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.     

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.     

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.     

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.     

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.     

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.     

Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis

Hyperextension of the metatarsophalangeal joint is the key component of claw toe deformity. We describe an arthroscopic technique to stabilize the plantar plate and reduce the metatarsophalangeal joint. Under arthroscopic guide, the dorsal capsule is released. The plantar plate is anchored and sutured to the extensor digiturum longus tendon. In case of overriding toe deformity, the medial capsule is also reduced and lateral capsule is plicated under arthroscopic guide     

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.     

Partial extensor carpi radialis longus turn-over tendon transfer for reconstruction of the extensor pollicis longus tendon in the rheumatoid hand: case report

Reconstruction of a distally ruptured extensor pollicis longus tendon in the rheumatoid patient generally involves a tendon transfer or intercalary graft. We present an alternative technique using the radial half of the extensor carpi radialis longus as a turn-over graft. Using the turn-over technique with a half-slip of the extensor carpi radialis longus avoids the traditional limitations of the extensor carpi radialis longus tendon in distal extensor pollicis longus tendon repairs and precludes the need for a free tendon graft.     

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.     

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.     

Transfer der Extensor-digitorum-longus-Sehne zur Behandlung des flexiblen Digitus quintus varus superductus

Objective

Pain relief through realignment of the fifth toe by dorsomedial capsular release at the fifth metatarsophalaneal joint and transfer of the extensor digitorum longus tendon to the aponeurosis of the abductor digiti quinti muscle.

Indications

Flexible overlapping fifth toe deformity.

Contraindications

Fixed deformity. Angular toe deformity distal to the metatarsophalangeal joint (e.g. delta phalanx). Lateral drift of all lesser toes.

Surgical technique

Dorsolateral approach to the fifth metatarsophalangeal joint. Release of the dorsomedial capsule. Tenotomy of the fifth extensor digitorum longus tendon at the dorsum of the foot. Transfer of the distally based tendon around the proximal phalanx to the aponeurosis of the abductor digiti quinti muscle. Correction of the deformity by tensioning the tendon graft appropriately.

Postoperative management

Ambulation with full weightbearing in a postoperative shoe. Toe alignment dressing for 6 weeks.

Results

A total of 48 patients (56 feet; average age 37 years) with a flexible overlapping fifth toe deformity were followed up after soft tissue release and transfer of the extensor digitorum longus tendon; 40 patients (48 feet) were re-evaluated clinically after 11.4 months (range 9–26 months). Postoperative complications were sensory disturbance at the lateral side of the fifth toe (n?=?5), superficial wound slough (n?=?3). Follow-up results included broad and hypertrophic scars at the fifth metatarsophalangeal joint (n?=?16), physiological alignment of the fifth toe in 37 feet (77.1?%), overcorrection (interdigital space 4/5?>?3 mm) in 4 feet (8.3?%), undercorrection in 7 feet (14.6?%). In 4 feet the undercorrection could be attributed to a Tailor’s bunion deformity, which was not treated appropriately.     

Tendon graft donor sites

Each of 480 extremities from 120 cadavers was dissected. Particular attention was given to potential donors for tendon grafts. Both the palmaris longus and the extensor digiti minimi had an average length of 16 cm and an average width of 3 mm. The extensor indicis tendon averaged 13 cm in length and 3 mm in width. The plantaris and second toe extensors averaged 35 cm in length and 2 to 2.5 mm in width. None of these measurements correlated well with age, sex, or hand or foot size. There was, however, a high correlation between right- and left-side measurements in each specimen, in spite of some degree of anatomic variation for all the tendons studied. The palmaris longus was missing in 25% of the upper extremities, and the plantaris in 19% of the lower extremities dissected.     

Extensor pollicis longus tenosynovitis mimicking de Quervain's disease because of its course through the first extensor compartment: a report of 2 cases

We present 2 cases of extensor pollicis longus tenosynovitis caused by the unusual course of the extensor pollicis longus tendon. The extensor pollicis longus tendon passed through the first extensor compartment and was constricted severely. The symptoms were similar to those of de Quervain's disease. The clinical presentation, diagnosis, and surgical technique of this very rare anatomic condition are discussed.     

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.     

Spontaneous rupture of the extensor pollicis longus tendon

An extensor pollicis longus tendon, ruptured after treatment of a giant cell tumor of the distal radius by packing the cavity with polymethylmethacrylate cement. The lack of extension was treated successfully with tendon transfer of the extensor indicis proprius to the extensor pollicis longus. Pathophysiology of the rupture is discussed.     

足部皮瓣治疗多指指背复合组织缺损

目的 介绍足部皮瓣治疗多指指背复合组织缺损的临床应用.方法 临床应用7例19指,均为2～4指指背复合组织缺损伤,并伴有伸肌腱缺损及指骨或指间关节外露,并指后指背创面大小为5.0 cm×1.5 cm～9.0 cm×2.5 cm.以(足母)趾腓侧、跖侧界线及第一、二跖骨间隙为轴线设计皮瓣,形状同并指后指背创面,面积稍大.皮瓣切取时携带大隐静脉、趾背静脉和第一跖背、跖底动脉及神经,分别与相应患指指背静脉及指固有动脉、神经吻合.保留趾短或趾长伸肌腱于皮瓣内,以修复指背缺失的伸肌腱.结果 术后皮瓣全部存活,皮瓣质地及外形好,皮瓣两点分辨觉为6～8mm.患指伸指功能得到重建,主、被动屈伸活动恢复满意.足部供区瘢痕轻微,功能良好,外形美观.结论 足背、趾蹼及(足母)趾腓侧复合皮瓣是治疗多指指背复合组织缺损较好的方案之一.     

Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics

PURPOSE: The spatial relationship of the extensor pollicis longus (EPL) to the thumb carpometacarpal (CMC) joint may be altered by its transposition from the third dorsal wrist compartment and by subcutaneous extensor indicis proprius (EIP) to EPL tendon transfer. Changes in tendon position could alter thumb function. This study examined changes in the EPL adduction moment arm after EPL tendon transposition from its extensor compartment or EIP transfer. METHODS: The EPL adduction moment arm at the thumb carpometacarpal joint was determined under 4 tendon conditions: (1) intact extensor pollicis longus, (2) transposed extensor pollicis longus, (3) extensor indicis proprius to extensor pollicis longus tendon transfer through an extensor retinacular pulley, and (4) extensor indicis proprius tendon transfer through a subcutaneous route. Each tendon condition was tested in 2 wrist positions: neutral and 40 degrees of flexion. RESULTS: The wrist neutral/flexion moment arms for the 4 tendon conditions, in millimeters, were 9.2/7.3, 3.6/1.2, 8.3/5.1, and 4.8/1.0. CONCLUSIONS: EPL transposition produces a significant decrease of its adduction moment arm at the thumb CMC joint, an effect exacerbated by wrist flexion. The moment arm mechanics of the pulley and subcutaneous EIP tendon transfer resemble those of the intact and transposed EPL, respectively. Diminution of the adduction moment arm could impair thumb function, especially adduction.     

A new modification of extensor indicis proprius transfer to extensor pollicis longus using a retinacular pulley

A new modification of the extensor indicis proprius transfer to the extensor pollicis longus tendon through a fourth dorsal compartment retinacular pulley is described. This new modification has been assessed in cadavers biomechanically via computer simulation and in a limited number of patients with success. It affords the benefit over the standard subcutaneous extensor indicis proprius to the extensor pollicis longus tendon transfer of maintaining the adduction moment arm of the thumb. The moment arm mechanics of the pulley transfer resemble those of the intact extensor pollicis longus. Therefore this new modification offers better thumb function in both adduction and circumduction motions.