor hallucis longus tendon

Extensor hallucis longus tendon contracture can lead to hyperextension deformity of the big toe. We describe an endoscopic approach of Z-lengthening of the tendon. Extensor hallucis longus tendoscopy is performed with a distal portal at the level of the metatarsal neck and a proximal portal at the level of the navicular. At the distal portal, the medial half of the extensor hallucis longus tendon is cut and a stay stitch of No. 2 ethibond is applied. It is then stripped proximally with a tendon stripper to the proximal portal. A stay stitch of No. 2 ethibond is applied to the lateral half of the tendon at the proximal portal and it is cut proximal to the stitch. With the ankle plantarflexed and the big toe kept in the similar position as the lesser toes, the tendon segments are kept in tension through the stay stitches via the proximal and distal portals. The stay stitches of distal tendon segment are sutured to the proximal segment at the same level of the cut end of the distal fragment with the aid of an eyed needle under arthroscopic visualization through the distal portal. The needle is passed through the tendon and then the skin. The suture is also passed through the skin and then retrieved to the proximal portal by a hemostat. It is then sutured to the proximal tendon segment at the proximal portal. Similarly, the proximal tendon end is sutured to the distal tendon segment at the corresponding level and the endoscopic Z-lengthening of the extensor hallucis longus tendon is then completed.     

Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis

We describe six patients aged from 10 to 15 years who, after injury to the distal tibial physis, presented with the following clinical findings: 1) severe pain and swelling of the ankle; 2) hypoaesthesia or anaesthesia in the web space of the great toe; 3) weakness of extensor hallucis longus and extensor digitorum communis; and 4) pain on passive flexion of the toes, especially the great toe. In four patients, the fractures were not reduced for more than 24 hours. The intramuscular pressure beneath the superior extensor retinaculum of the ankle was greater than 40 mmHg in all cases (40 to 130 mmHg), and less than 20 mmHg in the anterior compartment. Treatment consisted of release of the superior extensor retinaculum and stabilisation of the fracture. All patients had prompt relief of pain and improved strength and sensation within 24 hours, although two had some residual numbness in the web space of the great toe.     

Results of modified Robert Jones operation for clawed hallux.

The results of modified Robert Jones operation for clawed hallux carried out on 36 feet were reviewed by clinical and radiological investigations. Twenty-nine feet (80 per cent) achieved good results while 3 feet (8-5 per cent) obtained fair results and in 4 feet (11 per cent) the results were poor. Better results were obtained in the poliomyelitis cases than in the other groups. Correction of deformity appears to be achieved by the transferred extensor hallucis longus elevating the first metatarsal neck and by the flexor hallucis longus flexing the rigid toe obtained by interphalangeal arthrodesis. Tendon regeneration which is associated with recurrent clawing remains a problem. Internal fixation should be used for the interphalangeal arthrodesis.     

Acute tarsal tunnel syndrome following partial avulsion of the flexor hallucis longus muscle: a case report.

An acute posterior tibial nerve compression from a partially ruptured flexor hallucis longus (FHL) muscle is reported. This etiology for acute tarsal tunnel syndrome has not been previously described. A 17-year-old male sustained multiple injuries in a motor vehicle accident, including a tibial shaft fracture and a posterior medial right ankle laceration of the same limb. The injured limb had no sensation on the plantar aspect of the foot and heel, decreased active great toe flexion, and associated leg pain. Exploration of the posterior tibial nerve for presumed laceration revealed the nerve to be intact, but compressed in a tense tarsal tunnel from a retracted partially ruptured flexor hallucis longus tendon. Decompression of the tunnel and resection of the devascularized muscle resulted in complete neurologic recovery.     

A case of "trigger toe"

"Triggering" of the toes, in which local tendon hypertrophy prevents the smooth movement of the tendon, has been described as a problem more theoretical than real and only three cases have been reported. The authors report a case of partial tethering of the flexor hallucis longus tendon just distal to the medial malleolus in a 28-year-old jogger who had painful triggering of the great toe on plantar flexion of the ankle and great toe. Division of the flexor hallucis longus tendon pulley distal and posterior to the medial malleolus cured the patient.     

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.     

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.     

A Review of Extensor Hallucis Longus Variants Featuring a Novel Extensor Primi Internodii Hallucis Muscle Merging With Extensor Hallucis Brevis

The extensor hallucis longus (EHL) muscle/tendon complex has been used in a variety of tendon transfer and tenodesis surgeries to correct iatrogenic hallux varus deformity, equinovarus foot deformity, clawed hallux associated with a cavus foot, and dynamic hyperextension of the hallux and, even, to prevent pedal imbalance after transmetatarsal amputation. Although it is usually considered a unipennate muscle inserting into the dorsum of the base of the distal phalanx of the hallux, a vast majority of EHL muscles possess ≥1 accessory tendinous slips that insert into other neighboring bones, muscles, or tendons, which can complicate these surgeries. The present report reviewed the reported data on EHL variants and describe a new variant, in which the tendons of the extensor primi internodii hallucis muscle of Wood and extensor hallucis brevis muscle merged together proximal to the tarsometatarsal (Lisfranc) joint, a site of rupture for extensor tendons of the foot. The reported variant might have contributed to the development of the clawed hallux seen in our patient and could complicate its operative management by mimicking the normal extensor digitorum longus tendon. Knowledge of the EHL variants and the particular muscular pattern described in the present review could improve the diagnosis and tendon transfer and tenodesis operative planning and outcomes.     

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.