Flexor Hallucis Longus Tendon Research Articles

“Foot peak pressures are comparable to normal foot after flexor hallucis longus transfer for chronic retracted tendo-achilles tear: A pedobarographic analysis of normal foot versus affected foot”

IntroductionFoot pressure changes and morbidity after flexor hallucis longus (FHL) transfer in chronic retracted tendoachilles (TA) tears have not been documented. The primary aim of our study is to analyze the peak pressure changes in various zones of the foot at each successive follow-up in the affected foot versus normal foot. The secondary aim is to determine FHL tendon healing and muscle hypertrophy. MethodsThis is a prospective study of 46 patients who underwent FHL augmentation for chronic retracted TA tears (between 2019 and 2022). Included TA tear > 6 weeks duration and retraction > 2.5 cm. Excluded open TA tear, < 6 weeks and retraction < 2.5 cm. Depending on the amount of retraction, FHL augmentation combined with TA repair/VY plasty/turn-down-plasty. Functional outcome was analyzed with AOFAS hallux metatarsophalangeal scale. Pedobarographic analysis was done pre-operatively and at 3, 6, 9 months, 1 year and at the final follow-up. Parameters studied included forefoot peak pressure (FFPP), hindfoot peak pressure (HFPP), great toe peak pressure (GTPP), first Mmeta-tarso phalangeal peak pressure (MTPP), area under the pedobarograph and maximum force. At final follow-up MRI was done to assess FHL healing and hypertrophy. Statistical analysis was done for these parameters using appropriate tests. ResultsStudy involved 29 male and 17 female patients, mean age 49.5 years (33–65 years) and mean follow-up 26.8 months (14–38.4months). Mean hallux MTP-AOFAS score increased from 46.04 ± 7.31 preoperatively to 96.17 ± 3.22 at the final follow-up (P < 0.01). There was gradual improvement noted in FFPP, GTPP, MTPP Peak pressures at subsequent follow-ups, and by the end of 1-year foot pressures were comparable to normal side FFPP (8.02 ± 3.8 N/cm2 to 31.35 ± 3 N/cm2), GTPP(30.78 ± 13.01 N/cm2 to23.17 ± 7.5 N/cm2), MTPP(5.22 ± 2.64 N/cm2 to 23.3 ± 9.6 N/cm2). Initial high HFPP showed decline in subsequent follow-up and restored back to normal HFPP (36.91 ± 5.7 N/cm2 to 25.09 ± 3.7 N/cm2). Changes in pressures were statistically significant (< 0.001). Six patients had superficial wound infections healed with antibiotics. 23 patients who underwent a post-operative MRI showed a mean of 27 mm muscle thickness and 7.1 mm tendon thickness with complete incorporation of the FHL. ConclusionFoot peak pressures though initially deranged, are restored and comparable to normal foot after FHL transfer for chronic retracted TA tear. FHL hypertrophy is observed at the muscle thickness and at the distal tendon and provides adequate strength to repair and restore foot pressures. Level of evidence IIIProspective comparative study (normal versus operated foot).

Endoscopic flexor hallucis longus tendon transfer with horizontal calcaneal fixation and suturing onto itself

Endoscopic flexor hallucis longus (FHL) tendon transfer to replace the calcaneal tendon is being increasingly performed. The main advantage is minimisation of approach-related morbidity. Fixation of the FHL tendon is usually achieved with a tenodesis screw placed in a vertical calcaneal tunnel. Here, we describe an endoscopic technique with FHL fixation by tenodesis in a horizontal calcaneal tunnel combined with suturing of the tendon onto itself. Level of evidenceIV.

Impact of Dual-Energy Computed Tomography (DECT) Postprocessing Protocols on Detection of Monosodium Urate (MSU) Deposits in Foot Tendons of Cadavers.

To evaluate two different dual-energy computed tomography (DECT) post-processing protocols for the detection of MSU deposits in foot tendons of cadavers with verification by polarizing light microscopy as the gold standard. A total of 40 embalmed cadavers (15 male; 25 female; median age, 82 years; mean, 80 years; range, 52-99; SD ± 10.9) underwent DECT to assess MSU deposits in foot tendons. Two postprocessing DECT protocols with different Hounsfield unit (HU) thresholds, 150/500 (=established) versus 120/500 (=modified). HU were applied to dual source acquisition with 80 kV for tube A and 140 kV for tube B. Six fresh cadavers (4 male; 2 female; median age, 78; mean, 78.5; range 61-95) were examined by DECT. Tendon dissection of 2/6 fresh cadavers with positive DECT 120 and negative DECT 150 studies were used to verify MSU deposits by polarizing light microscopy. The tibialis anterior tendon was found positive in 57.5%/100% (DECT 150/120), the peroneus tendon in 35%/100%, the achilles tendon in 25%/90%, the flexor halluces longus tendon in 10%/100%, and the tibialis posterior tendon in 12.5%/97.5%. DECT 120 resulted in increased tendon MSU deposit detection, when DECT 150 was negative, with an overall agreement between DECT 150 and DECT 120 of 80% (p = 0.013). Polarizing light microscope confirmed MSU deposits detected only by DECT 120 in the tibialis anterior, the achilles, the flexor halluces longus, and the peroneal tendons. The DECT 120 protocol showed a higher sensitivity when compared to DECT 150.

Flexor hallucis longus tendon morphology in dancers clinically diagnosed with tendinopathy.

The unique demands of dance technique make dancers more prone to certain pathologies especially of the foot and ankle. Flexor hallucis longus (FHL) tendinopathy, colloquially known as "dancer's tendinopathy," is common in dancers and not well studied. The purpose of this study was to assess if morphological alterations in tendon structure occur as an adaptive response to dance activity by comparing the FHL tendon in dancers to non-dancers, and if pathology further alters tendon morphology in dancers clinically diagnosed with tendinopathy. Three groups of ten participants were recruited (healthy non-dancers, healthy dancers, and dancers with FHL tendinopathy). Ultrasound images of the FHL tendons were analyzed for macromorphology by measuring the tendon thickness. The micromorphology was analyzed by determining the peak spatial frequency radius of the tendon. Our study did find increased tendon proper and composite tendon thickness in dancers with tendinopathy but no difference between asymptomatic dancers and non-dancers. There was no significant difference in micromorphology found between any of the groups. As expected, dancers with tendinopathy demonstrated increased composite tendon and tendon proper thickness however, there was no evidence of adaptive thickening of the FHL tendon as might be expected for the dance population. There was also no evidence of micromorphological changes in the presence of clinically diagnosed FHL tendinopathy. Because of the limited normative data for this pathology, these results can help improve diagnosis and therefore treatment for dancers to decrease the impact of this injury on their careers.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review.

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.

Endoscopically Assisted Percutaneous Harvesting of the Flexor Hallucis Tendon in Zone 2: An Anatomical Study.

Flexor hallucis longus (FHL) transfer is a well-established method for treating chronic Achilles tendon ruptures and tendinopathy. Harvesting of the FHL tendon in zone 2 results in greater length but is also associated with an increased risk of injury to the medial plantar nerve and requires an additional plantar incision. Because of the anatomic proximity of the FHL tendon to the tibial neurovascular bundle in zone 2, the purpose of this study was to investigate the risk of vascular or nerve injury with arthroscopic assisted percutaneous tenotomy in zone 2 of the FHL tendon. Endoscopically assisted percutaneous FHL transfer was performed on 10 right lower extremities from 10 cadaveric human specimens. The FHL tendon lengths and the relationship between FHL tendon and the tibial neurovascular bundle at zone 2 was analyzed. We observed a complete transection of the medial plantar nerve in 1 case (10%). The mean length of the FHL tendon was 54.7 ± 9.5 mm and the mean distance from the distal stump of the FHL tendon to local neurovascular structures was 1.3 ± 0.7 mm. There is a risk of neurovascular injury after endoscopic FHL tenotomy in zone 2. The tenotomy site is within 2 mm of the local neurovascular structures in the majority of cases. The additional length gained from this technique is unlikely to be required for the majority of FHL tendon transfer procedures. If additional length is needed, we would recommend the use of intraoperative ultrasonography or a mini-open approach to minimize injury risk. Level V, expert opinion.

Transfer of the Flexor Hallucis Longus Tendon for Neglected and Degenerative Tendo Achillis Rupture: A Prospective Clinical Study

Transfer of the Flexor Hallucis Longus Tendon for Neglected and Degenerative Tendo Achillis Rupture: A Prospective Clinical Study

MRI evaluation of interconnections between flexor hallucis longus and flexor digitorum longus around the Master knot of Henry.

To demonstrate the magnetic resonance imaging (MRI) findings of interconnections between flexor hallucis longus (FHL) and flexor digitorum longus (FDL) around the Master knot of Henry (MKH). Fifty-two MRI scans of adult patients were retrospectively analyzed. The types and subtypes of interconnections between the FHL and FDL were evaluated using the classification suggested by Beger et al based on the direction and number of the tendon slips and contributions to the lesser toes. The layering organization formed by the FDL, quadratus plantae, and tendon slip from the FHL was evaluated. The distance between bony landmarks and the branching site of tendon slips and the cross-sectional area (CSA) of the tendon slips were measured. Descriptive statistics were reported. MRI scans revealed that type 1 interconnection was the most common (81%), followed by type 5 (10%) and types 2 and 4 (4% each). All tendon slips from the FHL contributed to the second toe, and 51% of the tendon slips contributed to the second and third toes. For the layering organization, the two-layered type was the most common (59%), followed by the three-layered (35%) and single-layered (6%) types. The mean distance between the branching site and bony landmarks was longer in the FDL to FHL cases than that in the FHL to FDL cases. The mean CSA of the tendon slips from the FHL to FDL was larger than that of the FDL to FHL. MRI could provide detailed information about the anatomical variations around the MKH. In lower extremity reconstruction surgery, the flexor hallucis longus and flexor digitorum longus tendons serve as donor tendons. A preoperative MRI scan could provide information on anatomical variations around the Master knot of Henry, which can help predict postoperative functional outcomes. • Normal anatomical variations around the Master knot of Henry were not extensively studied in the radiology literature before. • MRI identified the various types, sizes, and locations of interconnections between the flexor digitorum longus tendon and the flexor hallucis longus tendon. • MRI is a useful noninvasive tool for evaluating the interconnections between the flexor digitorum longus tendon and the flexor hallucis longus tendon.

Closed atraumatic flexor hallucis longus tendon rupture following hallux valgus correction repaired using a turn down flap

A case report of closed atraumatic rupture of flexor hallucis longus (FHL) tendon few months after hallux valgus correction in a high functioning individual is presented. There have been only two cases of FHL tendon rupture reported following hallux valgus correction in literature till now. Our patient underwent Hallux valgus corrective osteotomy, 4 months after which he presented with rupture of the FHL tendon, he subsequently underwent successful surgical turn down flap repair with good clinical outcome. Closed atraumatic rupture of FHL tendon as an isolated injury is a rare event evidenced by systematic review reporting only 10 cases in literature till now. Low clinical suspicion of FHL rupture in closed foot injuries could be one factor resulting in fewer cases being reported in literature. Acute rupture of FHL tendon following open foot injuries and partial closed rupture due to tendinitis in dancers have been reported frequently in literature. In conclusion, we emphasize careful handling of FHL tendon while performing corrective osteotomy of the hallux in any patient. Although, turn down flap is a well-documented technique to bridge gaps and repair chronic tendo-achilles rupture, we were able to replicate the same technique in our patient and produce good functional result using this effective tendon repair technique to bridge segmental gap as evidence by return of almost normal power of great toe plantar flexion.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

The AIUM Practice Parameter for the Performance of the Musculoskeletal Ultrasound Examination.

Short-term efficacy of posterior ankle arthroscopy and tendoscope on ankle-derived flexor hallucis longus ganglion

Objective: To investigate the short-term clinical efficacy of posterior ankle arthroscopy combined with tendoscope on ankle-origin flexor hallucis longus tendon ganglion. Methods: A follow-up study. Clinical data of 10 patients with hallux ganglion underwent posterior ankle arthroscopy combined with flexor hallucis longus tendoscope in the Tianjin First Central Hospital from January to June 2021 were analyzed retrospectively. There were 5 males and 5 females with a mean age of 42.7 (22-54) years. Disease distribution: 6 patients were on the right side and 4 cases were on the left side. The mean preoperative course of disease was 19.4 months (2-48 months). The patients were followed-up for a mean time of 12.4 months (8-20 months). The relationship between the origin of hallux ganglion and ankle joint was confirmed by ankle MRI and arthrography of ankle joint before the operation. During the operation, the joint capsule was explored, cleared and opened under the posterior ankle arthroscopy firstly, and then part of the tendon sheath of the forefoot was cleared and cut under the flexor hallucis longus tendoscope. American Orthopedic Foot and Ankle Society (AOFAS) forefoot rating scale and visual analogue scale (VAS) of pain were used to evaluate the clinical outcome before and after operation. Postoperative recurrence, perioperative and long-term complications were recorded spontaneously. Results: The cystic fluid signal of all patients could be traced from flexor hallucis longus tendon to the back of ankle joint by MRI before the operation. Intraoperative radiography showed that contrast media flowed from the back of ankle joint to the end of the hallux. The AOFAS score [M(Q1, Q3)] of the patients increased from 70.5(69.0, 87.8) before the operation to 100.0(85.8, 100.0) at the follow-up (P=0.002), and at the mean time, the VAS score decreased from 5.0(3.5, 6.0)to 0.5(0.0, 1.3) (P<0.001). No complications such as infection and recurrence occurred in all patients until the last follow-up. Conclusion: Posterior ankle arthroscopy combined with minimally invasive technique of tendoscope can treat ankle-origin flexor hallucis longus tendon ganglion effectively.

Reconstruction of Chronic Insertional Achilles Tendon Rupture Treated by Surgical Repair using Interference Screw and Augmentation with Flexor Hallucis Longus Tendon Transfer

Reconstruction of Chronic Insertional Achilles Tendon Rupture Treated by Surgical Repair using Interference Screw and Augmentation with Flexor Hallucis Longus Tendon Transfer

Fracture of The Sustentaculum Tali: Features and Surgical Management for Fracture Reduction

Sustentaculum tali is a horizontal shelf-like projection on the medial part of the calcaneum. The medial facet articulates to the talus and supports the medial column of the foot. The spring ligament originates at the plantar aspect of sustentaculum tali, and flexor hallucis longus passes below it and indirectly supports the longitudinal arch of the foot. Sustentaculum tali is a strong cortical bone, so its isolated fracture is unusual. Therefore, the fracture of the sustentaculum tali is easily misdiagnosed. The patients complain of pain below the medial malleolus and also on passive movement of the flexor hallucis longus tendon. The patient has a history of falls from height with the foot supinated or associated talus fracture. Sustentaculum tali fractures are sometimes considered to be extra-articular fractures. CT scan helps diagnose the intraarticular medial facet involvement in this fracture and is now regarded as intra-articular. Need of the study is to make the clinicians aware that these fractures, even if rare, do happen, if mismanaged, may lead to complications like impingement of flexor hallucis longus, post-traumatic arthritis etc. The study aimed to identify the clinical features and diagnosis of sustentaculum tali fracture and its management to prevent complications. Surgical reconstruction of the sustentaculum tali with a direct medial approach and fixation with cannulated cancellous screws. Ten patients were operated on in the last five years, and seven patients showed up for follow-up and had excellent results per the AOFAS scoring system. All of the fractures had signs of radiological union by the end of the third month. In Conclusion, Sustentaculum tali fracture, when suspected, should not be ignored, and the fracture must be fixed surgically. The current aspect of surgical fixation is befitting and should not be disregarded.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Positional and dimensional relation of tendons around the first metatarsal bone with hallux valgus

It was aimed to reveal whether the positions and dimensions of the extrinsic and intrinsic muscle tendons related to the hallux around the first metatarsal bone are affected by the severity of hallux valgus (HV) and whether tendon positional changes and tendon sizes affect each other. In formalin-fixed 46 feet, three HV angle subgroups (normal, mild, and moderate/severe) were defined. Width, thickness, and cross-sectional area (CSA) of tendons of the extensor hallucis longus (EHL) and brevis (EHB), abductor hallucis (AH), and flexor hallucis longus (FHL) were measured. On the clock model created in coronal plane, positional variations of each tendon were determined. In the moderate/severe HV group, thickness and CSA of the EHB, width and CSA of the AH were smaller, compared to mild HV. Width and CSA of the FHL were smaller in moderate/severe HV than in the normal. Regardless of HV, the width and CSA of the FHL were greater in cases where the FHL was located more lateral, and the width of both FHL and AT were greater in cases where AH located was more plantar. The smaller tendon size of two intrinsic (one plantar and one dorsal) and one extrinsic muscle in the moderate/severe HV group indicates that changes in the tendons are evident in cases of high severity of HV but not in cases of mild HV. Accordingly, the changes do not appear to be due to a factor limited to only one aspect of the foot. It is recommended to consider the possible biomechanical effects of AH, FHL, and EHB tendon dimensional weakness in surgical planning in moderate/severe HV cases.

Calf muscle evaluation during rehabilitation after flexor hallucis longus tendon transfer in neglected achilles tendon rupture: A case report

Introduction: Neglected achilles tendon rupture is generally defined as a rupture with a delay of more than 4 weeks prior to diagnosis or treatment. Difficulties in management make it one of the challenging problems in orthopedic practice. They have a greater tendency to develop complications and slightly poorer functional outcomes than patients with an acute rupture. Method: This case report features a case of 30 years old female with 3 months of neglected achilles tendon rupture after landing in the wrong position while playing badminton. The patient complains of continuous pain and inability to move her ankle downward, making walking difficult. On physical examination and CT imaging, we found achiles tendon rupture with significant gap and calf muscle atrophy. The patient was then managed operatively by debridement and tendon repair with flexor halucis longus tendon transfer. Result: Follow up 3 months post-operative, found a difference in calf muscle circumference in both legs. At the same time, there is still an improvement in active ROM ankle plantarflexion and positive single heel raise test on the affected side. The functional outcome measured by ATRS obtained 80 points, and AOFAS ankle-hindfoot scales with a value of 91 points. Discussion: With several advantages, FHL tendon transfer is the currently used technique for neglected cases of achiles tendon rupture. Despite long immobilization will induce other complications. Good operative techniques and accelerated rehabilitation are still recommended to gain good functional outcomes for the patient.

Talocalcaneal Coalition Resection in the Adult Population: A Systematic Review.

Tarsal coalition is a congenital malformation of the tarsal bones of the foot that typically presents with features such as pain, recurrent sprains, and flat foot in childhood. In a small number of patients, a delayed presentation may be apparent, with symptoms instead presenting in adulthood. The most commonly accepted hypothesis is that the tarsal coalition becomes more symptomatic as the coalition progressively ossifies. To this date, no author has systematically evaluated the literature to identify the best approach when surgically managing these patients, in particular concerning the resection of the coalition.This study aims to systematically review the literature, searching EMBASE, MEDLINE, Web of Science, Google Scholar, and the Cochrane Library to identify and evaluate studies that presented an outcome for resection of the adult talocalcaneal coalition. Alongside overall outcomes, details on the extent of the coalition, surgical method, post-operative regimen, and presenting symptoms were extracted for each patient studied. This was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.With 72 patients, this is the largest evaluation of an adult tarsal coalition population to date. Our findings indicate that talocalcaneal coalition in adulthood presents differently from the classical peroneal spasm found in childhood. Better scores were reported for coalitions either managed with an endoscopic approach or with interposition of the flexor hallucis longus tendon. Despite some reported benefits in the literature, a trial of conservative management or the use of a rehabilitation regimen had a limited impact on the overall patient outcome.Tarsal coalition in adulthood requires rigorous clinical evaluation to identify appropriate management options. Resection of the coalition is a safe approach to definitively managing these patients, but consideration should be given to the surgical method to ensure each patient has the best outcomes. In particular, consideration should be given to using an endoscopic approach or interposition of the flexor hallucis longus tendon in order to achieve the best patient outcomes. However, there remains a paucity of literature evaluating this demographic and further high-impact studies are required to comprehensively evaluate this population.

Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation andmay improve functional outcome.

Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation. Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24months. The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2min, p < 0.001). At 24months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24months (435 ± 37.9 vs 436 ± 39.7N, n.s.). Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome. Level II.

Neglected tendoachilles tear treated with flexor hallucis longus tendon transfer

Background: Neglected tendoachilles tear is one of the common condition that surgeons encounter and also difficult to manage. In Indian setting the most common reason for tendoachilles tear is lavatory pan injury, followed by road traffic accident. Various methods of treating neglected tendoachilles tear are described in literature but no single method is stated as ideal.Aim: The purpose of this study is to evaluate the technique, difficulties and functional outcome of neglected tendoachilles tear treated with flexor hallucis longus tendon transfer.Materials and Methods: 10 Patients with neglected tendoachilles tear (>4 weeks) are treated with flexor hallucis longus tendon transfer are included in this study. Pre-operative evaluation done both clinically and radio logically. All patients are followed up for a maximum period of 9 months and evaluated at 2 weeks,1,3,6, and 9 months. During follow-up all patients are evaluated using American Orthopaedic Association Foot and Ankle Score.Results: All patients with neglected tendoachilles tear treated with flexor hallucis longus tendon transfer showed an average AOFAS score of 88 and was able to do single heel raise test. All patients have difficulty in hallux interphalangeal joint flexion, but no patients have difficulty in doing day to day activities.Conclusion: Flexor hallucis longus tendon transfer for neglected tendoachilles showed good clinical outcome and patient’s satisfaction with insignificant and minimal complications.

Complete Closed Rupture of the Medial Bundle of the Flexor Hallucis Brevis Tendon Off the Medial Sesamoid Insertion

Category: Midfoot/Forefoot; Basic Sciences/Biologics; Sports; Trauma Introduction/Purpose: Flexor tendon injuries of the hallux are uncommon overall but when they happen, the flexor hallucis longus (FHL) tendon is the most frequent one affected. The rupture of FHL usually results from open injuries and deep cuts in the sole at the base of the toe;4 complete subcutaneous ruptures are extremely rare.5 There are around 36 cases reported of complete or partial closed ruptures of the FHL tendon along its entire course6 and the majority of the partial ruptures correspond to dancers and athletes.7 As far as FHB, we found a few reports of calcific tendinitis of the medial bundle and cases of calcifying tendinitis.8 To the best of our knowledge, this is the only case report of isolated closed rupture of the FHB tendon. Methods: A 33-year-old man, amateur soccer player, presented with mild swelling, ecchymosis, and increasing pain in the left hallux triggered by movement and palpation, relieved by rest. He sustained a direct axial blow and blunt force trauma with a soccer ball plus hyperextension. Standard bilateral weightbearing feet radiographs were normal. Physical exam revealed the left hallux normally aligned but with limited painful motion of 20° each way and no obvious instability. Palpation of the left first metatarsophalangeal joint was tender but not particularly over the sesamoids. MRI revealed an avulsion of the flexor Hallucis Brevis tendon off the proximal aspect of the medial sesamoid accompanied by fluid and edema, effusion in the first MTP joint and bone contusions in the first metatarsal head and dorsal base of the first proximal phalanx. Treatment with a toe spacer and postop sandal with the toe straight with an extension block was decided. Results: Tendon's blood flow around the sesamoids is limited making it susceptible to degenerative rupture. The most common mechanism of complete tendon rupture is direct open injury. Closed rupture is very rare and complete rupture in closed injury is even more. We did not find reports on third degree type of injuries, neither for any kind of isolated rupture of FHB. In our patient's case, dorsiflexion stretched all plantar soft tissue around the first MTP but he was able to do active movement of the great toe probably due to the FHL and lateral FHB insertion integrity. We found few reports of second-degree strain injury of FHL and FHB in a chronic setting, all treated conservatively with partial immobilization and strapping of the hallux to prevent extension. After conservative treatment at 3 months follow-up, our patient presented with no subjective complains, normal motion, stability and alignment of the hallux. Conclusion: Despite an extensive literature search, we did not find a similar injury, and this is probably the first time it is described. As found in our research, the most common injury related to the flexor tendons of the hallux are in soccer players and involve the FHL or both.23 These findings made us conclude that these injuries are either under-diagnosed or exceptional.