Arthroscopic Release of Flexor Hallucis Longus Tendon Sheath in Female Ballet Dancers: Dynamic Pathology, Surgical Technique, and Return to Dancing Performance

Flexor Hallucis Longus decompression under ultrasound guidance: A cadaver study

INTRODUCTION

The Flexor Hallucis Longus (FHL) is a muscle that can be subject to multiple impingements caused by exaggerated plantar flexion in athletes. The most common impingement is due to inflammation of the tendon at the retrotalar pulley. The constraints exerted on the FHL are responsible for a pathology called functional Hallux Limitus. Surgical treatment consists of tenolysis of the FHL arthroscopically or via open surgery, by opening the pulley. The objective of this study was to evaluate the risk of lesions of the neurovascular pedicle and the posterior tibial tendon after tenolysis of the Flexor Hallucis Longus under ultrasound guidance.

HYPOTHESIS

The hypothesis of this study is that tenolysis of the Flexor Hallucis Longus could proceed under ultrasound guidance without associated tendon lesions or neurovascular lesions.

MATERIAL AND METHODS

Thirteen cadaveric specimens were studied, resulting in an analysis of 26 feet. Following identification of the Flexor Hallucis Longus, tenolysis with a 19-gauge needle under ultrasound guidance was performed by an orthopedic specialist after hydrodissection to push back the posterior tibial pedicle. The dissection of the cadavers made it possible to verify the positioning of the posterior tibial pedicle, the FHL tendon and the opening of the retrotalar pulley.

RESULTS

Five cadaveric subjects, 10 cases, underwent a complete opening of the retrotalar pulley under ultrasound guidance. In 16 cases, the opening was partial, with a section of the pulley of 65.87±18%. The cases of partial openings showed no neurovascular or tendinous lesions. The 10 cases of complete opening resulted in 5 lesions of the tibial nerve, 4 vascular lesions: 1 venous and 3 arterial, and 6 lesions of the FHL tendon.

CONCLUSION

Tenolysis of the Flexor Hallucis Longus under ultrasound guidance at the level of its retrotalar pulley was systematically associated with neurovascular lesions in the event of complete release of the pulley by the method studied, unlike a partial release where no lesion was found.

LEVEL OF EVIDENCE

III; case-control study.

Arthroscopic treatment of ankle impingement syndrome

Arthroscopic treatment of ankle impingement syndrome (AIS) is a minimally invasive surgical procedure used to address symptoms caused by impingement in the ankle joint. This syndrome occurs when there is abnormal contact between certain bones or soft tissues in the ankle, leading to pain, swelling, or limited range of motion. Traditionally, open surgery was the standard approach for treating AIS. However, with advancements in technology and surgical techniques, arthroscopic treatment has become a preferred method for many patients and surgeons. With improved visualization and precise treatment of the arthroscopy, patients can experience reduced pain and improved functionality, allowing them to return to their daily activities sooner. In this paper, we reviewed the application and clinical efficacy the of arthroscopic approach for treating AIS, hoping to provide a reference for its future promotion.

Flexor Hallucis Longus Tendon Impingement Syndrome: All-inside Arthroscopic Treatment and Long-term Follow-up

This study aimed to evaluate the surgical technique and long-term clinical outcomes of all-inside arthroscopic treatment for flexor hallucis longus (FHL) tendon impingement syndrome. We retrospectively evaluated 34 FHL tendon impingement syndrome patients with complete follow-up data who were admitted from June 2015 to August 2018 and underwent the all-inside arthroscopy technique. The subjects consisted of 20 (58.82%) males and 14 (41.18%) females, with a mean age of 32.7 ± 10.2 (range 21-52) years. The cases consisted of 19 (55.88%) right and 15 (44.12%) left feet. The mean disease duration was 18.5 ± 9.1 (range 10-43) months. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS), Karlsson Ankle Functional Score (KAFS), and 36-item Short Form Health Survey questionnaire (SF-36) scores for pain were 3.6 ± 1.2, 84.1 ± 9.6, 86.3 ± 10.7, and 94.7 ± 9.3, respectively. All patients were treated with all-inside posterior arthroscopy for the debridement of the FHL tendon sheath combined with partial muscle belly resection. Post-operative follow-up and observation of the patients' pain and ankle movement were evaluated using VAS, AOFAS, KAFS, and SF-36. All incisions were healed in the first stage, and no complications such as nerve, blood vessel, or tendon injuries occurred. The hospital stays were 3 to 5 days, with a mean of 3.7 ± 1.3 days. All patients were followed up for 12 to 36 months, with a mean follow-up time of 25.4 ± 8.5 months. By the last follow-up, the ankle joint and hallux movement were normal and returned to the pre-pain state for these patients. The VAS score decreased to 0.2 ± 0.1, while the AOFAS, KAFS, and SF-36 scores increased to 97.7 ± 8.5, 97.9 ± 8.2, and 118.2 ± 8.4, respectively. Advantages of all-inside posterior arthroscopic partial muscle belly resection for the treatment of FHL tendon impingement syndrome include small surgical trauma, fast functional recovery, and reliable outcomes. This procedure is therefore worthy of clinical attention and promotion.

Posterior Ankle Arthroscopy for Flexor Hallucis Longus Entrapment: A Case Report

Introduction:

Stenosing tenosynovitis is a chronic disorder frequently observed in finger triggering of a digit. Regarding the toes, although entrapment of the flexor hallucis longus (FHL) has already been reported in a few cases among sports players, the clinical condition is uncommon. Besides, the case without any specific causes is particularly rare.

Case Report:

We report the case of a 26-year-old male with FHL entrapment. Even though he was unaware of any cause, he felt tenderness on the posteromedial side of his left ankle, and his great toe was locked in the flex position. Magnetic resonance imaging indicated effusion in the tendon sheath of the FHL and the possibility of a partial tear of the FHL. We hypothesized that the scar tissue secondary to the partial tear of the FHL may have been irritated at the retrotalar pulley below the sustentaculum tali, where the FHL glides. Therefore, posterior ankle arthroscopy was performed for the treatment of the FHL entrapment.

Conclusion:

Orthopedic surgeons should list this pathology as a differential diagnosis of posterior ankle pain, even in non-athletes.

Effect of extensive tenosynovectomy on diffuse flexor hallucis longus tenosynovitis combined with effusion

OBJECTIVE

The objective of this study was to examine the clinical and magnetic resonance imaging (MRI) outcomes of extensive tenosynovectomy on patients with diffuse flexor hallucis longus tenosynovitis combined with effusion (DFHLT-E).

METHODS

Consecutive patients undergoing extensive tenosynovectomy for DFHLT-E in the same foot and ankle center from January 2013 to December 2016 were selected; a total of 14 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, MRI, American Orthopaedic Foot and Ankle Society (AOFAS) clinical midfoot scale, and visual analog scale (VAS) pain scores.

RESULTS

The 14 patients were followed up for an average of 15.0 ± 2.3 months (12-18 months). There were no recurrences in all clinical examinations at the final follow-up. The AOFAS score was improved from 61.57 ± 10.70 before surgery to 90.28 ± 9.41 at the final follow-up. The difference was statistically significant (p = 0.001). The VAS score was improved from 4.00 ± 0.82 before surgery to 0.43 ± 0.53 at the final follow-up (p < 0.001). MRI examination revealed two patients with small residual and limited effusion with no clinical symptoms. Superficial pin infection was observed in one patient, and two patients had transient neurostimulation.

CONCLUSIONS

Extensive tenosynovectomy is an effective alternative for the treatment of DFHLT-E with less complications or recurrence.

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.

Ankle Injuries in Dancers

The term dance encompasses a broad range of different styles; much of the orthopaedic literature has focused on ballet dancers. Injury is common in dancers at all levels, and many serious dancers sustain multiple injuries as they progress through their career. Foot and ankle injuries are among the most common injuries experienced by dancers. These injuries include those that are specific to dancers because of the unique physical maneuvers required to effectively perform, but they can also include common injuries that may require relatively different treatment because of the physical demands of the dancer. Os trigonum syndrome and flexor hallucis longus tenosynovitis generally fall into the former category as they are injuries that are more prevalent in dancers due to the extreme plantarflexion involved in dancing, especially ballet, and the relative demand placed on the toe flexors, most notably the flexor hallucis longus. On the other hand, anterior ankle impingement occurs both in dancers and in the general public. In many cases, a team approach to treatment with knowledgeable physical therapists can obviate the need for surgical treatment. If surgical treatment proves necessary, good results can be achieved with sound surgical technique and a well thought-out rehabilitation program.

Endoscopic All-inside Repair of the Flexor Hallucis Longus Tendon in Posterior Ankle Impingement Patients

Longitudinal flexor hallucis longus (FHL) tendon tears are sometimes complicated by posterior ankle impingement syndrome (PAIS), especially in ballet dancers. In recent years, PAIS has been treated endoscopically, but it is difficult to suture FHL tendon tears endoscopically. In this report, we describe how to suture the FHL tendon endoscopically with the Meniscal Viper Repair system (Arthrex, Naples, FL). Without our endoscopic technique, when a patient is found to have a longitudinal tear of the FHL under endoscopy, we must choose to either neglect the tear or convert to an open repair. Open tendon suture techniques have reportedly had relatively good results but require a longer skin incision than endoscopic surgery for PAIS. Compared with the open repair, the advantages of our technique include earlier recovery, less pain, a lower rate of soft tissue complications, and improved healing through better preservation of the blood supply. This technique is an attractive and useful option because it is an easy and safe method for longitudinal FHL tendon tears.