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Winter P, Najefi AA, Lambert L, Landgraeber S, Tschernig T, Wagener J. Endoscopically Assisted Percutaneous Harvesting of the Flexor Hallucis Tendon in Zone 2: An Anatomical Study. Foot Ankle Int 2023; 44:888-894. [PMID: 37296541 DOI: 10.1177/10711007231177250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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 OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- Philipp Winter
- Department of Orthopaedic Surgery, University of Saarland, Homburg, Germany
| | - Ali-Asgar Najefi
- Department of Trauma and Orthopaedic, London North West University Hospital NHS Trust, London, United Kingdom
| | - Laura Lambert
- Department of Orthopaedic Surgery, University of Saarland, Homburg, Germany
| | - Stefan Landgraeber
- Department of Orthopaedic Surgery, University of Saarland, Homburg, Germany
| | | | - Joe Wagener
- Department of Orthopaedic Surgery, University of Saarland, Homburg, Germany
- Department of Orthopaedic Surgery, Hôpital Kirchberg, Luxembourg
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Galagali DA, Bhatia A, Ajoy SM, Vohra R. Navicular Tuberosity: A Surface Landmark for the Masterknot of Henry. Indian J Orthop 2023; 57:1100-1104. [PMID: 37384015 PMCID: PMC10293137 DOI: 10.1007/s43465-023-00883-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/24/2023] [Indexed: 06/30/2023]
Abstract
Background Medial aspect of foot is unexplored due to its complex anatomy. Masterknot of Henry is an important landmark in this region, which plays a key role during tendon transfer procedures especially in those involving the flexor hallucis longus and flexor digitorum longus. We aim to determine the exact anatomical location of masterknot of Henry with respect to the bony prominences of the medial aspect of the foot and compare these measurements to the length of the foot. Methods Twenty cadaveric below-knee specimens were dissected. Structures on the medial side of the foot were exposed. Distance of the masterknot of Henry from surrounding bony landmarks was measured. Depth of the masterknot from skin of the plantar aspect was also measured. Means of all parameters were calculated. Relation between measurements and the foot length was determined using correlation and regression analysis. P value of less than 0.05 was considered significant. Results Distance of masterknot of Henry from navicular tuberosity was found to be fairly constant of 19.965 mm. Foot length was found to be correlating with the distance between masterknot of Henry and medial malleolus, navicular tuberosity and its depth from the skin. Conclusions Navicular tuberosity can be considered an important surface landmark for the location of masterknot of Henry. Correlation of length of the feet with various measurements helps to find the masterknot considering the foot length to be an important variable. Good knowledge of surface anatomy leads to shorter operating time and less morbidity during procedures involving the flexor hallucis longus and flexor digitorum longus.
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Affiliation(s)
- Dev Anand Galagali
- Department of Orthopaedics, Ramaiah Medical College and Hospitals, Matthikere, Bangalore, 560054 Karnataka India
| | - Aanchal Bhatia
- Department of Orthopaedics, Ramaiah Medical College and Hospitals, Matthikere, Bangalore, 560054 Karnataka India
| | - S. M. Ajoy
- Department of Orthopaedics, Ramaiah Medical College and Hospitals, Matthikere, Bangalore, 560054 Karnataka India
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Miller CP, McWilliam JR, Michalski MP, Acevedo J. Endoscopic Haglund's Resection and Percutaneous Double-Row Insertional Achilles Repair. Foot Ankle Spec 2021; 14:534-543. [PMID: 33840259 DOI: 10.1177/19386400211002707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with nonsurgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double-row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infection. The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using minimally invasive surgery techniques while also incorporating a percutaneous double-row suture anchor repair. The technique utilizes 4 portals to access 2 endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double-row suture anchor repair.Levels of Evidence: Level V.
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Affiliation(s)
- Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James R McWilliam
- New York Medical College, Valhalla, New York.,White Plains Hospital Physicians Associates, White Plains, New York
| | - Max P Michalski
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jorge Acevedo
- Department of Orthopedics, Southeast Orthopedic Specialists, Jacksonville, Florida
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Gerstner G JB, Winson I, Campo J, Swords M, Camilo Medina J, Rammelt S, Gerstner S J, Cantor EJ, Ramírez C. Endoscopic Flexor Hallucis Longus Transfer for Achilles Noninsertional Tendinopathy: Description of Surgical Technique and Functional Outcomes. Foot Ankle Spec 2021; 14:46-54. [PMID: 31916453 DOI: 10.1177/1938640019895919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. The transfer of the flexor hallucis longus (FHL) tendon is an established treatment for replacing a dysfunctional Achilles tendon. Objectives. (1) Describe a new technique for endoscopic FHL transfer for noninsertional Achilles tendinopathy and (2) describe the functional outcomes and complications after endoscopic and open FHL transfer. Materials and Method. Retrospective study of patients who underwent open or endoscopic FHL transfer between 2014 and 2016. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale was used preoperatively and postoperatively to measure the functional results. Results. We included 18 endoscopic FHL transfers and 24 open FHL transfers. The mean age of endoscopic and open procedures was 47.5 years (range 25-77 years) and 61.2 years (range 43-72 years), respectively. An improvement on the average AOFAS of 52.8% (31.9 points) was observed in the endoscopy group during the follow-up from the baseline. The mean improvement in AOFAS score for the open group was 41.4% (24.5 points). Four and 7 cases reported complications in the endoscopy and open FHL transfer groups, respectively. Conclusion. While both procedures were effective in treating noninsertional Achilles tendinopathy, the described arthroscopic treatment led to a greater improvement in the AOFAS score and is slightly less prone to lasting complications.Level of Evidence: Level IV: Case series.
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Affiliation(s)
- Juan Bernardo Gerstner G
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Ian Winson
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Jimmy Campo
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Michael Swords
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Juan Camilo Medina
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Stefan Rammelt
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Jochen Gerstner S
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Erika J Cantor
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
| | - Carlos Ramírez
- Centro Médico Imbanaco de Cali S.A., Cali, Valle del Cauca, Colombia (JBGG, JC, JCM, JGS, EJC, CR).,Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK (IW).,Michigan Orthopedic Center, East Lansing, Michigan (MS).,University Hospital Carl Gustav Carus, Trauma and Reconstructive Surgery, Dresden, Germany (SR)
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Abstract
Haglund syndrome is a triad of posterosuperior calcaneal prominence (Haglund deformity), retrocalcaneal bursitis, and insertional Achilles tendinopathy. The sources of pain include the posterior calcaneal wall cartilage, retrocalcaneal and subcutaneous adventitial bursa, and the Achilles tendon. Resection of the posterosuperior calcaneal tubercle, bursectomy, excision of the Achilles tendon pathology, reattachment of the Achilles tendon, gastrocnemius aponeurotic recession, and flexor hallucis longus transfer have been proposed as surgical treatment options. All of them can be performed endoscopically or under minimally invasive approaches.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR 999077, China.
| | - Cho Yau Lo
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR 999077, China
| | - Yuk Chuen Siu
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR 999077, China
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Vega J, Vilá J, Batista J, Malagelada F, Dalmau-Pastor M. Endoscopic Flexor Hallucis Longus Transfer for Chronic Noninsertional Achilles Tendon Rupture. Foot Ankle Int 2018; 39:1464-1472. [PMID: 30124070 DOI: 10.1177/1071100718793172] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND: Operative management of chronic Achilles tendon ruptures is challenging, and numerous techniques have been described. Risk of infection and wound breakdown have been described after open techniques, and minimally invasive methods have been proposed to avoid them. The aim of this study was to describe the clinical and radiological results obtained after endoscopic flexor hallucis longus (FHL) tendon transfer in patients with chronic Achilles tendon rupture. METHODS: Between 2012 and 2015, a total of 22 patients were endoscopically treated for chronic Achilles tendon rupture. Mean age was 69 years (range, 59-84 years). Mean follow-up was 30.5 months (range, 18-46 months). Preoperative magnetic resonance imaging (MRI) was obtained and tendon gap measured. An MRI was obtained at 9 to 12 months following surgery to evaluate Achilles tendon changes. RESULTS: Preoperative MRI examination showed a mean tendon gap of 6.3 cm (range, 3-10.7 cm). The MRI control was obtained only in 12 patients, and a normal or close to normal Achilles tendon was observed in all but 1 patient. The mean American Orthopaedic Foot & Ankle Society score increased from 55 preoperatively (range, 26-75) to 91 (range, 74-100) at final follow-up. All patients returned to their daily activities without difficulties. No patients reported complaints or symptomatic deficits of great toe flexion strength. No major complications were encountered. CONCLUSION: Chronic Achilles tendon ruptures were successfully treated by an all-endoscopic procedure. The endoscopically assisted FHL transfer provided excellent results while benefiting from the minimally invasive procedure advantages. However, it entailed some technical challenges and may not be suitable for less experienced surgeons. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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Affiliation(s)
- Jordi Vega
- 1 Human Anatomy and Embriology Unit, University of Barcelona, Barcelona, Spain
- 2 Foot and Ankle Unit, Hospital Quirón Barcelona and, iMove Traumatology Tres Torres, Barcelona, Spain
- 3 Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied et de la Cheville (GRECMIP), Merignac, France
| | - Jesus Vilá
- 4 Orthopaedic and Trauma Surgery, Hospital Universitario 12 de Octubre, and Hospital Quirón Ruber, Madrid, Spain
- 5 Surgical Department, University Complutense of Madrid, Madrid, Spain
| | - Jorge Batista
- 6 Club Atletico Boca Juniors, Buenos Aires, Argentina
| | - Francesc Malagelada
- 7 Foot and Ankle Unit, Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Miki Dalmau-Pastor
- 1 Human Anatomy and Embriology Unit, University of Barcelona, Barcelona, Spain
- 3 Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied et de la Cheville (GRECMIP), Merignac, France
- 8 Faculty of Health Sciences at Manresa, University of Vic-Central University of Catalonia, Manresa, Barcelona, Spain
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