Bridging the gap: FHL transfer-- cheaper, stronger, and fewer - - PowerPoint PPT Presentation

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Bridging the gap: FHL transfer-- cheaper, stronger, and fewer - - PowerPoint PPT Presentation

Feb 03, 2024 240 likes •702 views

Bridging the gap: FHL transfer-- cheaper, stronger, and fewer complications Michael J. Coughlin MD Conflicts None for this talk Consultant with Arthrex, Stryker, Integra Royalties from Arthrex, Stryker, Integra, Erchonia

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Bridging the gap: FHL transfer-- cheaper, stronger, and fewer complications Michael J. Coughlin MD

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Conflicts

  • None for this talk
  • Consultant with Arthrex, Stryker, Integra
  • Royalties from Arthrex, Stryker, Integra,

Erchonia

  • Textbook royalties- Elsevier
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History

  • 40 year old laborer presents

6 months after work related injury: MRI ahows a gap of 3 cm. with weak plantar flexion and gap

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Acute vs. old ruptures

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Bridging the gap

Delay of a week may make repair difficult

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Old ruptures

  • 20-25% of acute

ruptures are not diagnosed by primary care physician

  • Gap leads to

significant plantar flexion weakness

Inglis A, Sculco T, Clin Ortho 1981

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The problems

  • Poor tissue
  • Contracture of skin
  • Need for a large exposure
  • Tension free closure
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Complications

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Do you have a good plastic surgeon available?

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Eradicate infection

  • Antibiotics
  • Debridement
  • Skin graft
  • Wound vac

But you still have a tendon defect?? What now??

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Courtesy J. DeOrio MD

Major turn down flap!!

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“V-Y” plasty (can get 3-5 cm)

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Flexor Hallucis Longus

  • S. Hansen-1991
  • K. Wapner-1993,1995
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Open FHL transfer?

  • TWO WAYS TO DO IT!
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Pulled proximal

Free up at knot-of- Henry

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Insert guide pin

Make a small incision around the pin site

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Separate incision for exit of drill and tendon

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Single incision technique

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Harvest the tendon, just above the tunnel

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Using the fiber loop to secure the tendon

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Size the tendon

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Drill pin out the plantar aspect

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Drilling hole with ACL reamer

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Passing the suture, and then the tendon

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Secure with appropriate tendon with biotenodesis screw

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Post-op care

  • Immobilize in cast for 6 weeks
  • Partial weight bearing at 3 weeks
  • Cam-boot, FWB with ROM at 6

weeks

  • Jogging, speed walking -12 wks
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Results of FHL transfer

  • High satisfaction rate
  • Improvement in pain

and function

Rahm et al. Operative treatment of irreparable Achilles ruptures with large FHL tendon transfers. FAI 2013 Den Hartog B. FHL transfer for chronic Achilles tendinosis FAI 2003 Wilcox, d, Bohay D, Anderson J, Treatment

  • f chronic Achilles tendon disorders with

FHL transfer. FAI 2000

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Can you transfer FHL alone?

  • Wong M, Ng V. Modified FHL transfer for Achilles insertion

rupture in elderly patients CO 2005

Near normal gait pattern

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Arthroscopic tendon transfer

  • Goncalves et al. Salvage FHL transfer for a

failed Achilles repair: endoscopic technique

  • Lui T. Endoscopic assisted FHL transfer in

the management of chronic rupture of the AT

  • Hirose C- our personal experience

FootInnovate Lecture June 27, 2016

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Exposing the FHL

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Grasping FHL

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Releasing FHL

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Bringing tendon out and placing Krakow suture

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Drill calcaneal hole

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Checking position of the fixation drill hole

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Pulling suture out the heel, tensioning the transfer

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Fixing tendon with interference screw

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Placing screw

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Post op 6 weeks

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Post-op protocol

  • Splint, plantar flexed
  • #2 POD- plantarflexion cast
  • #4 week post op- neutral

flexion BK cast

  • #8 week post op- Cam boot,

FWB, ROM

  • #12 week post op- boot

discontinued.

At 12 weeks, collagen fibers connected to bone in tunnel- best at 26 weeks

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Endoscopic indications

  • Old rupture
  • Prior infection
  • Thin skin, bad skin
  • Skin contracture
  • Collagen disease
  • ------------------
  • Avoid wound complication.
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FHL transfer

  • Good strength
  • Best of all tendons to transfer (Hansen)
  • Choices on technique:

– Two incision – One incision – endoscopic