Hallux flexion deformity secondary to entrapment of the flexor hallucis longus tendon after fibular fracture

Endoscopic Release of the Flexor Hallucis Longus Tendon at Posterior Ankle for Management of Checkrein Deformity of the Great Toe, Second Toe, and Third Toe

Checkrein deformity is rare and involves entrapment or fixed tethering of the flexor hallucis longus (FHL) in the posterior foot, just proximal to the flexor retinaculum of the ankle, and causes the "constant length phenomenon" of FHL. The clinical presentation is a dynamic flexion deformity of the great toe characterized by flexion contracture of the interphalangeal joint with mild extension contracture of the metatarsophalangeal joint, causing difficulty in walking since in the stance phase of gait, the hallux is forced into plantar flexion and impinges onto the ground. Because the FHL tendon has some interconnection to the tendons of the flexor digitorum longus at the master knot of Henry, deformities of the second and third toes are sometimes seen. There is no standard surgical treatment for checkrein deformity. Surgical release of the FHL muscle or release/lengthening of the FHL tendon has been proposed. The purpose of this Technical Note is to report the endoscopic release of the FHL tendon at the posterior ankle for management of checkrein deformity of the great toe, second toe, and third toe.

Management of Checkrein Deformity

Checkrein deformity is characterized by the dynamic status of the hallux, in which flexion deformity is aggravated by ankle dorsiflexion and relieved by ankle plantarflexion. In most cases, a checkrein deformity occurs secondary to trauma or following surgery. It has been suggested that the flexor hallucis longus tendon tethers or entraps scar tissue or fracture sites. Improvement with conservative treatment is difficult once the deformity has already become entrenched, and surgical management is usually required in severe cases. Various surgical options are available for the correction of checkrein deformities. It includes a simple release of adhesion at the fracture site; lengthening of the flexor hallucis longus by Z-plasty at the fracture site combined with the release of adhesion; lengthening of the flexor hallucis longus by Z-plasty at the midfoot, retromalleolar, or tarsal tunnel area; and flexor hallucis longus tenotomy with interphalangeal arthrodesis for recurrent cases. This review aimed to summarize the overall etiology, relevant anatomy, diagnosis, and treatment of checkrein deformities described in the literature.

Arthroscopic Tenotomy of the Flexor Hallucis Longus to Treat Checkrein Deformity

Checkrein deformity is a rare entity that results in alteration of the normal flexion and extension of the hallux, caused by a retraction or adhesion of the flexor hallucis longus (FHL) in its tendinous or muscular portion. It is usually caused by the sequelae of ankle and tibia fractures, such as adhesions and neuropathies, and often undiagnosed compartment syndromes. Its treatment is mainly surgical, and different techniques of release or lengthening of the FHL have been described. We present the clinical case of a 61-year-old patient treated by a simple arthroscopic tenotomy of the FHL at the retromalleolar level of the ankle, with complete functional recovery and absence of recurrence after 2 years of evolution. We recommend that this procedure should be considered for this pathology due to its technical simplicity, low iatrogenicity, early recovery, and theoretical absence of recurrence.Level of Evidence: Level V: Expert opinion, case report.

A Neglected Extensor Hallucis Longus Tendon Rupture Caused by Arthritic Adhesion

Extensor hallucis longus tendon injury is relatively rare and is principally caused by a laceration when a sharp object is dropped on the instep. Primary suturing is possible if the injury is acute, but if the tear is chronic, tendon contracture causes the space between the edges of the tear to widen, disrupting the end-to-end connection. In particular, a claw toe or checkrein foot deformity may develop over time due to adhesion of the lower leg tendons near the fracture site or scar. We report on a 44-year-old man who visited our outpatient clinic complaining of pain in the right foot and a hindered ability to extend his great toe. He had enjoyed playing soccer during his schooldays; since that time, the extension of that toe had become somewhat difficult. T2-weighted sagittal magnetic resonance imaging revealed that the continuity of the extensor hallucis longus tendon had been lost at the distal phalangeal base attachment site, and that the region of the proximal tendon was retracted to level of the middle shaft of the proximal phalanx. The findings allowed us to diagnose extensor hallucis longus tendon rupture accompanying osteoarthritic changes in the joint and soft tissues. We performed surgical tenorrhaphy and adhesiolysis. This is a rare case of extensor hallucis longus tendon rupture caused by minor trauma. Arthritis that developed at a young age caused the adhesions. If patients with foot and ankle arthritis show tendon adhesion at the arthritic site, tendon rupture can develop even after minor trauma or intense stretching.

Posttraumatic checkrein deformity following isolated Lauge-Hansen pronation external rotation stage IV malleolar fracture-a case report and literature review

The checkrein deformity is characterized by flexion contracture of the interphalangeal joint and extension contracture of the metatarsophalangeal joint. It is a rare condition occurring after lower extremity trauma, especially a malleolar fracture. Little is known about the possible cause and therapeutic strategy. This unique case presents a 20-year-old male patient with a diagnosis of the checkrein deformity secondary to open reduction and internal fixation of a Lauge-Hansen pronation external rotation stage IV malleolar fracture. After performing a detailed physical examination, radiographic evaluation, and ultrasonography, open exploration was performed to remove the hardware and correct the deformity with sole tenolysis of the flexor hallucis longus (FHL). In the 4-month follow-up, no recurrence of the checkrein deformity was observed. This deformity was caused by FHL adhesion. Interosseous membrane injury and fibular fracture together with local hematomas increases the risk of FHL adhesion. Open exploration and tenolysis of the FHL are feasible options to correct the checkrein deformity.

Retro-Malleolar Z-Plasty of Flexor Hallucis Longus Tendon in Post-Traumatic Checkrein Deformity: A Case Series and Literature Review

Checkrein deformity (CD) is a dynamic deformity of the hallux characterized by flexion contracture of the interphalangeal (IF) joint and extension contracture of the metatarsophalangeal (MTP) joint, worsened by ankle dorsiflexion. It is due to post-traumatic or ischemic retraction of the long hallux flexor tendon (FHL) following soft tissue trauma, leg fractures, ankle fractures and, more rarely, calcaneal or talar fractures. Diagnosis is essentially clinical, associated with imaging, to rule out unrecognized causes and evaluate fracture healing process. Few cases are reported in literature without univocal treatment. Background and Objectives: To analyze clinical and functional outcomes in patients with CD treated with release and retro-malleolar Z-plasty lengthening of FHL tendon. Materials and Methods: Patients diagnosed with CD treated with retro-malleolar (at tarsal tunnel) Z-plasty lengthening of the FHL tendon between January 2016 and August 2020 were included. Clinical and functional outcomes were collected on admission and post-surgery and analysed retrospectively. Patients with a minimum follow-up of 18 months were included. Results: A total of 14 patients, with mean age of 37.4 years old, with CD diagnosis were included in the study. All patients were suffering from post-traumatic CD and the mean time from trauma to onset of deformity was of 7 months (range 1−12). At a mean follow-up of 31.8 months (range 18−48) we found a significant improvement (p < 0.05) in terms of pain relief (VAS), function (AOFAS score) and ROM of the IP and MTP hallux joints. No recurrence, loss of strength, nerve injury or tarsal tunnel syndrome were observed. No patient required revision surgery. Conclusions: In this case series the retro-malleolar FHL tendon Z-plasty proved to be a suitable option for CD correction, allowing a good clinical and functional recovery.

Avoiding pitfalls in ankle fracture-dislocations: A case report of a dislocated tibialis posterior tendon causing persistent ankle subluxation

Tibialis posterior tendon dislocation, a rare complication in ankle fracture-dislocations, can impede anatomical reduction of the ankle mortise. We report on a 59-year-old healthy male with an open fracture-dislocation of the right ankle. Despite multiple attempts under direct vision of the anterior syndesmosis, anatomical reduction of the ankle mortise was not possible. Soft tissue windows in a computed tomography (CT) scan revealed the dislocated tibialis posterior tendon to be the impeding structure. At the level of the fibula fracture the tendon passed through the interosseous membrane anterior to the distal tibia and was then incarcerated in the medial talocrural joint before returning to the flexor retinaculum and its insertion on the navicular bone. Understanding the trauma mechanism and the course of the dislocated tendon as well as correct interpretation of CT and magnetic resonance images of the ankle enable surgeons to early diagnose and correctly treat this condition.

Irreducible Ankle Fracture Due to Incarceration of the Long Flexor Tendons Together With the Neurovascular Bundle in the Tibial Fibular Interosseous Space: A Case Report and Short Literature Review

Ankle fracture dislocations with frustrating attempts at closed reduction are a rare traumatic entity. We present a case of an irreducible ankle fracture due to incarceration of all the flexor tendons including the neurovascular bundle in the tibial fibular interosseous space; to date, only one such case has been published in the literature. A computed tomography scan in both bone and soft tissue windows was necessary to clarify the structures that were inhibiting repositioning. The decisive step for surgical treatment was removal of the trapped structures from the tibial fibular interosseous space by a dorsomedial approach. The malleolar joint was then reconstructed anatomically. After 12 weeks, the patient was fully mobile without restrictions in his daily professional activities.

Checkrein deformity: a case report of two patients with hallux deformity and pain following mandibular reconstruction in oral cancer treatment

BACKGROUND

Checkrein deformity is an uncommon disease with a well-described etiology. It is characterized by a dynamic deformity of the hallux or great toe. We report two cases of checkrein deformity due a fibular graft harvesting in two patients with a mandibular bone defect secondary to an oral cancer treatment.

CASE REPORT

We report two young patients with mandibular cancers that had been treated several years before our visit and were currently free of disease. The patients had a mandibular bone defect due to the maxillofacial treatment, solved with a free fibular graft. The current complaint was a great toe deformity that caused pain and made them walk with difficulties. Diagnosis was a checkrein deformity, and after a surgical release of the flexor hallucis longus tendon, both cases returned to normal activities with no walking limitations.

CONCLUSION

Our cases highlight that an accurate patient examination is warranted following these reconstructions as many of them can be misdiagnosed, and a relatively simple surgery can improve the patients' limitations.

Posterior Arthroscopic Treatment of a Massive Effusion in the Flexor Hallucis Longus Tendon Sheath Associated with Stenosing Tenosynovitis and Os Trigonum

We report a rare case of massive accumulation of fluid in the flexor hallucis longus tendon sheath with stenosing tenosynovitis and os trigonum. A 34-year-old woman presented to our hospital with pain and swelling in the posteromedial aspect of the left ankle joint after an ankle sprain approximately 8 months earlier. There was tenderness at the posteromedial aspect of the ankle, and the pain worsened on dorsiflexion of the left great toe. Magnetic resonance imaging revealed massive accumulation of fluid around the flexor hallucis longus tendon. We removed the os trigonum, performed tenosynovectomy around the flexor hallucis longus, and released the flexor hallucis longus tendon via posterior arthroscopy using standard posterolateral and posteromedial portals. At 1 week postoperatively, the patient was asymptomatic and able to resume her daily activities. There has been no recurrence of the massive accumulation of fluid around the flexor hallucis longus tendon as of 1 year after the surgery. To our knowledge, this is a rare case report of extreme massive effusion in the flexor hallucis longus tendon sheath with stenosing tenosynovitis and os trigonum treated successfully by removal of the os trigonum, tenosynovectomy around the flexor hallucis longus, and release of the flexor hallucis longus tendon via posterior ankle arthroscopy.

Contracture of extensor hallucis longus after fracture of distal tibia and fibula: A case report

Post-traumatic isolated big toe extensor contracture after tibiofibular fracture is uncommon and only a few cases have been reported. Major causes of it include anterior compartment syndrome, direct injury, entrapment or adhesion of the muscle or tendon.

We present an uncommon case of isolated extensor hallucis longus (EHL) tendon contracture following a distal tibiofibular shaft fracture without compartment syndrome of the affected leg or foot. The clinical outcome is good after Z-lengthening of the EHL tendon and abductor hallux tendon in 1-year follow-up.

Level of clinical evidence

5.

Checkrein Deformity of the Great toe Managed by Midfoot Flexor Hallucis Longus Z-Plasty: A Case Report

Introduction:

Checkrein deformities are rare and involve entrapment or fixed tethering of the flexor hallucis longus (FHL) tendon.

Case Report:

We present the case of a 25-year-old male who presented with complaint of clawing of his great toe. A history of previous open reduction internal fixation for distal tibia fracture was described 3 years back. Exploration of FHL tendons was performed at the level of the midfoot. Correction was achieved after z-plasty of FHL tendon. This case highlights another late complication of distal tibial fracture which should be actively looked for in patients with this injury. We describe the ease of surgical correction through an operative field free of scar tissue as compared to classical method of operating near fracture site and releasing adhesions of muscle belly.

Conclusion:

We suggest that exploration at the midfoot should be the primary surgical intervention in similar cases of checkrein deformity.

Endoscopic Adhesiolysis of Flexor Hallucis Longus Muscle

Adhesion of the flexor hallucis longus (FHL) muscle to the distal tibia can occur after distal tibial fracture, distal fibular fracture, low tibial osteotomy, soft-tissue injury at the posterior ankle, subclinical compartment syndrome of the distal deep posterior compartment of the leg, or Volkmann contracture after deep posterior compartment syndrome of the leg. The purpose of this Technical Note is to report the endoscopic approach of FHL muscle adhesiolysis. It is indicated in patients with symptomatic adhesion of the FHL muscle and contraindicated if there is entrapment of the FHL muscle or tendon in the fracture callus or if there is extensive fibrosis and contracture of the FHL muscle as a result of Volkmann contracture after deep posterior compartment syndrome of the leg.

Z-plasty of the flexor hallucis longus tendon at tarsal tunnel for checkrein deformity

PURPOSES

To review the outcome of Z-plasty of the flexor hallucis longus (FHL) tendon at the tarsal tunnel for checkrein deformity in 8 patients.

METHODS

Records of 6 males and 2 females aged 14 to 67 (mean, 39.5) years who underwent Z-plasty (lengthening) of the FHL tendon at the tarsal tunnel for checkrein deformity in the first and second toes by a single surgeon were reviewed. All patients had undergone 3 months of conservative treatment. The mean time from injury to surgical treatment was 8.4 (range, 5-12) months. All patients had associated injuries including distal tibiofibular fracture (n=6), distal fibular fracture (n=1), and crush injury aroundthe ankle (n=1); they were treated with intramedullary nailing (n=6), long leg splinting (n=1), and short leg splinting (n=1).

RESULTS

After a mean follow-up of 3.4 (range, 1-7) years, the FHL tendon was lengthened by a mean of 1.7 (range, 1.6-1.8) cm, and the mean American Orthopedic Foot and Ankle Society hallux score increased from 59 (range, 52-67) to 89 (range, 80-90). No patient had recurrence, nerve injury, or tarsal tunnel syndrome, although one patient had sensory disturbance of the posterior tibial nerve in the forefoot, which resolved spontaneously at week 2.

CONCLUSION

Z-plasty of the FHL tendon at the tarsal tunnel is a viable option for correction of checkrein deformity.

A radiological sign (which we are calling the 'tongues of flame' sign) in irreducible trimalleolar fractures of the ankle

BACKGROUND

The irreducible trimalleolar fracture case we describe is different from the Bosworth fracture, defined as a fixed posterior fracture-dislocation of the distal part of the fibula, in which the proximal fibular shaft fragment locks behind posterior tibial tubercle. This fracture is frequently irreducible by closed means as well.

METHODS

We describe a rare case of trimalleolar fracture/dislocation that cannot be reduced by closed means, and review the relevant literature.

RESULTS

The peroneal tendons were entrapped in a triangle between a postero-lateral displaced distal fibular fragment and a lateral displaced posterior malleolar (PM) fragment, and a proximal fragment of a Weber B fibular fracture. Intra-operative findings have proved that as soon as the peroneal tendons are disengaged from the triangle, the PM and fibular fractures can be easily reduced under direct vision (surgery). After the review of another 50 trimalleolar ankle fractures we describe a new radiographic sign, seen in the lateral radiographic view, with bony spikes from the distal fibular fragment posterior to the PM fragment, which we are calling the 'tongues of flame' sign. This feature was not noted on the radiographs of the other 50 trimalleolar fracture cases seen in our hospital.

CONCLUSION

The presence of this 'tongues of flame' sign should alert the treating surgeon to a possible irreducible ankle fracture/dislocation, which may need urgent attention for surgical management.

Medial malleolus fracture of the ankle combined with rupture of the Achilles tendon

A 59-year-old man fell off a 60-cm-high step, with his ankle in a twisted position, and sustained a closed fracture of the medial malleolus, with an ipsilateral complete Achilles tendon (TA) rupture. The TA rupture was initially missed but diagnosed by ultrasound examination, 2 weeks post-operatively. The ankle fracture was diagnosed from routine radiographs. Such a combination of injuries has been reported infrequently in the literature, but significant similarities have been described in the mechanism of injury and fracture patterns. Nevertheless, three of five reported cases with combined medial malleolus fractures were initially misdiagnosed.

Foot and Ankle Function at Maturity After Ilizarov Treatment for Atrophic-Type Congenital Pseudarthrosis of the Tibia: A Comprehensive Outcome Comparison with Normal Controls

BACKGROUND

The purpose of this study was to evaluate clinical outcomes and the biomechanical function of the foot and ankle at skeletal maturity of patients treated for atrophic-type congenital pseudarthrosis of the tibia (CPT) compared with healthy young adult controls.

METHODS

Twenty-four patients (mean age of 19.1 years) who had undergone Ilizarov treatment for unilateral atrophic-type CPT were compared with twenty-four controls (mean age of 19.6 years). All participants were evaluated using validated outcome questionnaires, radiographs, physical examination, instrumented motion analysis including a multisegmental foot model, and pedobarographic measurement.

RESULTS

Within the CPT group, the mean score of the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale was 89.9 (range, 76 to 100), and the mean score of the Oxford Ankle Foot Questionnaire (OAFQ) was 42.8 (range, 15 to 60). Motion analysis and pedobarographic measurement showed differences in biomechanical function of the foot and ankle on the side affected by CPT: a slower walking speed due to the short stride length; decreased dorsiflexion in hallux motion; increased hindfoot pronation in the presence of forefoot supination; diminished ankle push-off power; delayed time to heel-rise; and decreased forefoot pressure relative to hindfoot pressure. However, sagittal motion of the hindfoot and forefoot on the affected side was relatively well preserved. Subgroup analysis demonstrated no significant differences in terms of clinical outcome scores and most biomechanical parameters between the tibiofibular synostosis group and the intact-fibula group.

CONCLUSIONS

Children with atrophic-type CPT can obtain satisfactory foot and ankle function at maturity after successful Ilizarov treatment. Early stabilization of the ankle mortise by fibular stabilization and preservation of ankle mobility during and after treatment is thought to be crucial to maintaining function of the ankle in patients with CPT.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Flexor digitorum brevis tendon transfer to the flexor digitorum longus tendon according to Valtin in posttraumatic flexible claw toe deformity due to extrinsic toe flexor shortening

Claw toe deformity after posterior leg compartment syndrome is rare but incapacitating. When the mechanism is flexor digitorum longus (FDL) shortening due to ischemic contracture of the muscle after posterior leg syndrome, a good treatment option is the Valtin procedure in which the flexor digitorum brevis (FDB) is transferred to the FDL after FDL tenotomy. The Valtin procedure reduces the deformity by lengthening and reactivating the FDL. Here, we report the outcomes of FDB to FDL transfer according to Valtin in 10 patients with posttraumatic claw toe deformity treated a mean of 34 months after the injury. Toe flexion was restored in all 10 patients, with no claw toe deformity even during dorsiflexion of the ankle.

Checkrein Deformity Associated with Intra-Articular Talar Fracture: A Report of Three Cases

CASES

We present three cases of checkrein deformity associated with intra-articular talar fracture. Two of the cases were secondary to entrapment of the flexor hallucis longus (FHL) tendon between fracture fragments, and one was related to the increased pathway of the FHL tendon around the dislocated talar body. All cases were diagnosed and treated on the day of injury.

CONCLUSION

Physicians should suspect the entrapment of the FHL tendon in cases of flexion deformity of the hallux associated with talar fracture. Proper examination of the forefoot when a patient presents with a hindfoot injury will help to avoid missing such deformities.

Adhesion of flexor hallucis longus at the site of a tibial-shaft fracture--a cause of a checkrein deformity

Post-traumatic adhesion of toe flexors at the tibial fracture site resulted in checkrein deformity is rare and only a few case reports or case series were reported in the English literature. Major differential diagnosis includes deep compartment syndrome or adhesion of the muscle due to various causes. We are not able to conclude what is the best treatment option. Open exploration and adhesiolysis at the adhesion site together with tendon lengthening at the distal tibial level is a feasible surgical option with satisfactory result.

A case of check-rein deformities of the great and lesser toes treated through exploration at the midfoot

We present the case of a twenty-two year old man who presented to the orthopaedic clinic complaining of clawing of his great toe. Further examination revealed clawing of the lesser toes and surgical scarring to the fibula and tibia. A history of previous operative fixation for lower limb trauma was described. Exploration of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons was performed at the level of the midfoot. A full correction was achieved after release of the inter-tendinous connection between FHL and FDL tendons and z-plasty of the FHL tendon. This case highlights another possible complication of tibial fracture which should be actively looked for in patients with this injury. We describe and illustrate the ease of surgical correction through an operative field free of scar tissue which has the ability to possibly prevent unnecessary tendon z-plasty. We suggest that exploration at the midfoot should be the primary surgical intervention in similar cases of check-rein deformity.

Endoscopic adhesiolysis of the flexor hallucis longus muscle

Flexor hallucis longus muscle can adhere to the distal tibia after tibial fracture. The patient may complain of deep posteromedial ankle pain, checkrein deformity of the hallux, hallux flexus or development of hallux rigidus. Surgical treatment of release of the FHL muscle or lengthening of the FHL tendon has been proposed. We described an endoscopic approach of release of the FHL muscle from the distal tibia with the advantage of minimal soft tissue dissection.

LEVEL OF EVIDENCE

Therapeutic Level V: Expert Opinion/Technique.

Dynamic positional deformity of the hallux

The present study reports a case with concomitant tethering of the flexor tendon and extensor tendon of the hallux after closed tibiofibular shaft fractures. We have obtained good clinical results using tenotomy of the flexor hallucis longus tendon and Z-plasty lengthening of the extensor hallucis longus tendon. Because few studies have described the clinical results and operative methods for this type of combined deformity, we report a case with dynamic positional deformity of the hallux.

Checkrein deformity secondary to entrapment of FHL after talus fracture: a case report

Level of Evidence: V, Expert Opinion

Claw toes after tibial fracture in children

PURPOSE

The development of claw toe deformity following fracture of the tibia in children has not been described in our review of the literature. We report on the management of the acquired claw toe deformity after tibia fracture in five children.

METHODS

We report on five patients, between 5 and 15 years of age, who developed clawing of the hallux following a fracture of the tibia. In two patients, the lesser toes were involved. On examination, when the ankle was passively plantar flexed, a flexion contracture of the interphalangeal joint of the hallux became fully flexible. When the ankle was dorsiflexed, the clawing became more obvious and fixed. A magnetic resonance imaging (MRI) study in two cases demonstrated fibrosis under or just proximal to the tarsal tunnel.

RESULTS

The contractures were relieved by performing a tenolysis proximal to the medial malleolus. The operative findings demonstrated that the etiology could be possibly associated with a localized subclinical compartment syndrome.

CONCLUSIONS

We described five patients with a claw toe deformity following a tibia fracture associated with adhesions of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles to the surrounding structures under or just proximal to the flexor retinaculum. It is the authors' opinion that this condition may be related to a subclinical compartment syndrome localized in the distal part of the deep posterior compartment. Soft-tissue release without tendon lengthening allowed recovery in all patients.

Treatment of checkrein deformity of the hallux

We studied 11 patients with checkrein deformities of the hallux who underwent surgical treatment. Six had lengthening of the flexor hallucis longus tendon by Z-plasty in the midfoot, and five underwent release of adhesions and lengthening of the tendon by Z-plasty at the musculotendinous junction at the fracture site.

All six patients who underwent Z-plasty at the midfoot showed complete correction of the deformity without recurrence. Of the five who had release of adhesions and Z-plasty of the tendon at the fracture site, two showed partial and one showed complete recurrence.

Subcutaneous rupture of the Achilles tendon and ipsilateral fracture of the medial malleolus

Background

Although ankle fractures and an Achilles tendon rupture are relatively frequent in isolation, their association in the same injury is uncommon.

Case presentation

A 38 year old male tree surgeon fell six meters from a tree, sustaining a subcutaneous rupture of the Achilles tendon and an ipsilateral closed fracture of the medial malleolus. The injuries were diagnosed following clinical examination and imaging.

Conclusion

This injury combination is infrequent, and management of the Achilles tendon rupture should take into account the necessity not to secondarily displace the fracture of the medial malleollus.

Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment

BACKGROUND

Symptoms associated with flexor hallucis longus (FHL) pathology can manifest themselves anywhere along its length from the posterior leg to the plantar foot and the hallux. This study describes the spectrum of clinical presentations seen with FHL pathology, illustrates the relevant physical examination findings, and outlines a treatment approach.

MATERIALS

Computerized medical data was prospectively collected on 81 patients treated between January, 1997 and March, 2002. The 55 females and 26 males had an average age of 38.3 years, with a mean follow-up of 21.3 months. Forty-five of 81 had previous therapy that failed, usually for "plantar fasciitis." Twenty-seven were active athletically and 24 related the onset of symptoms to a specific traumatic episode. Pain was located at the posteromedial ankle in 40, plantar heel in 23, plantar midfoot in 22, and multiple locations in 16. All patients had tenderness of the FHL. Restriction of FHL excursion was demonstrated in 30 patients by limited hallux metatarsophalangeal joint dorsiflexion when the ankle was dorsiflexed ("FHL stretch test"). Thirty-four patients had magnetic resonance imaging of the FHL, 28 (82%) of which were positive for synovitis of the FHL. Treatment included an FHL stretching program, short-term immobilization, and operative decompression and synovectomy in patients for whom nonoperative treatment failed.

RESULTS

Of the 58 patients treated nonoperatively, 37 (64%) had successful results. Twenty-three patients had surgery, 20 at the posterior ankle fibro-osseous tunnel, and three in the sesamoid region. All patients treated operatively had successful outcomes. A subset of 10 patients had hallux rigidus symptoms without significant osteophyte formation. All 10 obtained successful results with treatment directed at restoring normal FHL excursion (nine nonoperatively, one by FHL release). This suggests that limited FHL excursion may be an etiology for the development of hallux rigidus.

CONCLUSIONS

Clinical syndromes related to the FHL are more frequent than previously reported. The close relationship of the FHL to commonly injured structures (such as the plantar fascia) contributes to significant delays in effective treatment.

Fracture of the ankle associated with rupture of the Achilles tendon: case report and review of the literature

SUMMARY

A thirty-five-year-old man fell two meters from a ladder and sustained a closed fracture of the medial malleolus with an ipsilateral complete Achilles tendon rupture. The Achilles tendon rupture was diagnosed by means of the patient's complaints and physical findings. The ankle fracture was diagnosed incidentally on routine radiographs. Such a combination of injuries has been reported infrequently in the literature, and striking similarities have been described in the mechanism of injury and fracture pattern. Remarkably, in three of four reports the combined injury was initially misdiagnosed.

Treatment of extrinsic flexion deformity of the toes associated with previous removal of a vascularized fibular graft

BACKGROUND

Complications from vascularized fibular bone-grafting are infrequent. We saw six patients who had a painful flexion deformity of the great and lesser toes after a free vascularized fibular graft had been obtained from the ipsilateral leg. In this report, we discuss our management of these patients.

METHODS

Painful flexion deformity of the toes that had developed in six adults after removal of a free vascularized fibular graft was treated by cutting of the flexor hallucis longus alone in three patients, by lengthening of the flexor hallucis longus alone in one, and by cutting of both the flexor hallucis longus and the flexor digitorum longus in two.

RESULTS

After an average duration of follow-up of six years and eleven months, the flexion deformity of the great and lesser toes had decreased or disappeared, leading to improved or full extension of the digits. Preoperative and postoperative measurements of muscle strength for plantar flexion of the interphalangeal joints did not change appreciably.

CONCLUSIONS

Cutting or lengthening of the flexor hallucis longus behind the ankle provides an adequate release of digital flexion deformities that occur after removal of a vascularized fibular bone graft.

Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report

This article presents a case of tethering of the flexor hallucis longus (FHL) tendon (checkrein deformity) and rupture of the posterior tibialis tendon after a closed Salter-Harris Type II ankle fracture. Delayed repair was affected by tenolysis of the FHL and flexor digitorum longus tendons and tenodesis of the posterior tibialis to the flexor digitorum longus tendon. This case represents the first such report of concomitant entrapment of the FHL tendon and rupture of the posterior tibialis tendon after a closed ankle fracture.

Fibular nonunion and equinovarus deformity secondary to posterior tibial tendon incarceration in the syndesmosis: a case report after a bimalleolar fracture-dislocation

A 39-year-old woman sustained a grade II open bimalleolar fracture-dislocation of the left ankle. Six months after an ORIF of these fractures was performed, she presented with a nonunion of the distal fibula fracture and with a fixed hindfoot equinovarus and forefoot adduction deformity. At surgery for repair of the fibular nonunion, the posterior tibial tendon (PTT) was found to be entrapped in the posterior tibiotalar joint, with a portion of the tendon interposed between the tibia and the fibula in the area of the posterior syndesmosis. After extrication of the PTT, the hindfoot varus and forefoot adduction deformity were corrected. To our knowledge, this is the first case report in the English literature of a missed PTT syndesmotic entrapment that resulted in a fibular nonunion and in a fixed foot deformity after an open bimalleolar ankle fracture dislocation.

Flexor hallucis longus dysfunction

Nineteen consecutive cases of flexor hallucis longus stenosing tenosynovitis that underwent operative tenolysis from September 1994 to December 1996 were retrospectively reviewed. This is classically a disorder of ballet dancers, and to a much lesser extent, running athletes. The patients were primarily nonathletic, male, and middle-aged. The mean symptom duration was 20 months, multiple physicians had been encountered, and misdiagnosis was common. Patients presented with overlapping signs and symptoms of flexor hallucis longus tendinitis, plantar fasciitis, and tarsal tunnel syndrome. A cross-reference of patients with posteromedial ankle pain, medial arch pain, and/or a positive Tinel's sign revealed that 14 (74%) and 6 (32%) feet had two of three, or all three signs, respectively. Magnetic resonance imaging and tenography proved valuable in establishing the correct primary diagnosis. Nonoperative protocols were unsuccessful. Flexor hallucis longus tenolysis was successful in each case with a mean return to regular activity at 9 weeks. Flexor hallucis longus stenosing tenosynovitis may be more prevalent than reported and should be a diagnosis of inclusion among all patient populations who present with posterior ankle, medial arch, and/or tarsal tunnel symptoms.