Flexor Hallucis Tendon Research Articles

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.

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.

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.

Arthroscopic, Single-Incision, and Double-Incision Approaches to Flexor Hallucis Longus Tendon Transfer Following Achilles Tendon Rupture: A Literature Review.

Achilles tendon rupture is a common athletic injury that results in a painful and antalgic gait. Flexor hallucis longus tendon transfer through arthroscopic, single-incision, or double-incision techniques is used as a treatment approach to address this rupture; however, no studies have compared postoperative complications between these three techniques. A systematic search of published articles was conducted using keywords "Achilles rupture," "flexor hallucis tendon," "transfer," and "recovery." Articles were then selected based on their title, abstract, and content following full-text review. From each article's reported surgical outcomes, a comparison was made between arthroscopic and single- and double-incision postoperative complications using a χ2 test with significance set at a value of P < .05 followed by post hoc analysis. The arthroscopic approach maintained the lowest rate of postoperative complications, followed by the single- and double-incision techniques. A significant difference in the number of postoperative complications was found between all incisional approaches. The pairwise comparisons, however, could not identify which incisional approaches significantly differed between each other. A reduction in postoperative complications places arthroscopy and the single-incision techniques as the preferred approaches for flexor hallucis longus tendon transfer following an Achilles tendon rupture. Although current literature shows arthroscopy to be superior to single- and double-incision methods, this review demonstrates the need for a greater number of published cases using arthroscopy to establish significance regarding postoperative complications.

Rupture complète fermée du tendon du long fléchisseur de l’hallux

PurposeA closed rupture of the longus flexor hallucis tendon is rarely observed and has few publications. A direct suture is the more often the case. The clinical result at long term depend on the integrity of the brevis fexor hallucis tendon. On the other hand, an old rupture is more uncommon. ResultsA case report of a old closed rupture of the longus flexor hallucis tendon on young women, the authors performed an arthrodesis of the hallux articulation with an excellent result.

Stenosing tenosynovitis

Tenosynovitis refers to an inflammatory condition involving the synovial sheath of a tendon. Stenosing tenosynovitis is a peculiar entity caused by multiple factors, including local anatomy, mechanical factors, and hormonal factors. The main forms include de Quervain tendinopathy; trigger finger (stenosing tenosynovitis involving the flexor digitorum tendons); stenosing tenosynovitis of the extensor carpi ulnaris, extensor carpi radialis, or extensor comunis tendons; stenosing tenosynovitis of the flexor hallucis tendon; and stenosing tenosynovitis of the peroneal tendons. The cardinal finding on ultrasonography is the presence of a thickened retinaculum or pulley that constricts the osseofibrous tunnel through which the tendon runs.

Letter to the Editor: Surgical Technique: Medial Column Arthrodesis in Rigid Spastic Planovalgus Feet

To the Editor: I read with interest the article “Medial Column Arthrodesis in Rigid Spastic Planovalgus Feet” by de Moraes Barros Fucs et al. [1] published online in November 2011. The study introduced a surgical technique to perform medial column arthrodesis in feet with rigid spastic planovalgus. I agree this technique can achieve a successful medial column reconstruction by means of arthrodesis. However, I have several questions and concerns. First, rigid spastic planovalgus is a complex deformity involving the medial column, lateral column, and hindfoot [3]. Although surgical trends continue to evolve, many basic principles have endured. Lin and Myerson [3] emphasized that restoring the hindfoot-midfoot-forefoot relationships and muscle balance was critical to correct the entire planovalgus foot deformity. The technique of de Moraes Barros Fucs et al. appears not to address the hindfoot and they express no views regarding this part of the deformity. To my understanding, it is well accepted to correct severe hindfoot deformity by means of either triple arthrodesis or calcaneal osteotomy [3, 4]. Therefore, I question whether valgus deformity of the hindfoot existed preoperatively and postoperatively in the patients reported, or in those in whom the authors would think the procedure indicated. Do the authors have data regarding hindfoot deformities or any views regarding how to achieve comprehensive aligment with this technique? Second, Wunschel et al. [5] showed degeneration of the adjacent joints was inherent to the arthrodesis. Degenerative osteoarthrosis in joints adajacent to the medial column arthrodesis joint was not reported by de Moraes Barros Fucs et al. [1]. Did the authors find any such degenerated joints or transferrence of pain in the forefoot after medial column arthrodesis? Third, hardware frequently is associated with complications in foot operations [2]. In the lateral radiograph (Fig. 2B in the article by de Moraes Barros Fucs et al. [1]), the screw in the talar head was obviously too long. They did not mention pain and/or skin problems even though the hardware was likely palpable. Considering the plate was placed in the inferior facet of the medial column, I wonder whether there was any impingement between the tendon (flexor hallucis tendon, tibial posterior tendon, etc), nerve, or vessel and the plate. Did this patient or others have symptoms from hardware? Did any patients require hardware removal? If no patient had hardware-related problems, can the authors offer guidance regarding plate and screw placement to avoid the tendon, nerve, vessel injuries, and impingement? Finally, in terms of the details of the operative procedure, how did the authors deal with the insertions of the anterior tibial and posterior tibial tendons? They mentioned only the periosteum and cartilage were removed in the procedure. The anterior and posterior tibial tendons play important roles in maintaining balance of the foot with an intact subtalar joint in the authors’ technique. How were these insertions treated? Did any patients experience imbalance with time?

Ultrasound of the ankle.

Ultrasound of the ankle.

Flexor hallucis longus tendoscopy: a technical note

The course of the flexor hallucis tendon (FHL) is divided into three zones. Zone 1 is located behind the ankle joint, from the musculotendinous junction to the orifice of the tunnel underneath the sustentaculum tali. Zone 2 is located from the tunnel underneath the sustentaculum tali to the knot of Henry. Zone 3 is located from the knot of Henry to the tendon insertion to the base of the distal phalanx of the big toe. The zone 1 FHL tendon is examined with posterior ankle endoscopy with the posterolateral and posteromedial portals. The zone 2 FHL tendon can be examined through the posteromedial and the plantar portals. The zone 3 FHL tendon is examined with the toe flexor tendoscopy. By means of different endoscopic approach to the each zone of the FHL tendon, the complete course of the tendon can be examined from the musclotendinous junction to its insertion.

Treatment of Chronic Achilles Tendinopathy and Ruptures with Flexor Hallucis Tendon Transfer: Clinical Outcome and MRI Findings

In patients with chronic Achilles tendinopathy, augmentation with flexor hallucis longus (FHL) tendon transfer can be performed to improve pain and functional limitations. There are no reports of postoperative imaging for evaluating tendon integration, inflammatory alterations or degeneration of the FHL muscle. The purpose of this study was to evaluate postoperative MR imaging based on clinical outcome and isokinetic strength. 13 patients with chronic Achilles tendinopathy (10 ruptures) underwent augmentation with FHL transfer. Clinical parameters, isokinetic strength and outcome measurements (AOFAS, SF-36) were evaluated at an average followup of 46.5 months. Qualitative and quantitative analyses of postoperative MRI were conducted using the non-operated side for comparison. All patients had a significant reduction of pain. The operated side had a torque deficit of 35% for plantar flexion. Ten patients returned to their former level of activity. MRI showed a complete integration of the FHL tendon in six patients. Fatty atrophy in the triceps surae was found in ten patients. The FHL was free of degeneration in all patients. Hypertrophy of the FHL of more than 15% was observed in eight patients. Augmentation with FHL transfer is a valuable option in the treatment of chronic Achilles tendinopathy with and without rupture. Our results demonstrate high patient satisfaction without donor site morbidity. The FHL tendon is well integrated into the Achilles tendon. Hypertrophy of the FHL muscle suggests functional incorporation into plantar flexion. The primary benefit of the operation is pain relief and increased muscle strength.

Endoscopic assisted flexor hallucis tendon transfer in the management of chronic rupture of Achilles tendon

Operative treatment is indicated in the management of chronic Achilles tendon rupture. Reconstruction of chronic Achilles tendon rupture can be classified into end-to-end repair, tendo Achilles advancement or flap reconstruction, local tendon transfer and implantation with autografts, allografts or synthetic materials. Following debridement of the tendon ends and with retraction of the proximal tendon fragment, a large gap will be present and direct tendon apposition with physiological tension is usually not possible. Flexor hallucis longus transfer is indicated if the tendon gap is more than 5 cm. We describe an endoscopic assisted flexor hallucis longus transfer in order to minimize the soft tissue dissection.

Sectional anatomy of connective tissue structures in the hindfoot of the newborn child and the adult

Background The knowledge of the normal anatomy of the newborn hindfoot is essential for the understanding of foot deformities. In the present study, we investigated tendons, ligaments, and soft tissue structures in the newborn foot. Methods The sectional anatomy of eight newborn feet was studied in 300–500-μm-thick sections processed by plastination histology. For comparison, 3–5-mm-thick plastinated sheets of adult feet were investigated. Results Our specimens show obvious differences of the newborn compared with the adult foot. In the subcutaneous adipose tissue, the heel pad and the fat pad of the Achilles tendon and the relative size and topography of adipose tissue pads are different. Moreover, the course of the flexor hallucis tendon and the insertion pattern of the Achilles tendon are distinct. Finally, there are differences in the course and in the relative length of some plantar ligaments. Conclusions Our data reveal that the differences between the newborn foot and the adult foot result mainly from the different shape and position of the tarsal bones. Our findings are of clinical importance for the evaluation of magnetic resonance imaging in the normal infant's foot and in foot deformities. © 1996 Wiley-Liss, Inc.

Sectional anatomy of connective tissue structures in the hindfoot of the newborn child and the adult.

The knowledge of the normal anatomy of the newborn hindfoot is essential for the understanding of foot deformities. In the present study, we investigated tendons, ligaments, and soft tissue structures in the newborn foot. The sectional anatomy of eight newborn feet was studied in 300-500-microns-thick sections processed by plastination histology. For comparison, 3-5-mm-thick plastinated sheets of adult feet were investigated. Our specimens show obvious differences of the newborn compared with the adult foot. In the subcutaneous adipose tissue, the heel pad and the fat pad of the Achilles tendon and the relative size and topography of adipose tissue pads are different. Moreover, the course of the flexor hallucis tendon and the insertion pattern of the Achilles tendon are distinct. Finally, there are differences in the course and in the relative length of some plantar ligaments. Our data reveal that the differences between the newborn foot and the adult foot result mainly from the different shape and position of the tarsal bones. Our findings are of clinical importance for the evaluation of magnetic resonance imaging in the normal infant's foot and in foot deformities.

Das Os-trigonum-Syndrom

The os trigonum is one of the most frequent accessory bones of the foot. It is located dorsal of the talus. Os trigonum syndrome means a typical pain syndrome localized in the back-foot caused by this ossicle. This syndrome occurs mostly in man with sports activities accompanied with intensive stress to different parts of the foot. It can be caused particularly by standing on the toe in the "en-pointe-position" in ballet dancers when the flexor hallucis tendon is under maximal tension or by activities accompanied with maximal plan-tarflexion in soccer players for instance. Typical complaints, findings and different therapeutic procedures are demonstrated in two cases. Therapy includes different non-operative methods. Resistance to non-operative procedures is indication for operative therapy. Excision of this ossicle is surgical therapy of first choice.

Os Trigonum Syndrome: A Clinical Entity in Ballet Dancers

Thirteen Swedish National classic ballet dancers were surgically treated for an "os trigonum syndrome."Their main symptom was an impingement pain in the hind foot while actively plantarflexing the ankle during ballet dancing. The surgical procedure included excision of an os trigonum or a prominent lateral posterior process of the talus, together with division of the flexor hallucis tendon sheath if it was thickened. This procedure was safe and resulted in return of the dancers to the same level of ballet dancing within 5 to 10 weeks.