Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction

Reconstruction of the extensor tendon on the dorsal pedis with a chimeric skin-aponeurosis flap from the groin region

BACKGROUND

Complex defects involving the extensor tendon on the dorsal pedis have been reconstructed using multiple procedures. Skin coverage and tendon transfers have also been performed. This study aimed to present our experience using a chimeric skin-aponeurosis flap for one-stage reconstruction of composite soft-tissue defects on the dorsal pedis.

METHODS

Between May 2017 and September 2020, 12 patients with these defects received total treatment using a chimeric groin flap. Based on the superficial circumflex iliac vessels, the skin paddle resurfaced the cutaneous defect, and the vascularised external oblique aponeurosis was rolled to form a tendon-like structure to simultaneously replace the absent segment of the extensor tendons. A suitable "Y" bifurcation was dissected to enlarge the vessel diameter. Single-stage reconstruction was performed using a set of vascular anastomoses at the recipient site.

RESULTS

Flap survival was achieved without significant complications. The hammertoe deformity was completely removed. The average dimension of the skin paddle was 8.0 × 13.0 cm (range, 6.5 × 11.0-10.0 × 14.0 cm), and the mean size of the aponeurosis was 8.0 × 4.0 cm (range, 6.0 × 3.0-10.0 × 5.0 cm). At the last follow-up visit, no morbidity was observed at the donor site. Natural shapes and walking functions were successfully achieved with a protective sensation.

CONCLUSION

The chimeric groin flap with sheets of external oblique aponeurosis is a great candidate for one-stage reconstruction of composite soft tissue loss on the dorsal pedis. This approach provides cosmetic coverage, allowing faster wound healing and reduced tendon adhesions.

Severe Soft Tissue Loss on Dorsum of the Foot with Irreparable Hallucis Extensors: An Orthoplastic Reconstruction Case Report

CASE

A motorcycle accident resulted in severe soft tissue loss on the foot's dorsum with irreparable hallucis extensors, with exposure of the first metatarsal and hallux. An arthrodesis of the hallux interphalangeal joint, a transfer of the second toe's extensor digitorum longus, and an anterolateral thigh free flap were performed simultaneously. The patient obtained a fair result and could wear regular shoes.

DISCUSSION

This is the first report describing this orthoplastic reconstructive option in these complex injuries. It replenished both hallux extensor tendons and soft tissue coverage losses without severely compromising the foot's contour, recreating anatomy and function.

Extensor digitorum longus (EDL) to extensor hallucis longus (EHL) tendon transfer for delayed EHL tendon rupture following anterior ankle arthroscopy - Case report

BACKGROUND

Arthroscopy of the ankle is an important surgical technique that has become increasingly popular over the years due to its usefulness in the treatment of many ankle conditions. Nevertheless, it's not deprived of complications. Extensor hallucis longus (EHL) tendon ruptures following anterior ankle arthroscopy have only been reported 3 times in the literature.

CASE REPORT

We report the case of a 52-year-old female submitted to ankle arthroscopy with removal of a bony fragment located at the tip of the lateral malleolus and ATFL ligament repair (arthroscopic Bröstrom-Gould). At the sixth postoperative week, she experienced a sudden "pop" located at the anterior aspect of the ankle with inability to actively extend the hallux and difficulty in walking barefoot with disruption of normal gait. MRI showed a complete rupture of the extensor hallucis longus tendon with approximately 6 cm separation between the tendon ends. Surgical treatment was performed: tendinous transfer of the extensor digitorum longus (EDL) to the EHL using a Pulvertaft technique. At the 12th postoperative week, the patient could actively extend the hallux and the second toe with a range of motion similar to the contralateral foot.

CONCLUSION

This case reports a delayed EHL tendon rupture following ankle arthroscopy treated surgically with a good functional result. To our knowledge, this is the first published case of delayed EHL tendon rupture following anterior ankle arthroscopy treated surgically with a tendinous transfer of the EDL to the EHL. The possible causes leading to this complication and the different surgical techniques that could have been used to treat this pathology were discussed.

Extensor hallucis longus tendon and soft-tissue reconstruction with palmaris longus tendon included in a radial forearm free flap: A case report

Reconstruction of foot structures is challenging because of the need to restore both anatomy and function. Extensor hallucis longus (EHL) excision without reconstruction could result in a flexion deformity of the toe at the interphalangeal joint. In this report, we present a case of the use of a palmaris longus tendon included in a fasciocutaneous radial forearm free flap to reconstruct EHL tendon and soft tissues of the distal foot dorsum. A 41-year-old woman presented with a recurrence of myxoinflammatory fibroblastic sarcoma on the medial part of the left foot dorsum. The EHL tendon was sacrificed, leaving a soft-tissue defect of 14 × 5 cm and 14-cm tendon gap. A 14 × 5 cm radial forearm flap with a 16-cm section of palmaris longus tendon was harvested from the left forearm. Radial artery and its comitant vein were anastomosed with dorsalis pedis artery and vein. EHL tendon repair was performed from the composite mass to the proximal and distal stumps. No complication in the postoperative period occurred. At latest follow-up, 12 months postoperatively, the patient showed a normal joint function and was satisfied with the treatment. Palmaris longus tendon included in a radial forearm free flap could be recommended for combined soft tissue and tendon defects, particularly on the foot dorsum.