Tendon Subluxation Research Articles

Chronic Injury of Sagittal Band by Metacarpal Head Osteoma: A Case Report

Injury of the sagittal band, a crucial component of the extensor hood, can occur in various situations, including spontaneous events, trauma, and rheumatic diseases. This case presents a rupture of the sagittal band resulting from chronic irritation caused by a metacarpal head osteoma. A 22-year-old female presented with ulnar subluxation of the extensor tendon at the left third metacarpophalangeal joint, without any history of trauma or pain. Ultrasonography and computed tomography revealed a 1.7 mm-sized bony lesion on the radial side of the metacarpal head, accompanied by a partial tear of the radial sagittal band. Our hypothesis that chronic irritation of the sagittal band by the adjacent bony lesion led to the partial tear was confirmed by intraoperative findings. The lesion was excised, and the radial sagittal band was reconstructed. Histopathological examination confirmed a diagnosis of osteoma. To our knowledge, this is the first reported case of sagittal band rupture caused by an osteoma of the metacarpal head. This case underscores the importance of considering an underlying metacarpal head osteoma in patients with non-rheumatoid joints presenting, in the absence of a traumatic history, with a sagittal band rupture due to chronic irritation.

A case report: Surgical Release for De Quervain Syndrome after conservative treatment of distal radius fracture

Objective Describe the clinical and paraclinical characteristics of De Quervain Syndrome and the result of the surgery for De Quervain Syndrome after conservative treatment of distal radius fracture Subjects and methods A case report. Results De Quervain Syndrome is a condition that involves tendon entrapment affecting the first dorsal compartment of the wrist. It has been reported that De Quervain Syndrome can also develops after distal radius fracture. We report a case that the patient was diagnosed with De Quervain Syndrome after conservative treatment of distal radius fracture. During surgery we noticed that the patient had separated tendon sheaths for abductor pollicis longus (APL) and extensor pollicis brevis (EPB). EPB tendon sheath was released and reconstructed to prevent tendon subluxation. After 6 months, patient was feeling no pain and very satisfied. Conclusions De Quervain Syndrome development after distal radius fracture is rare. The successful surgery got the patient came back to work normally.

De Quervain's Tenosynovitis Release With Excision of the First Dorsal Compartment: Novel Surgical Technique and a Case Series.

Incision of the dorsal side of the tendon sheath in release of De Quervain's tenosynovitis has traditionally been advocated to prevent the risk of volar tendon subluxation. We describe a novel technique of complete excision, rather than simple incision, of the first dorsal compartment tendon sheath. Over a 10-year period, 147 patients (154 wrists) underwent first dorsal compartment release using this technique of complete excision of the sheath. No postoperative immobilization is used. Patients were followed for a mean of 7.0 months. Records were assessed for any complications including reoperation, tendon subluxation, recurrence, wound complications, scar tenderness, and superficial radial sensory nerve paresthesias. There were no cases of recurrence, reoperation, or tendon subluxation after release with this technique. Postoperatively, 7 (4.5%) patients had scar tenderness and 5 (3.2%) of these patients also had superficial radial sensory nerve parasthesias, which all resolved at the time of final follow-up. Mean range of motion was 73±11 degrees of flexion and 69±10 degrees of extension. In contrast to simple incision, we propose that this technique provides a more complete release of the compartment without risk of symptomatic subluxation or bowstringing and provides a complete release of a separate extensor pollicis brevis subsheath or any concomitant retinacular cysts associated with the tendonitis. There is an immediate removal of the symptomatic swelling and visible, painful bump associated with the thickened retinaculum with this technique. Furthermore, no immobilization is required after surgery.

Hanges in force generation by two-finger striking methods: An experimental study

Purpose: Acute sagittal injury in boxer’s knuckle causes extensor tendon subluxation. We analyzed anatomical measurements for posture-related hand parts and measured the force generated when striking the fingers.Methods: In 120 healthy adults (55 males, 65 females), the palm area, finger length, finger length, finger circumference, and wrist circumference were measured. Using a digital force gauge, the force generated by striking with finger flexion (FFF) performed by the middle finger was measured. The forces generated during extension flicking (FEFs) by the index and ring fingers were also measured. The forces exerted by the hand and fingers was measured using a grip force meter. The relationships of measured values with sex and age were statistically analyzed.Results: The FFF of the middle finger was 12.9±7.0 N, and the FEFs of the index and ring fingers were 6.8±2.5 N and 5.8±2.3 N, respectively. The grip force was 343.3±134.7 N in the four fingers excluding the thumb, 108.4±41.6 N in the index finger, 110.5±45.4 N in the middle finger, and 83.6±36.5 N in the ring finger. Males had higher FFF for the middle finger (17.9±6.6 N) than females (8.6±3.9 N) (p<0.001), and greater FEFs for the index (8.5±2.0 N) and ring fingers (7.1±2.2 N) compared to females (5.3±1.7 N and 4.7±.8 N, respectively) (p<0.001). Cross-analysis results showed differences by sex and age. The circumference of the index finger exceeded that of the ring finger.Conclusion: The study findings shed light on the relationship between the forces generated in the process of finger flicking.

Recurrent Traumatic Subluxation of Peroneal Tendons Surgically Treated with Semitendinosus Tendon Graft – Case Report

Recurrent Traumatic Subluxation of Peroneal Tendons Surgically Treated with Semitendinosus Tendon Graft – Case Report

Fascial Lengthening at the Time of Surgical Release for de Quervain's Tenosynovitis to Prevent Postsurgical Tendon Subluxation.

De Quervain's tenosynovitis is a relatively common, painful condition. Although commonly managed nonoperatively, some patients have recalcitrant disease, necessitating surgical release. Traditional surgical release for de Quervain's tenosynovitis with simple retinacular release can leave patients susceptible to first dorsal extensor compartment tendon subluxation. We present a stair-step flap technique that releases the first dorsal compartment while simultaneously preventing postoperative tendon subluxation via fascial lengthening. All patients over the past decade who underwent surgical release with this technique were collected. Preoperative characteristics, surgical details, and postoperative outcomes were reviewed and aggregated as summary statistics. A total of 101 patients were found. Of these, 35 patients had isolated first dorsal compartment release. Tourniquet time for the total group was 1 hour and that for the isolated first dorsal compartment release subgroup was 20 minutes. The average follow-up was 590 days for the total group and only 440 days for the isolated first dorsal compartment release subgroup. No patients who underwent our novel technique experienced subluxation of the tendons postoperatively. One patient required oral antibiotics for a superficial cellulitis, and 1 patient had recurrent symptoms due to excessive scarring that resolved with scar massage and steroid injection. No patient required repeat operations. Our study demonstrates that first dorsal compartment release with a stair-step incision allows for closure of the compartment with a very loose sheath without subluxation and simultaneously provides satisfactory decompression. This procedure is safe and efficacious and can be considered a useful modification to traditional retinacular release alone. Level III.

Outcomes following Peroneal Tendoscopy for Peroneal Tendon Disorders: A Systematic Review

Category: Other; Ankle Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical and radiological outcomes at short-term follow-up following peroneal tendoscopy for the treatment of peroneal tendon disorders. Methods: During October 2022, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following peroneal tendoscopy for the treatment of peroneal tendon disorders. Data regarding patient demographics, pathological characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. Results: Nine studies were included. In total, 264 patients (269 tendons) underwent peroneal tendoscopy for the treatment of peroneal tendon disorders at a weighted mean follow-up of 30.5±11.4 months. The peroneal tendon disorders included: peroneal tendon tear (89 patients), peroneal tenosynovitis (85 patients), low lying muscle belly (54 patients) and peroneal tendon subluxation (17 patients). The weighted mean AOFAS score improved from a pre-operative score of 76.0 to a weighted mean post-operative score of 96.0. The complication rate was 3.8%, the most common of which was persistent lateral ankle pain (1.1%). Two failures (0.007%) were reported, both of which underwent repeat peroneal tendoscopy, tenosynovectomy and low lying muscle belly resection. Conclusion: This systematic review demonstrated improvement in subjective clinical outcomes together with a low complication rate and low failure rate at short-term follow-up following peroneal tendoscopy for the treatment of peroneal tendon disorders. However, the level of evidence was low and the quality of evidence was poor. In addition, there was significant heterogeneity between the included studies. Further higher quality studies are warranted to determine the optimal role of peroneal tendoscopy for the management of peroneal tendon disorders.

Snapping ankles: peroneal tendon subluxation and dislocation.

Peroneal tendon dislocation or subluxation is an orthopaedic condition that usually occurs as a result of injury to the superior peroneal retinaculum. The peroneal muscles are located in the lateral compartment of the leg, and their tendons run in the retromalleolar groove anchored by the superior peroneal retinaculum. Peroneal instability is usually classified using the Eckert and Davies classification, which was modified by Oden into a four-point grading system. The mechanism of injury is typically sudden forced dorsiflexion, resulting in aggressive tautness of the peroneal tendons, combined with a forced eversion of the hindfoot. Plain X-ray, ultrasound and magnetic resonance imaging are useful for imaging of the injury and in planning for surgery. Operative management has high success rates and there are multiple surgical techniques available, including superior peroneal retinaculum repair, tenoplasty, bone block procedures, groove deepening and endoscopic approaches, with little variation in outcome found between the approaches.

Arthroscopic Onlay Biceps Tenodesis Utilizing 2 Knotless All-Suture Anchors

Background: Tenodesis is an effective surgical technique for the management of a pathologic long head of the biceps tendon. Tenodesis is performed with either an onlay (tendon opposed to cortical surface) or inlay (tendon docked into a reamed intra-cortical tunnel). Both techniques can be performed either from a subpectoral location, which is typically done through an open approach, or from a suprapectoral location, which is performed arthroscopically. The arthroscopic suprapectoral approach, when compared with its subpectoral counterpart, has been shown to report similar patient outcomes and complication rates. Indications: Arthroscopic suprapectoral biceps tenodesis is most commonly indicated in patients undergoing surgical treatment with anterior shoulder pain and biceps tendonitis, often associated with concomitant pathology. Less common indications include patients with superior labrum anterior and posterior tears as well as biceps tendon subluxation or dislocations. Patients with ruptured proximal biceps tendons are contraindicated, as the tendon is typically too distal for arthroscopic management. Technique Description: The biceps tendon is identified arthroscopically within the bicipital groove, just proximal to the pectoralis major tendon superior border. Suprapectoral tenodesis is then performed utilizing 2 knotless suture anchors for fixation. Results: Patient-reported outcomes following arthroscopic suprapectoral tenodesis in the literature have been found to be excellent with minimal complications. Despite current literature being inconclusive regarding the optimal site of fixation, the arthroscopic procedure minimizes the risk of infection, cosmetic deformity, and neurovascular injury that is seen in the open approach. In addition, the use of onlay fixation has traditionally avoided the risk of humeral fracture that is seen with inlay fixation. Discussion/Conclusion: This arthroscopic onlay suprapectoral tenodesis has the benefit of a time-efficient and easily reproducible technique that safely minimizes the risk of humeral fracture or neurovascular injuries. This technique historically has provided a strong fixation with excellent patient-reported outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

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

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

Partnering with people living with rheumatoid arthritis for care of their hands: Four case reports using relative motion orthoses

Study DesignCase report. IntroductionDespite better disease control with more effective medications, people with rheumatoid arthritis (RA) continue to experience persistent and fluctuating levels of pain, swelling and functional limitations in their hands. PurposeTo describe therapists and people living with RA working together to understand what could be occurring in their hands because of the RA and how relative motion (RM) orthoses may be used to self-manage common hand RA related problems. MethodsCase reports are used to demonstrate how patient self-report, clinical exam, and observation of hand movement and function are integrated into the design of RM orthoses for individuals with RA. The cases are supported by photos and videos, including a personal narrative video exploring 1 persons’ personal perspective on their use of RM orthoses. ResultsCase reports illustrate adaptive and/or protective RME orthoses use for RA related finger malalignment, tendon subluxation, joint pain and instability in the hand. The narrative video also introduces a person living with RA, who speaks candidly about her multiple RM orthoses and how she decides which orthosis is “best” for a given activity and the current level of RA related problems in her hands. DiscussionIt is not unusual for individuals with RA to have multiple RM orthoses, made for different purposes and fabricated from different materials. Mulitple RM orthosis options allows a person to select what is “best” for them, depending on the context of use and priorities or needs. ConclusionPartnering with people living with RA to understand how to use simple, low-profile, adaptive and protective RM orthoses may be an effective way to support self-management of common RA related hand problems.

Modified posterior fibular groove deepening procedure with repair of the superior peroneal retinaculum for peroneal tendon subluxation.

To evaluate the clinical results of modified peroneal sulcus deepening combined with superior peroneal retinaculum repair in peroneal tendon subluxation treatment. From 2016 to 2020, 18 patients with peroneal tendon subluxation were diagnosed and treated; all patients underwent modified peroneal sulcus deepening combined with superior peroneal retinaculum repair. The visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS-AH) score, and subjective patient satisfaction were evaluated before surgery and during follow-up. The operative time was 66.44 ± 5.22min. All patients' surgical incisions showed grade A healing, and there were no complications. All patients were followed up for 24-48months; no patients were lost to follow-up. At the last follow-up, the VAS and AOFAS-AH scores were significantly improved compared with those pre-operatively (P < 0.05). There was no significant difference in the activity of the 18 patients between pre- and post-operatively, and all patients recovered their normal gait before injury. Modified fibular groove deepening combined with superior peroneal retinaculum repair for treating peroneal tendon subluxation may be a simple operation with minimal trauma, rapid recovery, and good clinical efficacy.

Partial Resection of First Dorsal Compartment Extensor Retinaculum in De Quervain's Stenosing Tendovaginitis Release.

Various surgical techniques exist to treat de Quervain's stenosing tendovaginitis. Specific surgical techniques for de Quervain's are designed to avoid complications including injury to branches of the superficial branch of the radial nerve, inadequate decompression, reflex sympathetic dystrophy, and palmar subluxation of the released tendons. A simple dorsal incision through the extensor retinaculum is advocated by many as a means to release the compartment while preventing postoperative subluxation. A single incision through the retinaculum limits exposure of the compartment and could lead to reannealing of the retinaculum and recurrent symptoms. Partial resection of the extensor retinaculum provides a more complete release and has not been found to lead to palmar tendon subluxation.

Utilizing Bone Anchors in Sagittal Band Reconstruction with Extensor Tendon Centralization: A Case Series and Literature Review

Objective: There are multiple complex tissue reconstruction techniques described for repair of sagittal band rupture in patients with subluxation of extensor tendons over the metacarpophalangeal joint. In our surgeon group, we have been performing a technically simpler repair using bone anchors with good success for several years. Our objectives are to report these findings and review any previously reported use of the technique. Methods: We reviewed all operative reports in a group of sixteen hand surgeons coding for centralization of extensor tendon from 2011 to 2022. Within those cases we selected out each case that utilized bone anchors for sagittal band repair. We then reviewed records for evidence of recurrent symptoms, subluxation, pain, or re-operation. We also noted the duration of follow up. Results: The procedure was performed by four of the sixteen surgeons. Twelve patients were identified by searching for the centralization of extensor tendon code and reviewing operative reports. We identified two additional patients who returned to our clinic for other reasons, one performed as early as 1997. We suspect several more were missed due to not searching prior to 2011 or different coding. These fourteen patients totaled 31 fingers all together. Of those, etiologies included six cases (21 fingers) of rheumatoid arthritis or other inflammatory arthritis, eight cases (10 fingers) of trauma, spontaneous rupture, or osteoarthritis. The patients with inflammatory arthritis tended to have multiple finger involvement. Follow up ranged from 6 weeks to 25 years, an average of 30 weeks (excluding the 1997 case) or 65 weeks including it. We found one case of recurrence in the first 90 days requiring reoperation. This was thought to be due to a technical error. All patients reported postoperatively no locking or clicking, reduction in pain, and improved range of motion. We excluded three patients (10 fingers) that were repaired similarly with suture tunnels through bone rather than bone anchors. These had similar postoperative results. We were only able to identify three case reports of similar repairs using bone anchors performed in the literature. These each reported good results at 1 year. Conclusion: Repair of sagittal band rupture and extensor tendon subluxation at the metacarpophalangeal joint with suture anchors is a simple, and effective technique. Although we are not the first to publish such a technique, we did identify several cases that were performed prior to the identified publications. Our data is the largest case series reported to date, and is consistent with the previously reported excellent results. Corresponding Author: Matthew Shaheen, MD, 627 Butternut Ave., Royal Oak, MI 48073

Endoscopic Superior Peroneal Retinaculum Reconstruction Using Q-FIX MINI Suture Anchor

Post-traumatic peroneal tendon subluxation or dislocation is most commonly caused by injury to the superior peroneal retinaculum. Classic open surgeries usually require extensive soft-tissue dissection and have potential risks of peritendinous fibrous adhesions, sural nerve injury, limited range of movement, recurrent or persistent peroneal tendon instability, and tendon irritation. The purpose of this Technical Note is to describe the details of endoscopic superior peroneal retinaculum reconstruction using Q-FIX MINI suture anchor. This endoscopic approach has the advantages of minimally invasive surgery, including better cosmesis, less soft-tissue dissection, less postoperative pain, less peritendinous fibrosis, and less subjective tightness at peroneal tendons. Insertion of the Q-FIX MINI suture anchor can be performed inside a drill guide, and trapping of the surrounding soft tissue can be avoided.

Superior Peroneal Retinaculum Reconstruction For Traumatic Peroneus Longus Subluxation: A Case report

Background: Peroneal tendon subluxation is a rare condition that often misdiagnosed, generally associated with sport related injury. Subluxation of the peroneal tendons is uncommon and is frequently misinterpreted as an ankle sprain, usually in young and active patients. The most common pathological mechanism is a dorsiflexory and mostly caused by avulsion of the superior peroneal retinaculum (SPR) from its fibular insertion. Treatment may be conservative or surgical, although there is no agreement on the best technique to use. Case Report: A 35-year-old man presented with pain and swelling of the lateral side of the left foot after play badminton. The patient felt pain upon palpation and snapping sign during flexion–extension of the left ankle. The patient was treated with conservative treatment for 1 month with no improvement, and we recommended to do surgical treatment for relieved the pain. Discussion: Superior Peroneal Retinaculum Reconstruction shows an great result; after the procedure, there are no significant side effects such infections, wound issues, or ongoing discomfort. The surgical outcome was viewed as satisfactory overall. Following surgery, the ankle was put in a semi-equinus position for two weeks while being immobilized with a non-weight-bearing, temporary below-knee cast. Conclusion: Acute peroneus longus subluxation might be difficult to diagnose since it is usually misinterpreted as an ankle sprain. The occurrence of peroneal tendon subluxation is rather low, and surgery is the main treatment for this injury. If conservative treatment shows no improvement, variety of surgical techniques are available. Several literature reported superior peroneal retinaculum reconstruction has satisfactory outcome.

Trigger Wrist with Carpal Tunnel Syndrome Accompanied with Trifid Median Nerve: A Case Report and Literature Review.

Trigger wrist, characterized by a clicking or snapping sensation around the wrist joint during finger or wrist motion, and bifid or trifid median nerve, which occurs in carpal tunnel syndrome along with anatomical variation of median nerve, are rare conditions. We report the case of a patient with a thickened tendon caused by severe tenosynovitis and flexor tendon subluxation to the hamate hook due to bowing of the flexor retinaculum, thereby resulting in trigger wrist as well as an anatomical median nerve variation (bifid median nerve in the right wrist and trifid median nerve in the left wrist). A 59-year-old housewife visited our hospital with bilateral fingertip numbness, tingling sensation, and aggravated severe night cramping that began 2 months ago. She also complained about trigger wrist during small finger flexion. Based on magnetic resonance imaging, ultrasonography, and nerve conduction study, trifid median nerve and bilateral severe median nerve neuropathy of the wrist were diagnosed; therefore, transverse carpal tunnel release and exploration under wide-awake anesthesia were planned. Intraoperative findings showed trifid and bifid median nerves in left and right wrists, respectively. Additionally, bowing of flexor retinaculum and severe flexor tendon tenosynovitis were observed. Tenosynovitis with thickened flexor sheath resulted in subluxation of the small finger flexor tendon above the hamate hook. After transverse carpal ligament release with antebrachial fascia release and tenosynovectomy, subluxation of the flexor tendon was resolved. At 6 months postoperatively, the tingling and dullness in fingertips also resolved, and no trigger wrist or any other complications were noted.

Ultrasound Imaging and Prevalence of Intrasheath Peroneal Tendon Subluxation in Asymptomatic Volunteers

Category: Ankle; Other Introduction/Purpose: Intrasheath peroneal tendon subluxation is typically an incidental finding in athletes with sports-related injuries and is characterized by a temporary reversal in the anteroposterior positions of the peroneus longus (pL) and peroneus brevis (pB) tendons within their common tendon sheath. It is currently unclear whether intrasheath subluxation represents normal physiologic or pathologic tendon motion. This study aims to determine the normal variation in motion of supramalleolar pB and pL tendons in multiple ankle positions and to determine the overall prevalence of intrasheath tendon subluxation in asymptomatic volunteers. Methods: Static sonographic images of the peroneal tendons in 22 asymptomatic volunteers were collected in the neutral position, in eight fixed ankle positions (active and passive pronation, dorsiflexion, supination, and plantarflexion), and during dynamic ankle circumduction. The center of each tendon in relation to the lateral fibular cortex and in relation to each other was measured in each position and used to calculate absolute and percentage displacement. Two-way ANOVA was used to determine the significance of passive versus active motion and two-tailed paired sample t-test was used to compare the mean displacement of pL and pB in active and passive positions. Results: Intrasheath subluxation was not visualized in any static position but was visualized in 33% of patients during active ankle circumduction, regardless of direction or laterality. Percent displacement was greatest in active ankle plantarflexion (55%) for pB and in active pronation (34%) for pL. A statistically significant difference in the tendon positions in relation to each other was found in the anteroposterior direction (p=0.026), but there were no statistically significant differences between active and passive motions or with ankle positioning. A non-painful ankle 'snap' was palpated by the sonographer in all cases of intrasheath subluxation. Conclusion: Intrasheath subluxation is a fairly common occurrence seen in one third of our volunteers. Our results suggest that a snapping ankle in otherwise asymptomatic patients is highly suggestive of intrasheath peroneal tendon subluxation and can be well-documented with dynamic ultrasound. Establishing the normal ranges of motion of supramalleolar peroneal tendons may assist in the evaluation of patients with lateral ankle pain.

Proximal Flexor Hallucis Longus Transfer to Peroneus Brevis for Treatment of Peroneal Muscle Paralysis

Category: Hindfoot; Ankle; Other Introduction/Purpose: Equinovarus foot deformities typically present with equinus contractures, hindfoot varus, dorsiflexion of the medial midfoot, and adduction deformities of the forefoot. Whether of neurologic or muscular origin, all forms result muscular imbalance. Flexor hallucis longus (FHL) transfer to peroneus brevis (PB) is indicated when both peroneal muscles are in unrepairable condition to restore active eversion. However, in cases of muscle paralysis where the PB is still in continuity, we recommend a novel technique where FHL is tenodesed proximal to the peroneal retinaculum within the leg to avoid the additional morbidity associated with more distal fixation or tenodesis. Methods: Surgical intervention first involved a posterolateral approach to the ankle and an Achilles tendon Z-lengthening to fix her equinus contracture. The ankle and subtalar joint capsules were contracted requiring release. Flexor digitorum longus (FDL) and FHL were tenotomized, which immediately corrected her claw toes. Since the tendon had already been released, we were able to deliver the FHL tendon into the posterolateral leg wound. The peroneal fascia and sheath were opened proximal to the superior peroneal retinaculum to prevent tendon subluxation. PB was identified by confirming that it produced foot eversion and by visualizing the peroneus longus (PL). The tension of PB was confirmed by observing that it did not cause tension at PL insertion on the plantar 1st ray. FHL was then transferred to the PB utilizing a Pulvertaft weave technique with the tendon appropriately tensioned in mid eversion in the middle of the Blix curve (Figure 1). Results: After FHL transfer, the patient was immediately allowed to weight bear as tolerated in a short leg cast. This was due to her deconditioned state to limit atrophy and the effects of prolonged recumbency in this medically fragile young woman. The patient ultimately was casted for 10 weeks total as she was unable to tolerate a CAM boot or other orthotic due to the weight and problems with the fit. At 4 months follow up, her foot is corrected and she is able to stand in a neutral, plantigrade position. Using a new AFO, she can walk without issue. Her foot remains well balanced and plantigrade. Conclusion: This simple FHL transfer technique decreases morbidity since the transfer occurs within the leg, proximal to the superficial peroneal retinaculum (SPR). The transfer pulls on the paralyzed, but intact PB instead of routing the FHL to the 5th metatarsal base or PB stump. This technique is only recommended if PB is intact but non-functional. It should be noted that adequate tensioning is essential for a successful transfer. Benefits of this procedure include no cluttering under the SPR and no risk of scarring that region which can lead to decreased tendon excursion.

An Analysis of Extensor Carpi Ulnaris Groove Morphology and Tendon Instability.

The extensor carpi ulnaris (ECU) tendon has a distinct subsheath at the distal ulna. Symptomatic tears of this subsheath and subluxation of the ECU tendon often require reconstruction. We sought to determine the anatomical constraints of the ECU subsheath. The ECU subsheath was exposed on 12 fresh-frozen upper extremities. The tip of the ulnar styloid, the distal ulnar joint surface, and the proximal extent of the distal radio-ulnar joint were identified and dimensions measured. Subluxation of the tendon was then assessed with and without an intact subsheath in 9 specimens. The travel of the tendon was measured in pronation through supination and flexion before and after sectioning of the subsheath. The ECU subsheath is 8.9 mm (standard deviation [SD] = 0.8 mm) wide proximally and 9.0 mm (SD = 1.2 mm) distally. The distal ulnar insertion is 0.5 mm (SD = 0.8 mm) proximal to the tip of the styloid, and stretches 10.2 mm (SD = 2.7 mm) proximally. From maximum pronation to maximum supination and flexion, the ECU tendon traveled 3.32 mm (SD = 4.24) medially when the subsheath was intact and 5.42 mm (SD = 5.0 mm) after sectioning. The maximum depth of the ulnar groove was 2.5 mm (1.59-3.56 mm). There was no significant association between changes in ECU subluxation and the depth of the ECU groove (Spearman's rho = 0.25). The ECU subsheath is roughly 1 cm square stretching proximally from the ulnar styloid. ECU groove depth is not a significant independent predictor of tendon subluxation.