Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series

@#Introduction: To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy. Materials and methods: A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score. Results: Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the sixmonth follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011). Conclusion: FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.

Effectiveness of a modified posterior approach for arthroscopic resection on painful talocalcaneal coalition in adults / 中国修复重建外科杂志

Objective: To investigate the effectiveness of arthroscopic talocalcaneal coalition resection in painful adults via a modified posterior approach. Methods: Between January 2015 and December 2017, 9 patients with painful talocalcaneal coalition accepted arthroscopic resection via the posterior malleolus high lateral observation approach combined with the lower medial operation approach. Of them, 6 were male and 3 were female, aged from 19 to 30 years (mean, 24 years). Among them, 2 cases had no definite local trauma and 7 cases had a history of sprain of foot and ankle. The disease duration ranged from 6 to 30 months, with a median of 12 months. Rozansky classification of talocalcaneal coalition for the 9 patients: 5 cases (5 feet) were type Ⅰ, 2 cases (2 feet) type Ⅱ, and 2 cases (2 feet) type Ⅲ. The patients had no sequelae of limb dysfunction and no limb joint surgery in the past. All the patients received anteroposterior and lateral X-ray films and CT scans of the ankle joint during follow-up. The visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score were used to evaluate the effectiveness. Results: The operation time was 60-90 minutes (mean, 76 minutes). All patients were followed up 12-24 months (mean, 18 months). All the incisions healed by first intention, without infection, skin necrosis, lower extremity deep vein thrombosis, vascular nerve and tendon injury, bone bridge recurrence, and other complications. The ankle function recovered well and the pain was relieved obviously after operation, and the patients returned to work at 3-5 months after operation, with an average of 3.9 months. At last follow-up, the VAS score was 0.7±0.5, which was significantly improved ( t=20.239, P=0.000) when compared with preoperative score (4.2±0.5); the AOFAS ankle-hind foot score was 94±4, which was significantly improved ( t=-27.424, P=0.000) when compared with preoperative score (62±2). According to AOFAS ankle-hindfoot scoring system, the results were excellent in 7 cases and good in 2 cases at last follow-up. Conclusion: It is more intuitive, more space, and more flexibility for operation via the modified posterior malleolus high lateral observation approach combined with the lower medial operation approach in talocalcaneal coalition. It is feasible to remove talocalcaneal coalition programmatically according to the specific anatomic signs during the operation.

Study On Tendinous Connections Between Flexor Hallucis Longus And Flexor Digitorum Longus

Introduction: Flexor Hallucis Longus (FHL) and Flexor Digitorum Longus (FDL) are long flexors of the toes, oftenwith the interconnecting tendinous slips at various points. These interconnecting slips hold great significance inreconstruction surgeries of ankle and foot such as chronic Achilles tendon rupture, posterior tibial tendondysfunction (PTTD) and peroneal tendon rupture. In view of the above this study was aimed to find out varioustypes of connections between tendons of FHL & FDL.Materials and methods: This cross sectional study was carried out in the Department of Anatomy ACSR GovernmentMedical College, Nellore, conducted in a total of 34 lower limbs. Flexor digitorum brevis and abductor hallucismuscles were reflected distally after the removal of the skin, superficial fascia and plantar aponeurosis toexpose FHL and FDL tendons which were examined for the interconnections. Specimens with interconnectionswere photographed and documented.Result: Out of 34 samples, 17 were right sided and 17 were of left sided. Mean foot length was 22.4 ± 1.9 cm. Threetypes of connections i.e. type 1, 4 & 5 were documented at 17 (50%), 16 (47.1%) and 1 (2.9%) type 5 respectively.Type 1 tendinous connections were further classified into 3 sub types i.e. type 1A were 10 (58.8%), type 1B were5(29.4%) and type C were of 2(11.8%).Conclusion: This study finds maximum distribution of type1 interconnections followed by type 4 and sub type 1Aamong type 1. This study also reports for the first time a common origin of 1st lumbrical from distal part oftendinous slip as well as from 1st digital slip of FDL. These interconnections provide stable base and enhancedpropulsion by toes and also act as natural tenodesis

The anatomy and clinical applications of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy / 中华显微外科杂志

Objective To evaluate the effectiveness of flexor hallucis longus tendon transfer in treatment of chronic Achilles tendinopathy using different technique.Methods Sixty-four embalmed feet of 32 cadavers were analyzed and classified anatomically with respect to the individual cross links in the Henry's knot.These three techniques were then combined to determine the total potential tendon graft length obtainable using single incision,double incision and minimally invasive incision.From January,2012 to June,2015,10 patients (10 feet) with chronic Achilles tendinopathy were treated with double incision technique.The score was 63.04 ±7.75 according to American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score system.Results Only two different configurations were found.Type 1,a tendinous slip branched from the FHLT to the FDLT was 96.9％(62 of 64 feet).Type 2,a slip branched from the FHLT to the FDLT and another slip from the FDLT to FHLT was 3.1％(2 of 64).The average length of the FHLT graft available from a single incision measured (5.08±1.09)cm,double incision technique measured (6.72 ± 1.02) cm,and minimally invasive incision measured (17.49 ± 1.80)cm.The difference between the lengths obtained from these three techniques was statistically significant.Ten patients were followed-up 12-36 months (mean,13.7 months).At 12 months after operation,the AOFAS ankle and hindfoot score was 93.28 ± 3.72,showing significant difference when compared with that before operation.The results were excellent in 6 cases,good in 3 cases,and fair in 1 case with an excellent and good rate of 90％.No sural nerve injury,posterior tibial nerve injury,medial plantar nerve injury,and lateral plantar nerve injury occurred.Conclusion In over 96 ％ of the feet,a proximal to distal connection from the FHLT to the FDLT was found,which might contribute to the residual function of the lesser toes after FDLT transfer.The distal stump of the FHLT tendon should be sutured onto the FDLT tendon under tension to en able a co-activation of the great toe,preserved hallux plantar flexion.Chronic Achilles tendinopathy reconstruction with flexor hallucis longus tendon harvested using double incision technique offers a desirable outcome in operative recovery,tendon fixation,preserved hallux plantar flexion and less complications.

The Tendinous Slip of the Flexor Digitorum Longus for the Great Toe: An Anatomic Variation / 체질인류학회지

This report describes a variation of the tendinous slip of the flexor digitorum longus (FDL) for the great toe. In addition, compositions of the long flexor tendons for all five toes were examined. The tendons of the FDL in the foot were investigated in 66 specimens of embalmed Korean adult cadavers. The tendons of the flexor hallucis longus (FHL) and the FDL with the lumbrical muscles were cut at the calcaneus and the metatarsophalangeal joints and were removed en bloc specifically to observe the FDL and the FHL tendons of the great toe. The tendinous slip of the FDL for the great toe was found bilaterally in the foot of a 52-year-old male. Its prevalence was two of 66 specimens (3.0%). The tendinous slip of the FDL for the great toe passed forward the great toe, and it constituted the superficial portion of the long flexor tendon for the great toe. The tendon of the FHL passed forward to constitute the deep portion of the long flexor tendon for the great toe. Thus, both the tendinous slip of the FDL and the tendon of the FHL composed the long flexor tendon for the great toe. The tendinous slip of the FDL and the tendon of the FHL for the great toe were similar in thickness; thus, each tendinous slip of the FDL and the tendon of the FHL were approximately one-half of the long flexor tendon for the great toe in thickness. The present study demonstrated an anatomical variation of the interconnection between the FHL and the FDL tendons, which will be useful for various surgeries and biomechanical research.

Treatment of Massive Defect in Achilles Tendon with Tendon Allograft: A Case Report / 대한족부족관절학회지

Deep infection of Achilles tendon is one of the serious complications that occur after open repair of the tendon. It sometimes leads to a very large tendon defect during the course of treatment. We report on a case of massive defect in Achilles tendon, which was successfully treated with Achilles tendon allograft and flexor hallucis longus tendon transfer.

Clinical Outcomes and Complications of Tendoscopic Treatment for Flexor Hallucis Longus Tenosynovitis / 대한족부족관절학회지

PURPOSE: To report the clinical outcomes and complications of flexor hallucis longus (FHL) tendoscopy using 3 portals. MATERIALS AND METHODS: Between January 2012 and April 2013, 10 patients (10 ankles) received tendoscopic surgery for the treatment of FHL tenosynovitis. Patients complaining of pain and tenderness along the course of FHL despite over 6 months of conservative treatments were indicated for surgery. The mean age was 41.7 years (range: 18-57) and the follow up period was 12.7 months (range: 6-20). Tendoscopy was performed using posteromedial, posterolateral, and plantar portals. Clinical evaluations included preoperative and postoperative visual analogue scale (VAS), American orthopaedic foot and ankle society (AOFAS) score, and patients' satisfaction. RESULTS: Tendoscopic findings included tenosynovitis in 10 cases, degenerated vinculae in 6 cases, stenosis of the tendon at its entrance into the fibro-osseous tunnel in 5 cases, and degenerative partial tendon tear in 3 cases. Two cases had associated symptomatic os trigonum and 3 cases had posterior ankle impingement syndrome. Preoperative pain decreased from median VAS 6 (range: 4-10) to 2.1 (range: 1-5) at the last follow up and AOFAS score improved from 50.1 (range: 36-63) to 82.1 (range: 61-89) (p<0.05). Nine patients were satisfied or very satisfied with the outcome. Injury of the lateral plantar nerve occurred in one case. CONCLUSION: FHL tendoscopy using 3 portals is a feasible and useful minimal invasive surgical technique for the management of FHL tenosynovitis.

Symptomatic Hallucal Interphalangeal Sesamoid Bones Successfully Treated with Ultrasound-guided Injection: A Case Report

The hallucal interphalangeal sesamoid bone is usually asymptomatic, but it is not uncommon for it to be symptomatic in cases of undue pressure, overuse, or trauma. Even in symptomatic cases, however, patients often suffer for extended periods due to misdiagnosis, resulting in depression and anxiety that can steadily worsen to the extent that symptoms are sometimes mistaken for a somatoform disorder. Dynamic ultrasound-guided evaluations can be an effective means of detecting symptomatic sesamoid bones, and a simple injection of a small dose of local anesthetics mixed with steroids is an easily performed and effective treatment option in cases, for example, of tenosynovitis.

Proximal Flexor Hallucis Longus Tendon Transfer for the Ossification of the Achilles Tendon: A Case Report / 대한족부족관절학회지

Ossification of the Achilles tendon is a rare condition that is characterized by the presence of an ossific mass contained within the substance of the tendon. The ossified mass is usually asymptomatic but when it grows large and painful, it deteriorates the function of Achilles tendon. We report a case of ossification of the Achilles tendon, which was successfully treated by removal of the ossific mass and proximal flexor hallucis longus (FHL) tendon transfer.

Vascular Malformation of Flexor Hallucis Longus Muscle Associated with a Flexion Deformities of Toes: A Case Report / 대한골관절종양학회지

Vascular malformations may typically present with palpable mass that can be either asymptomatic or can present with symptoms including swelling and pain. On rare occasions, vascular malformation of muscle may produce joint deformities caused by contracture of the involved muscle. When vascular malformation involves the flexor muscle of the leg, ankle equinus deformity may occur. However, there are no reports of toe deformities secondary to intermuscular or intramuscular vascular malformations of flexor muscles of toe. Thus, we report a case of vascular malformation of flexor hallucis longus muscle with flexion contracture of toes in a 40-years-old woman who was treated with surgical excision.

Synoivial Chondromatosis of the Ankle Joint and Flexor Hallucis Longus Tendon Sheath / 대한족부족관절학회지

Synovial chondromatosis is a benign lesion forming multiple round cartilagenous nodules or osseous loose bodies in joint cavity. Predilection sites are known as knee, hip and elbow joints. However, the involvement of ankle joint was rarely reported in the literature. Moreover, extraarticular chondromatosis in synovial sheath or bursa of extremities is extremely rare. We present a case of synovial chondromatosis of the left ankle joint and flexor hallucis longus tendon sheath.

Evaluation of flexor hallucis longus tendon transfer as a treatment for Achilles tendon defects of more than 6 cm / 中华创伤骨科杂志

Objective To evaluate the clinical results of flexor hallucis longus (FHL) tendon transfer in treatment of patients with Achilles tendon defects of more than 6 cm. Methods Between January 2005 to February 2009, 19 patients with Achilles tendon defects, 13 males and 6 females, were treated with FHL tendon transfer. Their ages ranged from 20 to 61 years, with an average of (42. 6 ± 8.2)years. Fifteen defects were found during tendonitis debridement, and 4 were old ruptures. Time from rupture to surgery ranged from 0 to 6 months (average, 2.6 months). Defects were 6 cm to 10 cm long. Procedures were performed in a two-incision manner. The postoperative ROM of ankle joint, American Orthopaedic Foot and Ankle Society(AOFAS) and visual analogue scale(VAS) scores were recorded at 3 months, 12 months,and the last follow-up. The results were statistically analyzed to evaluate the functional recovery. Results Follow-ups lasted from 12 to 48 months (average, 22. 2 months). At the last follow-up, the average ROM of ankle joint was 17.8°± 1.9° at dorsal flexion and 39.1°±2.3° at plantar flexion, and the last average AOFAS score was up to (91.8 ± 1.7), significantly different from those at 3 months after surgery (P＜0.05), but not significantly different from those at 12 months (P＞0.05). The difference were significant between the results of 3 months and 12 months (P＜0.05). The last average VAS score was (1.0±0.7),significantly different from those at 3 months and 12 months(P＜0.05) . There was also significant differences between the VAS scores of 3 months and 12 months (P＜0.05). Patient's satisfaction was 100%.Conclusion FHL tendon transfer is an efficient procedure for long Achilles tendon ruptures associated with tendonitis in relieving pain and maintaining the function of ankle joint.

Tenosynovial Chondromatosis on Plantar Area: A Case Report / 대한족부족관절학회지

Tenosynovial chondromatosis is a multinodular cartilaginous proliferation that arises from the tenosynovial membranes. It is rare, benign neoplasm, most commonly affects the tendon of the wrist and hand. It is clinically important because of its high rate of recurrence with a unique histopathological pattern which not infrequently displays considerable focal cellular atypia and hypercellurality nevertheless it is benign, but it has not been well recognized because of its rarity. We report here a rare case of tenosynovial chondromatosis of the tendon sheath of flexor hallucis longus and flexor digitorum longus in plantar area.

Reconstruction of Neglected Achilles Tendon Rupture with Flexor Hallucis Longus Augmentation Using One Incision Technique / 대한족부족관절학회지

PURPOSE: The purpose of this study was to evaluate the clinical outcome of neglected Achilles tendon rupture treated with reconstruction and augmentation with flexor hallucis longus (FHL) tendon using one incision technique. MATERIALS AND METHODS:Between July 2006 and March 2008, eleven patients with neglected Achilles tendon rupture received surgical treatment. Through one incision technique, augmentation with auto FHL tendon transfer was performed using a Bio-Interference screw (Arthrex, Naples, FL) and followed by V-Y advancement (5 cases) or gastronemius fascial turn-down flap procedure (6 cases). After mean follow up of 20.7 months (range, 11.8-33.3 weeks), clinical outcomes were evaluated with Visual Analogue Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) score, 10 repetitive double heel raise test, 10 repetitive single heel raise test and subjective satisfaction. RESULTS:The length of the gap after debridement was 5.4+/-2.0 cm. The VAS improved from 4.1+/-0.9 to 1.5+/-0.8 at last follow up (p<0.05). The AOFAS score increased from 38.9+/-12.2 to 91.5+/-8.9 at last follow up (p<0.05). Eight patients were satisfied with excellent results and three were satisfied with good results. All patients were able to perform 10 repetitive double heel raise and nine out of eleven patients were able to perform 10 repetitive single heel raise at last follow up. There were no complications including deep infection or re-rupture. CONCLUSION: Augmentation with FHL tendon transfer and reconstruction with V-Y advancement or turn-down flap through one incision technique appeared to be effective and safe. This technique is recommendable for the treatment of neglected Achilles tendon rupture.

Irreducible Fracture of Calcaneus due to Flexor Hallucis Longus Tendon Interposition: A Case Report / 대한족부족관절학회지

In closed calcaneus fractures, the occurrence of FHL interposition in subtalar joint is relatively rare and difficult to diagnosis preoperatively. But careful physical examination and significant radiologic findings could be useful tools to diagnosis preoperatively. This findings is shearing off a superior medial fragment made up of the sustentaculum talus connected to a significant portion of the medial wall and medial aticular surface of the posterior facet.

Treatment of Deep Infection Following Repair of Achilles Tendon Rupture / 대한족부족관절학회지

PURPOSE: Theaim of this study was to review the results of treatment for deep infection following repair of Achilles tendon rupture using reverse sural arterialized flap and/or flexor hallucis longus transfer. MATERIALS AND METHODS: Five cases of Achilles tendon infection in five patients were treated using reverse sural arterialized flap and/or flexor hallucis longus transfer at our hospital with followed up of average 23.6 months (range, 13-43 months). Three patients were male and average age at surgery was 52.0 years (range, 42-59 years). Clinical results were evaluated by the method of Percy and Conochie, and the isokinetic peak torque value was interpreted according to the guideline of Sapega. RESULTS: The clinical result was excellent in three cases, good in one case and fair in one case. The isometric peak torque value for 30 degrees per second was normal in two cases, possibly abnormal in one case, and probably abnormal in two cases, and for 120 degrees, normal in one case, probably abnormal in four cases. Five cases in five patients were satisfied with the result of treatment. CONCLUSION: We can expect satisfactory results of treatment for deep infection following repair of Achilles tendon rupture using reverse sural arterialized flap and/or flexor hallucis longus transfer.

Surgical Treatment of Tuberculous Achilles Tendinitis: Case Report / 대한족부족관절학회지

Although Achilles tendinitis is a relatively common disease, tuberculous involvement of Achilles tendon is rare. We report a case of tuberculous Achilles tendinitis, which was successfully treated with chemotherapy and a combined surgical procedure (Achilles tendon parital excision and FHL tendon transfer).

Surgical Treatment of Tuberculous Achilles Tendinitis: Case Report / 대한족부족관절학회지

Although Achilles tendinitis is a relatively common disease, tuberculous involvement of Achilles tendon is rare. We report a case of tuberculous Achilles tendinitis, which was successfully treated with chemotherapy and a combined surgical procedure (Achilles tendon parital excision and FHL tendon transfer).

Trigger Toe in Soccer Player: A Case Report / 대한족부족관절학회지

A 18-year-old male soccer player had painful triggering and occasional locking of the great toe caused by entrapment of the flexor hallucis longus tendon within the flexor sheath posterior to the right medial malleolus. After other treatment modalities failed, the condition was relieved by a surgical procedure that removed the nodule on the flexor hallucis longus tendon and the ganglion under flexor retinaculum. Tendon rupture was not found, although there was tendinitis.

Tendonitis of the Flexor Hallucis Longus with Triggering of the Great Toe: A Case Report / 대한정형외과학회잡지

We present an unusual case of 31 year old lady with a longitudinal tear of flexor hallucis longus(FHL) caused by trauma. Tendonitis of the FHL, well known as dancers tendonitis, can be characterized by triggering of the great toe. As the foot is brought into plantar flexion with a forcible active contraction of the FHL, a snap is noted in the region of the posteromedial aspect of the ankle. Magnetic resonance imaging may be helpful in establishing diagnosis. The patient has obtained longterm satisfactory relief of her symptoms with surgical treatment. The literature on tendonitis of the FHL is reviewed with a reported case.