Surgical Reconstruction and Mobilization Therapy for a Retracted Extensor Hallucis Longus Laceration and Tendon Defect Repaired by Split Extensor Hallucis Longus Tendon Lengthening and Dermal Scaffold Augmentation

doi:10.1053/j.jfas.2012.04.018

The Journal of Foot and Ankle Surgery

Volume 51, Issue 4, July–August 2012, Pages 509-516

https://doi.org/10.1053/j.jfas.2012.04.018 Get rights and content

Abstract

A reconstructive technique and physical therapy protocol is presented for the treatment of extensor hallucis longus (EHL) lacerations with critical size defects caused by tendon retraction. The primary goal of treatment was to restore EHL structure and function without the use of a bridging allograft or tendon transfer. The technique is performed by split lengthening the distal segment of the lacerated EHL and rotating the lengthened segment proximally 180° to bridge the tendon defect. The lengthened tendon is then sutured to the proximal segment of the EHL. The EHL is then tubularized with an acellular dermal scaffold at the region of tendon rotation to improve tendon strength, minimize the probability of tendon overlengthening or re-rupture, and improve the tendon gliding motion, which can be compromised by the tendon irregularity caused by rotation of the tendon. Postoperative range of motion therapy should be initiated at 3 weeks postoperatively. A case report of this technique and postoperative mobilization protocol is presented. The American Orthopaedic Foot and Ankle Society midfoot score at 3 and 6 months postoperatively was 90 of 100. The patient regained active dorsiflexion motion of the hallux without functional limitations, deformity, or contracture of the hallux. The advantages of this technique include that a large cadaveric allograft is not needed to bridge a critical size tendon defect and tendon lengthening provides a biologically active tendon graft without the secondary comorbidities and dysfunction commonly associated with tendon transfer procedures.

Section snippets

Case Report

A 36-year-old female presented with a complete laceration of the EHL tendon in April 2011 when a kitchen knife fell on the dorsum of her foot. The patient presented 1 week after the initial injury with a complaint of pain, a wound, inability to raise the great toe, and difficulty walking. The patient's occupational demands included extensive weightbearing, bending, and climbing activities as an owner and operator of a domestic cleaning business. The patient's medical history included medically

Discussion

Although tendon lengthening procedures have been described for repair of Achilles tendon ruptures, similar concepts and techniques have not been reported for repair of extensor tendon lacerations of the foot 64, 65. The split tendon lengthening technique reported in the present study is the first reported for delayed surgical repair of a critical tendon defect caused by complete laceration and retraction of the EHL. The rationale for the use of a split tendon lengthening approach in this case

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Cited by (21)

Extensor hallucis longus distal tenotomy for spasticity in a patient with interphalangeal joint hyperextension after stroke
2021, Fuss und Sprunggelenk
The extension deformity of the interphalangeal (IP) joint of the hallux is a rare focal clinical entity usually detected in patients with no underlying pathology. It may be due to extensor hallucis longus (EHL) overactivity, although it has not been previously reported in patients with neurological disorders. The lesion should be differentiated from the persistent hyperextension of the great toe at the metatarsophalangeal (MTP) joint. Although MTP hyperextension of the hallux due to hypertonia of the EHL is a typical sequel of stroke, it has also been detected in a wide variety of disorders.
A patient with right hemiparesis following stroke, which had an almost complete functional recovery, is presented. She was disabled by focal spasticity of the EHL, leading to persistent hyperextension of the IP joint of the hallux. The deformity appeared on the long-term follow-up, on both sides within a 3-year period. It was treated with bilateral percutaneous distal EHL tenotomy. On the left side, a percutaneous dorsal IP joint capsulotomy was additionally performed.
A complete reduction of the deformity was achieved on both sides with functional rehabilitation. It is assumed that EHL hyperactivity following stroke in our patient was complicated by IP instead of MTP extension deformity, due to the coexistent flexor hallucis longus weakness. Bilateral distal EHL tenotomy, associated with percutaneous dorsal IP joint capsulotomy on the left side, provided satisfactory long-term results.
Die Hyperextensionsdeformität des Interphalangeal (IP)-Gelenkes der Großzehe ist eine seltene fokale Fehlstellung welche typischer Weise bei Patienten ohne Grunderkrankung gesehen wird. Sie kann als Folge der Hyperaktivität des M. extensor hallucis longus (EHL) angesehen werden, wurde jedoch bislang noch nicht bei Patienten mit neurologischen Erkrankungen beschrieben. Die Deformität sollte von einer persistierenden Hyperextension der Großzehe im Metatarsophalangeal (MTP)-Gelenk abgegrenzt werden, welche eine typische Folge von Schlaganfällen und zahlreichen anderen Pathologien darstellt.
Der Fall einer Patientin mit nahezu vollständiger funktioneller Erholung von einer rechtsseitigen Hemiparese nach einem Schlaganfall wird berichtet. Sie blieb jedoch durch die fokale Spastik des EHL mit persistierender Hyperextension im IP-Gelenk der Großzehe beeinträchtigt. Die Deformität trat als Spätfolge 3 Jahre nach dem Schlaganfall zu Tage. Die Therapie bestand in einer bilateralen perkutanen distalen Tenotomie der EHL-Sehne. Auf der linken Seite wurde zusätzlich eine perkutane dorsal Kapsulotomie des IP-Gelenkes durchgeführt.
Eine vollständige und dauerhafte Korrektur mit funktioneller Wiederherstellung wurde erreicht. Es wird angenommen, dass die EHL-Hyperaktivität in unserem speziellen Fall durch eine zusätzliche Schwäche des M. flexor hallucis longus zu einer Hyperextension im IP- statt im MTP-Gelenk geführt hat. Die perkutane distale Tenotomie der EHL-Sehne mit zusätzlicher perkutaner IP-Gelenk-Kapsulotomie führte zu einem guten Langzeitergebnis.
Tension matters – Reconstruction of a chronic rupture of extensor hallucis longus tendon by combination of turn-down-technique, membrane augmentation and selective nerve block
2020, Fuss und Sprunggelenk
Die Versorgung von chronischen Rupturen der Extensor hallucis longus-Sehne stellt aus verschiedenen Gründen eine Herausforderung dar. Oft ist eine direkte Rekonstruktion der Sehnenenden aufgrund Retraktion und Degeneration nicht mehr möglich, ausserdem kann das intraoperative Erreichen einer adäquaten Sehnenspannung grosse Probleme bereiten.
Wir berichten über den Fall eines 24-jährigen Patienten bei dem verschiedene Probleme durch die Kombination einer Matrix-verstärkten turn-down-Plastik mit Anwendung eines selektiven Nervenblocks umgangen werden konnten. Intraoperativ konnte durch aktive Bewegungen der Grosszehe die optimale Adaptionsspannung festgelegt werden.
Die geplante Operationstechnik konnte problemlos umgesetzt werden. 6 Monate postoperativ präsentierte sich der Patient im beschwerdefreien Zustand und einer aktiven Dorsalextension bis 40° bei vollem Kraftgrad.
Das sehr gute Endergebnis bestätigt dieses Vorgehen und zeigt somit eine elegante Möglichkeit zur Versorgung von chronischen Rupturen der Extensor hallucis longus-Sehne auf.
Reconstruction of a chronic rupture of extensor hallucis longus tendon can be very challenging for various reasons. Direct tendon repair is often not possible due to retraction or degeneration. In addition, the choice of adequate tension of tendon during surgery may be difficult.
We report a case of a 24-year-old patient in which various problems could be avoided by combining a turn-down-reconstruction and membrane augmentation. A selective nerve block was used to enable active movements of the toe during surgery to confirm adequate tension of the reconstructed tendon.
The procedure was performed succesfully. After 6 months the patient presented without any complaints. He performed a good range of motion with full power.
This technique shows up an elegant way for reconstruction of a chronic rupture of extensor hallucis longus tendon.
Technique tip: EDL-to-EHL double loop transfer for extensor hallucis longus reconstruction
2019, Foot and Ankle Surgery
Citation Excerpt :
Results are summarized on Table 3. A myriad of surgical techniques have been described to reconstruct the extensor hallucis longus tendon with satisfactory outcomes [1,6–9,13], including interpositional fascia lata allograft [9], EDL tenodesis [1] or free tendon autograft reconstruction using semitendinosus [3,8], gracilis [10] or EDL [1,4], to address small segment defect reconstruction. The use of palmaris longus [7], plantaris and peroneus tertius [6] tendons have been described when a longer graft length is required.
Extensor hallucis longus (EHL) tendon injuries often occur in the setting of lacerations to the dorsum of the foot. End-to-end repair is advocated in acute lacerations, or in chronic cases when the tendon edges are suitable for tension free repair. Reconstruction with allograft or autograft is advocated for cases not amenable to a primary direct repair. This is often seen in cases with tendon retraction and more commonly in the chronic setting. In many countries the use of allograft is very limited or unavailable making reconstruction with autograft and tendon transfers the primary choice of treatment. Tendon diameter mismatch and diminished resistance are common issues in other previously described tendon transfers.
We present the results of a new technique for reconstruction of non-reparable EHL lacerations in three patients using a dynamic double loop transfer of the extensor digitorum longus (EDL) of the second toe that addresses these issues.
At one-year follow up, all patients recovered active/passive hallux extension with good functional (AOFAS Score) and satisfaction results. No reruptures or other complications were reported in this group of patients. No second toe deformities or dysfunction were reported.
Second EDL-to-EHL Double Loop Transfer for Extensor Hallucis Longus reconstruction is a safe, reproducible and low-cost technique to address EHL ruptures when primary repair is not possible.
IV (Case Series).
Split Peroneus Longus Free Tendon Autograft Transplantation for the Treatment of Neglected Extensor Hallucis Longus Tendon Laceration: A Case Report
2018, Journal of Foot and Ankle Surgery
Citation Excerpt :
Zielaskowski and Pontious (9) reported on 1 patient who had undergone EHL reconstruction with a fascia lata allograft, with the intent of restoring active ROM to the hallux. At the last follow-up visit, the patient was able to only minimally extend the hallux, most likely because of a prolonged and chronic inflammatory reaction that led to fibrosis and adhesions to the allograft (8,9). This prolonged inflammatory reaction is a risk that is obviated with the use of an autograft.
A neglected laceration of the extensor hallucis longus (EHL) tendon is rare. Retraction of the tendon ends often occurs when a laceration is neglected, leading to a substantial tendon deficit. A paucity of case reports is available describing the treatment of EHL laceration with a large area of gap secondary to retraction. Therefore, the treatment recommendations are limited. We present the case of a neglected EHL tendon laceration with a 10.5-cm gap in a healthy 22-year-old female. The EHL tendon laceration was repaired using a split peroneus longus tendon autograft that, to the best of our knowledge, has not been previously reported. At the 3-year follow-up evaluation, the patient retained full function of her hallux and was free of symptoms.
Reconstruction of subcutaneous chronic rupture of extensor hallucis longus tendon with semitendinosus autograft
2017, Fuss und Sprunggelenk
Injury to the extensor hallucis longus (EHL) tendon is uncommon – most of the reported cases result from open lacerations. Complete closed subcutaneous ruptures are very rare. Reconstructive surgery is the treatment of choice for chronic ruptures with functional restriction. The study presents a case of a subcutaneous chronic rupture of the EHL tendon reconstructed with semitendinosus tendon autograft. The patient regained nearly full force and range of motion and was able to perform martial arts at eight months after reconstruction.
Verletzungen der Extensor hallucis longus (EHL) Sehne sind selten. Die meisten Fallberichte beziehen sich auf offene Lazerationen durch scharfe Gegenstände. Komplette geschlossene subkutane Rupturen sind ausgesprochen selten. Die wiederherstellende Chirurgie ist die Therapie der Wahl für chronische Rupturen mit persistierendem funktionellem Defizit. In dieser Studie präsentieren wir einen Fall einer chronischen subkutanen Ruptur der EHL-Sehne welche mit einem freien Semitendinosus-Sehnentransplantat rekonstruiert wurde. Der Patient erlangte nahezu die volle Kraft und den kompletten Bewegungsumfang wieder und war in der Lage, 8 Monate nach der Rekonstruktion seinen Kampfsport wieder aufzunehmen.
Tendon 'turnover lengthening' technique
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Two stage tendon reconstruction involving silastic rod insertion, and tenoplasty using both flexor digitorum profundus and superficialis tendons, are technically challenging and require intensive rehabilitation before benefit is appreciated.3,14,15 Split lengthening of the distal stump of a retracted extensor hallucis longus tendon injury has been described and in addition to tendon stump rotation, an acellular dermal scaffold was utilised.16 Another report of delayed FPL avulsion repair after distal stump lengthening has been described, whereby the distal stump was re-attached with wire sutures.17
Tendon defect reconstruction is amongst the most technically challenging areas in hand surgery. Tendon substance deficiency reconstruction techniques include lengthening, grafting, two-stage reconstruction and tendon transfers, however each is associated with unique challenges over and above direct repair. We describe a novel ‘turnover lengthening’ technique for hand tendons that has successfully been applied to the repair of several cases, including a case of attritional flexor and traumatic extensor tendon rupture in two presented patients where primary tenorrhaphy was not possible. In both cases a good post-operative outcome was achieved, as the patients were happy having returned back to normal activities of daily living such that they were discharged 12 weeks post-operatively. Our technique avoids the additional morbidity and complications associated with grafting, transfers and two stage reconstructions. It is quick, simple and reproducible for defects not exceeding 3–4 cm, provides a means of immediate one stage reconstruction, no secondary donor site morbidity and does not compromise salvage by tendon transfer and/or two-stage reconstruction in cases of failure. To our knowledge no such technique has been previously been described to reconstruct such hand tendon defects.

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Case Reports and SeriesSurgical Reconstruction and Mobilization Therapy for a Retracted Extensor Hallucis Longus Laceration and Tendon Defect Repaired by Split Extensor Hallucis Longus Tendon Lengthening and Dermal Scaffold Augmentation

Abstract

Section snippets

Case Report

Discussion

J Plast Reconstr Aesthet Surg

Injury

J Foot Ankle Surg

Arthroscopy

Hand

Hand Clin

Hand

J Orthop Res

Arthroscopy

Clin Podiatr Med Surg

Biomaterials

Clin Podiatr Med Surg

J Shoulder Elbow Surg

J Foot Ankle Surg

Biomaterials

J Hand Ther

Hand Clin

Arch Phys Med Rehabil

J Hand Surg Am

J Hand Surg Br

J Hand Surg Am

J Hand Surg Am

J Foot Ankle Surg

J Hand Ther

J Hand Surg Am

J Hand Ther

J Hand Surg Br

J Hand Surg Br

J Shoulder Elbow Surg

J Hand Surg Eur

Br J Plast Surg

J Hand Ther

J Hand Ther

J Hand Surg Am

A three-year follow-up study of hammer digit syndrome of the hallux

J Am Podiatr Assoc

Spontaneous rupture of extensor hallucis longus tendon

Foot Ankle Int

Acute rupture of the extensor hallucis longus tendon

Foot Ankle Int

Tendon injuries around the ankle

J Bone Joint Surg Br

Tendon lacerations in the foot

Foot Ankle

Dynamic splinting after extensor hallucis longus tendon repair: a case report

Phys Ther

Case Reports and Series
Surgical Reconstruction and Mobilization Therapy for a Retracted Extensor Hallucis Longus Laceration and Tendon Defect Repaired by Split Extensor Hallucis Longus Tendon Lengthening and Dermal Scaffold Augmentation