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Tsang CY, Lui TH. 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. Arthrosc Tech 2024; 13:102936. [PMID: 38835445 PMCID: PMC11144810 DOI: 10.1016/j.eats.2024.102936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
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.
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Affiliation(s)
- Cho Yin Tsang
- Department of Orthopaedics and Traumatology, Tuen Mun Hospital, Hong Kong SAR, China
| | - Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong SAR, China
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Kyung MG, Cho YJ, Lee DY. Management of Checkrein Deformity. Clin Orthop Surg 2024; 16:1-6. [PMID: 38304213 PMCID: PMC10825257 DOI: 10.4055/cios23229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 02/03/2024] Open
Abstract
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.
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Affiliation(s)
- Min Gyu Kyung
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Yun Jae Cho
- Department of Orthopedic Surgery, Hanil General Hospital, Seoul, Korea
| | - Dong Yeon Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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Yuan Y, Gao J, Jia J. Application of ultrasound in preoperative localization diagnosis of checkrein deformity: A retrospective case series. J Orthop Surg (Hong Kong) 2023; 31:10225536231189783. [PMID: 37458778 DOI: 10.1177/10225536231189783] [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: 07/20/2023] Open
Abstract
BACKGROUND Checkrein deformity, is a rare claw toe dynamic deformity of the hallux or great toe. This study investigated the use of diagnostic ultrasound in positioning the accurate injury location causing checkrein deformity and its clinical significance for etiological diagnosis and selection of surgical methods. METHODS This retrospective study included patients with confirmed checkrein deformities (according to typical symptoms) at the Department of Traumatic Orthopedics of Tianjin Hospital (Tianjin, China) from March 2017 to July 2021. RESULTS A total of 11 patients (8 males and 3 females) with a mean age of 36.7 ± 16.8 (range 19-61) were included in this study. The injuries included six cases of tibia and fibula fracture, one case of single tibia fracture, and one case of single fibula fracture. Four patients were treated with steel plate internal fixation, three patients with intramedullary nailing, and one patient with external fixation. Three patients reported no history of any high-energy trauma or surgery. The ultrasound results showed that seven patients suffered from flexor hallucis longus (FHL) lesions, two patients suffered from flexor digitorum longus (FDL) lesions, and two patients suffered from FHL and FDL lesions. The patients underwent different surgeries tailored to their specific lesions. Toe flexion deformity was completely corrected after operation in all patients. The function of the toes was recovered to varying extent. CONCLUSION The results of this study demonstrates that the checkrein deformities can be confirmed by ultrasound. It could be used to determine the adhesions before the operation, acting as guidance while establishing the surgical planning.
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Affiliation(s)
- Yu Yuan
- Department of Ultrasound, Tianjin Hospital, Tianjin, China
| | - Jinmei Gao
- Department of Ultrasound, Tianjin Hospital, Tianjin, China
| | - Jun Jia
- Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China
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Polichetti C, Greco T, Inverso M, Maccauro G, Forconi F, Perisano C. Retro-Malleolar Z-Plasty of Flexor Hallucis Longus Tendon in Post-Traumatic Checkrein Deformity: A Case Series and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1072. [PMID: 36013539 PMCID: PMC9412890 DOI: 10.3390/medicina58081072] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Chiara Polichetti
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Greco
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michele Inverso
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulio Maccauro
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Orthopedics and Trauma Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fabrizio Forconi
- Casa Di Cura Villa Stuart, Via Trionfale 5952, 00135 Rome, Italy
| | - Carlo Perisano
- Department of Ageing, Neurosciences, Head-Neck and Orthopedics Sciences, Orthopedics and Trauma Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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Pinto Moura A, Caldeira-Dantas S, Vaz Pinto G, Madeira S, Protásio J, Seno MJ. Lateral subtalar dislocation associated with a lateral malleolus and a nutcracker cuboid fracture: Case report of a rare pattern of lesion. Int J Surg Case Rep 2021; 89:106593. [PMID: 34798553 PMCID: PMC8605261 DOI: 10.1016/j.ijscr.2021.106593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/07/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction and importance Combined fracture of the lateral malleolus and cuboid due to a lateral subtalar dislocation is an uncommon injury. Literature is scarce on this trauma association. To the best of our knowledge, this represents a new lesion pattern. Hereby we describe its mechanism, management and outcomes. Case presentation We report a case of a 58-year-old woman, who fell from the stairs and presented with pain and an acute deformity of the left foot and ankle. Plain radiographs and CT scan revealed a lateral subtalar dislocation with a lateral malleolus and cuboid fractures. After a failed closed reduction, the patient underwent an open reduction and fixation of the talonavicular joint. An external fixator was applied to address the cuboid fracture. The lateral malleolus was treated conservatively with 5.5 weeks of immobilization. At 38 months of follow-up, the patient scored 87% on the AOFAS ankle-hindfoot scale and returned to normal daily activity. Radiographs demonstrate signs of posttraumatic arthritis at the subtalar and talonavicular joints. Clinical discussion After reduction of the lateral subtalar dislocation, addressing the nutcracker cuboid fracture was essential, since it can contribute to a flatfoot deformity. Although the patient progressed to posttraumatic arthritis, the sequelae are usually well tolerated and a good outcome was achieved. Conclusion The rarity of this pattern of lesion is related to the necessary multidirectional forces. Correct management of the associated fractures is essential. Our study demonstrates a new lesion pattern of lateral subtalar dislocations, its mechanism, management and outcomes. Lateral subtalar dislocation with lateral malleolus and cuboid fractures are rare. Combined eversion and lateral foot column compression result in this pattern. Both lateral dislocations and cuboid fractures may result in a flatfoot deformity. CT scan is vital for fracture identification and proper surgical planning. Adequate treatment of the associated fractures is essential to a successful outcome.
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Affiliation(s)
- André Pinto Moura
- Orthopaedics Department, Hospital do Litoral Alentejano, Monte do Gilbardinho, 7540-230 Santiago do Cacém, Portugal.
| | - Sofia Caldeira-Dantas
- Orthopaedics Department, Hospital do Litoral Alentejano, Monte do Gilbardinho, 7540-230 Santiago do Cacém, Portugal
| | - Gonçalo Vaz Pinto
- Orthopaedics Department, Hospital do Litoral Alentejano, Monte do Gilbardinho, 7540-230 Santiago do Cacém, Portugal
| | - Sofia Madeira
- Orthopaedics Department, Hospital Garcia de Orta, Avenida Torrado da Silva, 2805-267 Almada, Portugal
| | - João Protásio
- Orthopaedics Department, Hospital Beatriz Ângelo, Avenida Carlos Teixeira 3, 2674-514 Loures, Portugal
| | - Maria José Seno
- Orthopaedics Department, Hospital do Litoral Alentejano, Monte do Gilbardinho, 7540-230 Santiago do Cacém, Portugal
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McLaughlin WM, Moran J, Brand J, Kahan JB, Yoo B. Posterior Talar Body Fracture With Flexor Hallucis Longus Incarceration: A Case Report & Literature Review. JBJS Case Connect 2021; 11:01709767-202112000-00024. [PMID: 34714777 DOI: 10.2106/jbjs.cc.21.00493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 58-year-old man presented with entrapment of the flexor hallucis longus (FHL) tendon between fractured fragments of the talar body. The patient was successfully treated with atypical operative approaches to release the tendon and reduce the fracture. At the 1-year follow-up, the patient remained asymptomatic with the ability to extend and flex of all toes. This case illustrates a unique surgical approach for this presentation. CONCLUSIONS With proper utilization of positioning and fluoroscopy, posterior talar body fractures with entrapment of the FHL can be stabilized and corrected with dual use of medial-sided approaches.
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Affiliation(s)
- William M McLaughlin
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, Connecticut
| | - Jay Moran
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jordan Brand
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, Connecticut
| | - Joseph B Kahan
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, Connecticut
| | - Brad Yoo
- Department of Rehabilitation & Orthopaedics, Yale School of Medicine, New Haven, Connecticut
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Closed Pantalar Dislocation With Checkrein Deformity: A Unique Case Report and Literature Review. J Am Acad Orthop Surg Glob Res Rev 2021; 5:01979360-202110000-00013. [PMID: 34678856 PMCID: PMC8542153 DOI: 10.5435/jaaosglobal-d-20-00253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 09/08/2021] [Indexed: 11/18/2022]
Abstract
Closed pantalar dislocations are a rare variant of an uncommon injury. Pantalar dislocations are typically caused by high-energy trauma resulting in an open injury with associated fracture of the articulating bones. Given its obscurity, the literature on closed pantalar dislocations is scarce, and no standard treatment protocol has been accepted. This case report chronicles the treatment and outcome of a 29-year-old man who presented with a checkrein deformity of all digits after a closed pantalar dislocation with 6-month follow-up. A comprehensive literature review found 28 articles representing 39 patients with closed pantalar dislocations without talar neck or body fractures. Roughly equal numbers of closed and open reduction techniques were performed with avascular necrosis occurring in 7 of 36 patients. Although outcome measures and follow-up were variable, what can be considered a suitable outcome was seen in approximately 83% of patients, with only 3 of 35 requiring a secondary operation. Long-term studies with well-defined outcome measures are needed to adequately predict the prognosis of this rare injury and efficacy of treatment protocols.
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Sallent A, Soza D, Duarri G, Busquets R. Checkrein deformity: a case report of two patients with hallux deformity and pain following mandibular reconstruction in oral cancer treatment. Oral Maxillofac Surg 2020; 24:359-362. [PMID: 32500381 DOI: 10.1007/s10006-020-00852-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Andrea Sallent
- Orthopedic Department, Hospital Vall d'Hebron, Paseo Vall d'Hebron, 119-129 08035, Barcelona, Spain.
| | - Diego Soza
- Orthopedic Department, Hospital Vall d'Hebron, Paseo Vall d'Hebron, 119-129 08035, Barcelona, Spain
| | - Gemma Duarri
- Orthopedic Department, Hospital Vall d'Hebron, Paseo Vall d'Hebron, 119-129 08035, Barcelona, Spain
| | - Rosa Busquets
- Orthopedic Department, Hospital Vall d'Hebron, Paseo Vall d'Hebron, 119-129 08035, Barcelona, Spain
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