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     

(足母)长屈肌腱移位替代跟腱治疗跟腱缺损的疗效分析

目的 探讨(足母)长屈肌腱移位替代跟腱治疗6 cm以上跟腱缺损的疗效.方法 2005年1月至2009年2月采用(足母)长屈肌腱移位替代跟腱治疗19例跟腱缺损患者,男13例,女6例;年龄20～61岁,平均(42.6±8.2)岁;跟腱炎清创后跟腱缺损15例,其中10例合并急性跟腱断裂;陈旧性跟腱断裂4例.跟腱断裂至手术时间为0～6个月(平均2.6个月).跟腱缺损长度为6～10 cm.19例患者均采用两切口(足母)长屈肌腱移位替代跟腱术治疗.记录患者术后3个月、1年及末次随访时的踝关节活动度、美国足踝外科协会(AOFAS)踝与后足评分与视觉模拟法(VAS)疼痛评分,并进行统计学比较.评价患者术后足踝部功能的恢复情况及患者的满意度. 结果 19例患者术后获12～48个月(平均22.2个月)随访.患者末次随访时踝关节背伸、跖屈及AOFAS踝与后足评分平均分别为17.8°±1.9°、39.1°±2.3°及(91.8±1.7)分,与术后3个月比较差异均有统计学意义(P＜0.05),与术后1年比较差异无统计学意义(P＞0.05),术后3个月与术后1年比较差异有统计学意义(P＜0.05);VAS疼痛评分平均为(1.0±0.7)分,与术后3个月和术后1年比较差异均有统计学意义(P＜0.05),术后3个月与术后1年比较差异有统计学意义(P＜0.05).术后患者对手术满意率达100%. 结论 (口止母)长屈肌腱移位替代跟腱术是一种有效的手术方式,适用于跟腱较长缺损时的重建治疗.手术可以明显解除疼痛,改善足部功能,且对足部影响较小.     

微创切取长屈肌腱重建慢性跟腱断裂

目的探讨微创切取长屈肌腱转移重建慢性跟腱断裂的临床效果。方法 2006年7月-2009年12月,收治22例22足慢性跟腱断裂患者。男16例,女6例;年龄28～65岁,中位年龄48岁。21例有患足用力蹬地史,1例无明显诱因。患者出现症状至手术时间为27～1 025 d,中位时间51 d。均有走路无力症状,Thompson试验呈阳性。根据美国矫形足踝协会(AOFAS)踝与后足疗效评价标准评分为(53.04±6.75)分。MRI示跟腱缺损长度为4.2～8.0 cm。术中作中足足底内侧切口和趾间关节跖侧平行横纹的小切口分步切取长屈肌腱,切取长度为超过跟骨结节10.5～13.5 cm,作3束反折编织缝合。界面螺钉或锚钉于跟骨后结节固定肌腱。结果术后患者切口均Ⅰ期愈合,无早期并发症发生。22例均获随访,随访时间12～42个月,平均16.7个月。术后12个月根据AOFAS踝与后足疗效评价标准评分为(92.98±5.72)分,与术前比较差异有统计学意义(t=—40.903,P=0.000);获优18例,良2例,可2例,优良率90.9%。随访期间均未见胫、腓肠神经损伤、跖底部痛性瘢痕、足底内外侧神经损伤。结论微创切取长屈肌腱转移重建慢性跟腱断裂具有切口小、术后恢复快、肌腱固定强度高以及并发症少的优点。     

拇长屈肌腱转移修复陈旧性跟腱断裂

2007年9月～2010年9月,我科采用拇长屈肌腱转移修复陈旧性跟腱断裂10例,效果满意,报道如下。1材料与方法1.1病例资料本组10例,男7例,女3例,年龄20～53岁。左侧4例,右侧6例。跟腱断裂部位:止点部断裂3例,腱     

Flexor hallucis longus tendon branch test: Development and validation of a new method to assess anatomical variation of the tendinous slip

BackgroundThe flexor hallucis longus (FHL) muscle often has a tendinous slip with a variable number of branches. We aimed at developing the FHL branch test to determine the number of FHL branches.MethodsIn anatomical validation study, 6 intact cadavers were used. The toe flexion angles were measured while the FHL and flexor digitorum longus (FDL) were manually pulled individually. For electrophysiological studies, 4 healthy men participated. The FHL was electrically stimulated, and electromyography (EMG) of the FHL and FDL were recorded during the FHL branch test.ResultsThe toe flexion angles’ changes in the FHL pulling condition were equivalent with pulling FDL in toes with FHL branching. The electrical stimulation of the FHL produced similar flexion as the FHL branch test. EMG of the FHL was higher than FDL during the FHL branch test (p = 0.036).ConclusionsThe FHL branch test could be used to evaluate the number of FHL branches.     

A semi-quantitative technique to assess excursion of the flexor hallucis longus

BackgroundRecent research indicates that restriction in excursion of flexor hallucis longus (FHL) contributes to hallux rigidus development. As described in the literature, clinical evaluation of FHL excursion has poor interobserver reliability. A simple, inexpensive, easily used FHL relative excursion measurement device was developed and tested.Methods64 subjects were enrolled with shoe size, height, weight, BMI, and age compared. Using a footplate and series of mechanical wedges, maximum ankle dorsiflexion was measured with the great toe in 15°, 30°, and 45° of dorsiflexion.ResultsAnkle dorsiflexion decrease with progressive hallux dorsiflexion increase was statistically significant with a linear correlation (r² = .814 p < .001) and was not statistically related to shoe size, height, weight, BMI, or age.ConclusionsThis technique provides consistent assessment of the limitation to ankle dorsiflexion incurred by decreased FHL excursion, establishing groundwork for future studies to assess the relationship between diminished FHL excursion and FHL pathology.     

Hypertrophy of the flexor hallucis longus muscle after tendon transfer in patients with chronic Achilles tendon rupture

BackgroundFlexor hallucis longus tendon (FHLT) transfer has become a popular method for reconstructing a chronic Achilles tendon rupture (ATR). The purpose of this study was to evaluate the clinical outcomes and possible hypertrophy of the FHL muscle after FHLT transfer in patients with chronic ATR.MethodsSeven patients with chronic ATR underwent an FHLT transfer to heel through single incision. The patients were clinically evaluated 27 (16–39) months after the surgery. The patient satisfaction was assessed with Achilles Tendon Total Rupture Scale (ATRS). Isokinetic strength was measured from both legs. The FHL muscle hypertrophy was evaluated from MRI of both legs. All subjects also performed a gait analysis with an instrumented walkway system (GAITRite^®).ResultsThe plantar flexion strength was 16.1% (-45, 7-2, 4%) weaker in the operated leg. ATRS scores averaged 70.3. Marked hypertrophy, +52% (9–104%) of the FHL muscle was seen in the operated leg compared to the non-operated leg. The gait analysis did not show any marked pathology in any of the patients.ConclusionsA mean hypertrophy of 52% of the FHL muscle was found after FHLT transfer for the chronic ATR. This indicates strong adaptation capacity of this muscle after FLHT transfer in situation where the function of the gastro-soleus complex was severely impaired preoperatively. The reconstruction of chronic ATR with FHLT transfer provided a good functional outcome and excellent patient satisfaction.     

Entrapment of the flexor hallucis longus tendon following ankle arthrodesis

Impingement following arthroscopic ankle arthrodesis has not been reported in the literature previously. We present a case report of a 68-year-old male 9 months following an uncomplicated arthroscopic ankle fusion presenting with persistent posteromedial ankle pain. Flexor hallucis longus (FHL) tendon impingement resulting from a prominent os trigonum was identified. This was successfully treated utilising hindfoot endoscopy with excision of the os trigonum and FHL release.     

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.     

Dynamic medial column stabilization using flexor hallucis longus tendon transfer in the surgical reconstruction of flatfoot deformity in adults

BackgroundA common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column.MethodsWe retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated.ResultsAll radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon.ConclusionDMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity.     

Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction

BackgroundExtensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers.MethodsWe present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues.ResultsAt one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported.ConclusionsSecond EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible.Level of evidenceIV (Case Series).     

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.     

Patient reported outcomes and satisfaction following single incision Flexor Hallucis Longus (FHL) augmentation for chronic Achilles tendon pathologies

BackgroundVarious procedures exist to augment or reconstruct the Achilles tendon (AT) in patients suffering from chronic pathologies. The aim of this study is to assess patient reported outcomes and satisfaction following single incision FHL augmentation using a short tendon harvest with interference screw fixation.MethodsThis is a multicentre case series where postoperative patient reported outcome and satisfaction scores were collected on 30 patients. Outcome measures included EQ-5D, EQ-VAS, Achilles Tendon Rupture Scores (ATRS), and satisfaction scores. Scores were also collected on the unaffected limbs for comparison.ResultsMean patient age was 61 years (range 40–79, SD 11). Mean EQ-5D index value was 0.750 (0.100–1.00, SD 0.238), and mean EQ-VAS score was 74 (36–99, SD 15), at a mean follow-up of 57 months (4–118, SD 32). For patients with ≥24 months’ follow-up, a mean deficit of 16 ATRS points was found between the operated and unaffected limb. Overall satisfaction was over 86%. In cases of chronic AT rupture, younger age and increasing time from initial injury to surgery were predictors of greater residual deficit. No serious complications or failures occurred.ConclusionsFHL augmentation using short tendon harvest and interference screw fixation is a safe treatment option. It appears to take at least 24 months to functionally recover following this procedure, and despite a residual function deficit, there is a high level of patient satisfaction. Further studies are required to determine optimal patient selection and timing of surgery.     

长屈肌腱转位手术治疗老年跟腱断裂的疗效分析

背景：慢性跟腱疾病发展到后期往往需要行肌腱转位治疗,长屈肌腱转位手术是常用的治疗方式。但老年患者的功能恢复、生活方式有别于其他人群。目的：探讨长屈肌腱转位手术治疗老年人跟腱断裂的临床效果。方法：回顾性分析2007年9月至2012年7月在我院行长屈肌腱转位手术的老年患者的病例资料（＞60岁）。共14例（16足）,男女各7例,年龄60~83岁,平均67.1岁。2例女性患者为双侧跟腱断裂同时行手术修补,均采用单切口长屈肌腱转位替代跟腱疗法。分别评估患者术前与术后美国足踝外科协会踝-后足评分（AOFAS-AH）,美国足踝外科协会趾-跖趾-趾间关节评分（AOFAS-MTPIP）,视觉模拟法（VAS）疼痛评分,跟腱断裂评分（ATRS）及手术相关并发症情况。最后进行统计学比较,评价患者足踝部功能恢复情况及患者满意情况。结果：14例患者术后获得21~67个月随访。AOFAS-AH评分从术前（68.2±6.2）分提高到术后的（93.2±5.3）分;AOFAS-MTPIP评分术前为（94.2±2.9）分,术后为（95.1±3.2）分;VAS评分术前（5.1±1.4）分,术后为（1.0±0.7）分;ARTS评分从术前（52.7±9.3）分提高到术后（86.3±10.3）分。16足术后均未出现伤口感染等手术并发症,也未在围手术期出现肺部感染、深静脉血栓等其他并发症。结论：长屈肌腱转位手术在老年人中的应用不但具有很好的手术疗效,并且安全性较高。     

Der Flexor hallucis longus Transfer zur Revision von ausgedehnten Defekten der Achillessehne

Aim of the flexor hallucis longus transfer (FHL-transfer) is to bridge extended defects of the Achilles tendon. A part of the muscle belly is placed into the paratendon sheath which supports wound healing, especially in patients with critical soft tissues.In a series of 25 consecutive patients (m: 15, f: 10, average age 61 years (R: 37-79) it was possible to reconstruct the Achilles tendon function in all patients. The AOFAS Hindfoot Scale improved from 62 to 89 points. Especially in the category “pain”, the patients reached 38 of a maximum of 40 points. Compared to the healthy leg a limitation in maximum strength in plantar flexion was found (42 of a maximum of 50 points).     

Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores

PurposeChronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores.MethodIt is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50–77 years) followed by over 35.6 months (Range 22–48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits.ResultsAll the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22–48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.30⁰+ 4.9⁰ and 12.5⁰ + 4.7⁰ respectively. Three patients had minor wound complications. All the patients returned to activities of daily living.ConclusionFHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.     

Anatomy of Master Knot of Henry: A morphometric study on cadavers

Objective

The objective of this study was to evaluate the features of flexor hallucis longus (FHL), flexor digitorum longus (FDL) and flexor digitorum accessorius (FDA) muscles with relevance to the tendon grafts and to reveal the location of Master Knot of Henry (MKH).

Combined flexor hallucis longus tendon transfer and gastrocnemius recession for reconstruction of gapped chronic achilles tendon ruptures

ObjectiveThe aim of this study was to assess the functional outcomes after a combined FHL transfer and a gastrocnemius recession for treatment of chronic ruptures of Achilles tendon with a gap and to investigate the patient's satisfaction about the great toe function after transfer.Material and methods19 patients with chronic rupture of the Achilles tendon with a gap were treated with a flexor halluces longus tendon transfer combined with a gastrocnemius recession, Clinical diagnosis depends on the presence of gap in the tendon on examination, inability of tip toe walking on the affected side and positive calf-squeeze test, MRI was used to confirm the clinical diagnosis. American Orthopedic Foot & Ankle Society hind foot score was used for assessment of the results.ResultsThe AOFAS score improved significantly from a mean of 65 preoperatively to 94 at the last follow up (p < 0.001), there was no significant difference in the final outcome between patients with FHL tendon weaved through the stump of the Achilles tendon and those with trans osseous tunnels, the mean AOFAS score at the last follow up was 94.2, 93.8 respectively, no patient complained of big toe dysfunction.ConclusionManagement of chronic rupture of the Achilles tendon with a gap with flexor halluces longus tendon transfer combined with a gastrocnemius recession is a safe and reliable method with a significantly improved functional outcome, muscle advancement through gastrocnemius recession decreases the length of the gap without affecting the muscle function, flexor halluces longus tendon transfer doesn't harm the big toe function.