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.     

趾长屈肌腱和长屈肌腱移位修复陈旧性跟腱断裂

目的：探讨趾长屈肌腱、[足母]长屈肌腱移位修复陈旧性跟腱断裂的手术方法和疗效。方法：13例陈旧性跟腱断裂患者,男9例,女4例;年龄32～69岁,平均41岁;左侧8例,右5例;受伤至手术时间3～8个月,平均4.5个月。13例患者均有明确外伤史,均为闭合性损伤跟腱断裂。采用趾长屈肌腱移位修复陈旧性跟腱断裂5例,行[足母]长屈肌腱移位修复陈旧性跟腱断裂8例。结果：13例随访时间11个月～4.5年,平均2年,伤口无感染,跟腱无再断裂,踝关节活动基本正常,足背屈跖屈功能良好,未发生锤状趾畸形。按Arner-Lindholm疗效评定标准评定,优9例（[足母]长屈肌腱移位修复6例,趾长屈肌腱移位修复3例）,良3例（[足母]长屈肌腱移位修复2例,趾长屈肌腱移位修复1例）,差1例（趾长屈肌腱移位修复）。结论：采用趾长屈肌腱、[足母]长屈肌腱移位修复陈旧性跟腱断裂的手术方法,可获得良好的疗效,是较理想的治疗方法。而采用长屈肌腱移位修复陈旧性跟腱断裂更趋近于合理。     

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.     

V-Y肌腱瓣结合屈(足母)长肌腱转移治疗退变的跟腱断裂

目的 介绍V-Y肌腱瓣结合屈(足母)长肌腱转移治疗退变的跟腱断裂的术式、手术指征及疗效.方法 2003年10月至2006年5月对21例跟腱断裂采用V-Y肌腱瓣结合屈躅长肌腱转移治疗,其中采用铆钉17例,界面螺钉4例.介绍该手术方法,并根据文献和实践总结手术指征. 结果 本组所有患者获得12～18个月(平均14个月)随访.根据Arner-Lindholm疗效评价标准:优19例,良2例.术后伤口均一期愈合,随访期间跟腱无再次断裂,无伤口感染,无皮肤坏死,踝关节活动好,无僵直,无神经血管损伤.行走步态基本正常,对前足推进影响不大.该术式修复强度允许跟腱早期功能锻炼. 结论 采用V-Y肌腱瓣结合足屈(足母)长肌腱治疗跟腱断裂疗效好,该术式适用于跟腱组织退变、炎症和部分缺损(<3cm)患者,术中单纯V-Y肌腱瓣修补强度不够可采用屈(足母)长肌腱转移.     

Dynamic Positional Deformity of the Hallux

The present study reports a case with concomitant tethering of the flexor tendon and extensor tendon of the hallux after closed tibiofibular shaft fractures. We have obtained good clinical results using tenotomy of the flexor hallucis longus tendon and Z-plasty lengthening of the extensor hallucis longus tendon. Because few studies have described the clinical results and operative methods for this type of combined deformity, we report a case with dynamic positional deformity of the hallux.     

Mechanical Properties of Reconstructed Achilles Tendon with Transfer of Peroneus Brevis or Flexor Hallucis Longus Tendon

Treatment of chronic Achilles tendon ruptures can be technically difficult because of tendon retraction, atrophy, and short distal stumps. Surgical repair of chronic Achilles tendon ruptures focuses on local and free tendon transfers, as well as reconstruction with allografts or synthetic materials. This study examined the in vitro mechanical properties of a reconstructed Achilles tendon with the peroneus brevis or the flexor hallucis longus tendons in a human cadaver model. The tendons were harvested from 17 fresh-frozen human cadavers, and the same techniques were used for all of the model reconstructions. Biomechanical measurements included the failure load, stiffness, energy-to-peak load, and mode of failure. The mean failure load was significantly higher in the peroneus brevis group (P = .036), and there was no significant difference in stiffness and energy-to-peak load between the peroneus brevis and flexor hallucis longus groups. In every case, the mode of failure involved the tendon graft pulling through either the distal or proximal stump of the Achilles tendon. The greater failure loads observed with the use of peroneus brevis may not be clinically relevant, however, because of the magnitude of the peak loads observed in the cadaveric model. The present study supports the use of either peroneus brevis or flexor hallucis longus for reconstruction of chronic Achilles tendon ruptures and indicates the need for surgeons to carefully reinforce the attachment of the transferred tendon grafts to the stumps of the Achilles tendon to prevent pullout.     

A Biomechanical Analysis of Interference Screw Versus Bone Tunnel Fixation of Flexor Hallucis Longus Tendon Transfers to the Calcaneus

The flexor hallucis longus tendon transfer is commonly used to restore function in chronic Achilles tendon ruptures and chronic Achilles tendinopathy. The tendon is often secured to the calcaneus either through a bone tunnel or by an interference screw. We hypothesized that tenodesis using the bone tunnel method would be mechanically superior to interference screw fixation for flexor hallucis longus transfers. Eight matched pairs of cadaveric specimens were assigned randomly to the bone tunnel or interference screw technique and were loaded to failure. Biomechanical analysis was performed to evaluate the ultimate strength, peak stress, Young's modulus, failure strain, and strain energy. Unpaired comparison, paired comparison, and linear regression analyses were used to determine statistical significance. A slight 22% ± 9% decrease in Young's modulus and a 52% ± 18% increase of strain energy were found in the interference screw group. However, no differences in ultimate strength, peak stress, or failure strain were seen between the 2 groups on paired comparison. Our findings suggest that interference screw fixation provides similar spontaneous biomechanical properties to the use of a bone tunnel for flexor hallucis longus transfer to the calcaneus. The interference screw is a practical option for fixation of the flexor hallucis longus tendon to the calcaneus and can be performed through a single incision approach.     

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report.

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.     

拇长屈肌腱断裂修复方法选择的探讨

[目的]介绍拇长屈肌腱断裂的治疗方法。[方法]共治疗拇长屈肌腱断裂15例，拇长屈肌腱断裂残端小于0．5cm，则给予切除，末节指骨钻孔钢丝缝合固定；肌腱断裂部位距掌指关节1cm以内，应用肌腱劈开延长，吻合口避开拇长屈肌腱鞘狭窄区；其余行直接吻接。[结果]所有病例均获得满意疗效，无术肌腱粘连和断离的发生。[结论]本方法修复肌腱获得了较好的效果，值得选用。     

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.     

拇长屈肌腱转位结合挤压螺钉重建KuwadaⅣ型陈旧性跟腱断裂

目的:探讨拇长屈肌腱转位后应用挤压螺钉重建陈旧性KuwadaⅣ型跟腱断裂的临床效果。方法:回顾性分析2010年9月至2012年6月,拇长屈肌腱转位后采用挤压螺钉固定重建26例陈旧性跟腱断裂患者的临床资料,其中男18例,女8例;年龄20～66岁,平均44.2岁。所有患者为单侧损伤。MRI显示跟腱断端距离为6.0～9.0 cm.观察术后并发症情况,并采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分及Leppilahti跟腱修复评分进行评价疗效。结果:26例获得随访,时间18～68个月,平均30.4个月。术后无神经损伤及切口感染,所有患者切口Ⅰ期愈合。术后踝关节外形及功能恢复良好,AOFAS踝与后足评分由术前52.27±12.30提高至术后90.92±6.36(t=-18.26,P<0.05).Leppilahti跟腱修复评分术前34.23±12.86提高至术后90.00±5.10分(t=-22.67,P<0.05).结论:拇长屈肌腱转位后应用挤压螺钉固定来重建陈旧性KuwadaⅣ型跟腱断裂具有操作简单,术后恢复快、肌腱固定牢靠、并发症少的优点。     

Closed subcutaneous rupture of the flexor hallucis longus tendon. Case report and review of the literature

A case of complete closed rupture of the flexor hallucis longus (FHL) tendon at the level of the first metatarsal head in a young athlete is discussed. In the absence of systemic diseases as predisposing factors, this injury is a rare event. Available literature reports eight cases, only one of which showed the same lesion pattern as in the case we describe. As termino-terminal tendon suture was impossible, a suture of the FHL distal caput on the flexor hallucis brevis tendon was performed. This avoided hyperextension of the distal phalanx and achieved the overall plantar flexion of the big toe. Received: 4 October 2000; Accepted: 8 November 2000     

Blood supply of the flexor hallucis longus tendon with regard to dancer's tendinitis: injection and immunohistochemical studies of cadaver tendons

The flexor hallucis longus is the most common site of lower extremity tendon disorders in ballet dancers. Reduced vascularity is an important factor contributing to tendon degeneration and rupture under strain. A study was conducted on the vascular pattern of the human flexor hallucis longus tendon with injection techniques and immunohistochemically by using antibodies against laminin. Blood supply arose from the posterior tibial and the medial plantar artery. Peritendinous blood vessels penetrated the tendon and anastomosed with a longitudinally oriented intratendinous network. Injection specimens and immunohistochemistry revealed one avascular zone in which the tendon passed behind the talus and a second in which the tendon wrapped around the first metatarsal head. These are the most typical areas for tendon degeneration and rupture.     

V-Y推进结合踇长屈肌腱转位修复KuwadⅢ型慢性跟腱损伤的疗效观察

目的：探讨V-Y推进结合踇长屈肌腱转位修复Kuwad Ⅲ型慢性跟腱损伤的手术技巧和临床疗效。方法选择2012年2月-2014年2月收治的26例慢性跟腱断裂患者,其中男20例,女6例;年龄18~65岁,平均34.6岁,术中跟腱清创后腱缺损为3~5 cm。采用有限切开V-Y推进结合踇长屈肌腱转位进行治疗,记录损伤愈合时间及相关并发症,并比较术前与末次随访时美国骨科足踝外科协会后足评分、疼痛视觉模拟评分量表及Leppilahti跟腱修复评定标准评分,采用配对样本t检验。结果21例患者术后获12~26个月(平均16.4个月)门诊随访,5例失访。患者切口均一期愈合,无感染、神经损伤及跟腱再断等并发症发生。术后MRI示跟腱愈合时间平均为12周,挤压螺钉骨化时间平均为18个月。末次随访时,21例患者美国骨科足踝外科协会中足评分由术前平均(52.6±15.4)分上升至(96.8±2.5)分;疼痛视觉模拟评分量表评分由术前平均(5.71±1.56)分降低至(1.24±0.44)分;依据Leppilahti跟腱修复评分从术前(68.56±7.43)分提高到术后(92.58±5.1)分。以上项目术前与末次随访时比较差异均有统计学意义(均P<0.05)。结论 V-Y推进结合踇长屈肌腱转位治疗慢性跟腱损伤较适合断端缺损在3~5 cm间的患者,该方法操作简单、并发症少,是一种安全、有效的手术选择。     

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.     

Flexor hallucis longus dysfunction: an overview

Whereas acute and chronic injuries of the tibialis posterior, peroneal and Achilles tendon are frequently encountered, disorders of the flexor hallucis longus tendon are often overlooked, which may contribute to chronic pain and disability. Patients with stenosing tenosynovitis of the flexor hallucis longus tendon frequently present with overlapping signs and symptoms of flexor hallucis longus tendinitis, plantar fasciitis and tarsal tunnel syndrome, which the authors collectively refer to as "flexor hallucis longus dysfunction." A keen awareness of the presenting signs and symptoms and use of ancillary MR imaging and FHL tenography will assist the practitioner in recognizing this commonly misdiagnosed condition.     

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.     

Flexor tendon ruptures in the rheumatoid patient

In patients with rheumatoid arthritis, flexor tendon ruptures are much less common than extensor tendon ruptures. The most common cause of flexor tendon rupture is direct abrasion on a bony prominence. The most common flexor tendon rupture is the flexor pollicis longus (FPL) attritional rupture within the carpal canal. The best treatment for flexor tendon rupture is prevention. Flexor tenosynovectomy is indicated when medical management does not control wrist tenosynovitis. A variety of techniques are available for reconstruction of flexor tendon ruptures. Irrespective of the reconstructive method, the results of reconstruction for rheumatoid flexor tendon rupture are poor.     

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.     

Flexor carpi radialis tendon rupture as a complication of a closed distal radius fracture: a case report

Although extensor pollicis longus tendon ruptures have been noted as a complication of distal radius fractures, flexor tendon ruptures in association with acute fractures of the distal radius are rare. We report a rupture of the flexor carpi radialis tendon as a complication of an acute distal radius fracture that was discovered during operative management of the fracture.