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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

      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.

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      References

        • Al-Qattan M.M.
        Surgical treatment and results in 17 cases of open lacerations of the extensor hallucis longus tendon.
        J Plast Reconstr Aesthet Surg. 2007; 60: 360-367
        • Woodhams L.E.
        A three-year follow-up study of hammer digit syndrome of the hallux.
        J Am Podiatr Assoc. 1974; 64: 955-966
        • Mulcahy D.M.
        • Dolan A.M.
        • Stephens M.M.
        Spontaneous rupture of extensor hallucis longus tendon.
        Foot Ankle Int. 1996; 17: 162-163
        • Poggi J.J.
        • Hall R.L.
        Acute rupture of the extensor hallucis longus tendon.
        Foot Ankle Int. 1995; 16: 41-43
        • Menz P.
        • Nettle W.J.
        Closed rupture of the musculotendinous junction of extensor hallucis longus.
        Injury. 1989; 20: 378-381
        • Griffiths J.C.
        Tendon injuries around the ankle.
        J Bone Joint Surg Br. 1965; 47: 686-689
        • Floyd D.W.
        • Heckman J.D.
        • Rockwood Jr., C.A.
        Tendon lacerations in the foot.
        Foot Ankle. 1983; 4: 8-14
        • Skoff H.
        Dynamic splinting after extensor hallucis longus tendon repair: a case report.
        Phys Ther. 1988; 68: 75-76
        • Lipscomb P.R.
        • Kelly P.J.
        Injuries of the extensor tendons in the distal part of the leg and in the ankle.
        J Bone Joint Surg Am. 1955; 37-A: 1206-1213
        • Scaduto A.A.
        • Cracchiolo III, A.
        Lacerations and ruptures of the flexor or extensor hallucis longus tendons.
        Foot Ankle Clin. 2000; 5: 725-736
        • Bronner S.
        • Ojofeitimi S.
        • Rose D.
        Repair and rehabilitation of extensor hallucis longus and brevis tendon lacerations in a professional dancer.
        J Orthop Sports Phys Ther. 2008; 38: 362-370
        • Park H.G.
        • Lee B.K.
        • Sim J.A.
        Autogenous graft repair using semitendinous tendon for a chronic multifocal rupture of the extensor hallucis longus tendon: a case report.
        Foot Ankle Int. 2003; 24: 506-508
        • Zielaskowski L.
        • Pontious J.
        Extensor hallucis longus tendon repair using a fascia lata allograft.
        J Am Podiatr Med Assoc. 2002; 92: 467-470
        • Wicks M.H.
        • Harbison J.S.
        • Paterson D.C.
        Tendon injuries about the foot and ankle in children.
        Aust N Z J Surg. 1980; 50: 158-161
        • Berens T.A.
        Autogenous graft repair of an extensor hallucis longus laceration.
        J Foot Surg. 1990; 29: 179-182
        • Franck W.M.
        • Olk A.
        • Hennig F.F.
        Combined rupture of the tibialis anterior and the extensor hallucis longus tendons—functional reconstruction.
        Arch Orthop Trauma Surg. 2005; 125: 277-280
        • Kass J.C.
        • Palumbo F.
        • Mehl S.
        • Camarinos N.
        Extensor hallucis longus tendon injury: an in-depth analysis and treatment protocol.
        J Foot Ankle Surg. 1997; 36: 24-27
        • Leung Y.F.
        • Ip S.P.
        • Chung O.M.
        A new method of functional tendon transfer for the dysfunction of extensor hallucis longus.
        Foot Ankle Int. 2002; 23: 1124-1125
        • Scheffler S.U.
        • Schmidt T.
        • Gangey I.
        • Dustmann M.
        • Unterhauser F.
        • Weiler A.
        Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligament reconstruction: delayed remodeling and inferior mechanical function during long-term healing in sheep.
        Arthroscopy. 2008; 24: 448-458
        • Chow S.P.
        • Hooper G.
        • Chan C.W.
        The healing of freeze-dried rabbit flexor tendon in a synovial fluid environment.
        Hand. 1983; 15: 136-142
        • Buck B.E.
        • Malinin T.I.
        • Brown M.D.
        Bone transplantation and human immunodeficiency virus: an estimate of risk of acquired immunodeficiency syndrome (AIDS).
        Clin Orthop Relat Res. 1989; 240: 129-136
        • Greenberg D.D.
        • Robertson M.
        • Vallurupalli S.
        • White R.A.
        • Allen W.C.
        Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction.
        J Bone Joint Surg Am. 1989; 92: 2402-2408
        • Gelberman R.H.
        • Siegel D.B.
        • Woo S.L.-Y.
        • Amiel D.
        • Takai S.
        • Lee D.
        Healing of digital flexor tendons: importance of the interval from injury to repair—a biomechanical, biochemical, and morphological study in dogs.
        J Bone Joint Surg Am. 1991; 73: 66-75
        • Rockwell W.B.
        • Butler P.N.
        • Byrne B.A.
        Extensor tendon: anatomy, injury, and reconstruction.
        Plast Reconstr Surg. 2000; 106: 1592-1603
        • Lister G.
        Indications and techniques for repair of the flexor tendon sheath.
        Hand Clin. 1985; 1: 85-95
        • Gelberman R.H.
        • Amifl D.
        • Gonsalves M.
        • Woo S.
        • Akeson W.H.
        The influence of protected passive mobilization on the healing of flexor tendons: a biochemical and microangiographic study.
        Hand. 1981; 13: 120-128
        • Meyer D.C.
        • Hoppeler H.
        • von Rechenberg B.
        • Gerber C.
        A pathomechanical concept explains muscle loss and fatty muscular changes following surgical tendon release.
        J Orthop Res. 2004; 22: 1004-1007
        • Snyder S.J.
        • Arnoczky S.P.
        • Bond J.L.
        • Dopirak R.
        Histologic evaluation of a biopsy specimen obtained 3 months after rotator cuff augmentation with GraftJacket matrix.
        Arthroscopy. 2009; 25: 329-333
        • Cornwell K.G.
        • Landsman A.
        • James K.S.
        Extracellular matrix biomaterials for soft tissue repair.
        Clin Podiatr Med Surg. 2009; 26: 507-523
        • Gilbert T.W.
        • Sellaro T.L.
        • Badylak S.F.
        Decellularization of tissues and organs.
        Biomaterials. 2006; 27: 3675-3683
        • Valentin J.E.
        • Badylak J.S.
        • McCabe G.P.
        • Badylak S.F.
        Extracellular matrix bioscaffolds for orthopaedic applications: a comparative histologic study.
        J Bone Joint Surg Am. 2006; 88: 2673-2686
        • Brown B.
        • Lindberg K.
        • Reing J.
        • Stolz D.B.
        • Badylak S.F.
        The basement membrane component of biologic scaffolds derived from extracellular matrix.
        Tissue Eng. 2006; 12: 519-526
        • De Deyne P.G.
        • Kladakis S.M.
        Bioscaffolds in tissue engineering: a rationale for use in the reconstruction of musculoskeletal soft tissues.
        Clin Podiatr Med Surg. 2005; 22: 521-532
        • Coons D.A.
        • Barber F.A.
        Tendon graft substitutes—rotator cuff patches.
        Sports Med Arthrosc. 2006; 14: 185-190
        • Derwin K.A.
        • Baker A.R.
        • Spragg R.K.
        • Leigh D.R.
        • Iannotti J.P.
        Commercial extracellular matrix scaffolds for rotator cuff tendon repair: biomechanical, biochemical, and cellular properties.
        J Bone Joint Surg Am. 2006; 88: 2665-2672
        • Aurora A.
        • McCarron J.
        • Iannotti J.P.
        • Derwin K.
        Commercially available extracellular matrix materials for rotator cuff repairs: state of the art and future trends.
        J Shoulder Elbow Surg. 2007; 16: S171-S178
        • Lee M.S.
        GraftJacket augmentation of chronic Achilles tendon ruptures.
        Orthopedics. 2004; 27: s151-s153
        • Barber F.A.
        • McGarry J.E.
        • Herbert M.A.
        • Anderson R.B.
        A biomechanical study of Achilles tendon repair augmentation using GraftJacket matrix.
        Foot Ankle Int. 2008; 29: 329-333
        • Lee D.K.
        A preliminary study on the effects of acellular tissue graft augmentation in acute Achilles tendon ruptures.
        J Foot Ankle Surg. 2008; 47: 8-12
        • Bond J.L.
        • Dopirak R.M.
        • Higgins J.
        • Burns J.
        • Snyder S.J.
        Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket allograft: technique and preliminary results.
        Arthroscopy. 2008; 24: 403-409
        • Johnson K.A.
        • Rogers G.J.
        • Roe S.C.
        • Howlett C.R.
        • Clayton M.K.
        • Milthorpe B.K.
        • Schindhelm K.
        Nitrous acid pretreatment of tendon xenografts cross-linked with glutaraldehyde and sterilized with gamma irradiation.
        Biomaterials. 1999; 20: 1003-1015
        • Courtman D.W.
        • Errett B.F.
        • Wilson G.J.
        The role of crosslinking in modification of the immune response elicited against xenogenic vascular acellular matrices.
        J Biomed Mater Res. 2001; 55: 576-586
        • van Wachem P.B.
        • Brouwer L.A.
        • Zeeman R.
        • Dijkstra P.J.
        • Feijen J.
        • Hendriks M.
        • Cahalan P.T.
        • van Luyn M.J.A.
        Tissue reactions to epoxy-crosslinked porcine heart valves post-treated with detergents or a dicarboxylic acid.
        J Biomed Mater Res. 2001; 55: 415-423
        • Strickland J.W.
        The scientific basis for advances in flexor tendon surgery.
        J Hand Ther. 2005; 18: 94-110
        • Strickland J.W.
        Delayed treatment of flexor tendon injuries including grafting.
        Hand Clin. 2005; 21: 219-243
        • Carl H.D.
        • Forst R.
        • Schaller P.
        Results of primary extensor tendon repair in relation to the zone of injury and pre-operative outcome estimation.
        Arch Orthop Trauma Surg. 2007; 127: 115-119
        • Talsma E.
        • de Haart N.
        • Beelen A.
        • Nollet F.
        The effect of mobilization on repaired extensor tendon injuries of the hand: a systematic review.
        Arch Phys Med Rehabil. 2008; 89: 2366-2372
        • Takai S.
        • Woo S.L.
        • Horibe S.
        • Tung D.K.
        • Gelberman R.T.
        The effects of frequency and duration of controlled passive mobilization on tendon healing.
        J Orthop Res. 1991; 9: 705-713
        • Gelberman R.H.
        • Nunley J.A.
        • Osterman A.L.
        • Breen T.F.
        • Dimick M.P.
        • Woo S.L.
        Influences of the protected passive mobilization interval on flexor tendon healing: a prospective randomized clinical study.
        Clin Orthop Relat Res. 1991; 264: 189-196
        • Gelberman R.H.
        • Botte M.J.
        • Spiegelman J.J.
        • Akeson W.H.
        The excursion and deformation of repaired flexor tendons treated with protected early motion.
        J Hand Surg Am. 1986; 11: 106-110
        • Langley C.
        • Hobbby J.
        Focus on flexor tendon repair.
        J Bone Joint Surg Br. 2010; 89-B: 1396-1401
        • Elliot D.
        • Moiemen N.S.
        • Flemming A.F.
        • Harris S.B.
        • Foster A.J.
        The rupture rate of acute flexor tendon repairs mobilized by the controlled active motion regimen.
        J Hand Surg Br. 1994; 19: 607-612
        • Kim H.M.
        • Nelson G.
        • Thomopoulos S.
        • Silva M.J.
        • Das R.
        • Gelberman R.H.
        Technical and biological modifications for enhanced flexor tendon repair.
        J Hand Surg Am. 1994; 35: 1031-1037
        • Taras J.S.
        • Raphael J.S.
        • Marczyk S.C.
        • Bauerle W.B.
        Evaluation of suture caliber in flexor tendon repair.
        J Hand Surg Am. 2001; 26: 1100-1104
        • Barrie K.A.
        • Wolfe S.W.
        • Shean C.
        • Shenbagamurthi D.
        • Slade J.F.
        • Panjabi M.M.
        A biomechanical comparison of multistrand flexor tendon repairs using an in situ testing model.
        J Hand Surg Am. 2000; 25: 499-506
        • Mowlavi A.
        • Schall J.
        • Wilhelmi B.J.
        Extensor hallucis longus tenorrhaphy by using the Massachusetts General Hospital repair.
        J Foot Ankle Surg. 2004; 43: 412-418
        • Groth G.N.
        Current practice patterns of flexor tendon rehabilitation.
        J Hand Ther. 2005; 18: 169-174
        • Gelberman R.H.
        • Woo S.L.
        • Lothringer K.
        • Akeson W.H.
        • Amiel D.
        Effects of early intermittent passive mobilization on healing canine flexor tendons.
        J Hand Surg Am. 1982; 7: 170-175
        • Pettengill K.M.
        The evolution of early mobilization of the repaired flexor tendon.
        J Hand Ther. 2005; 18: 157-168
        • Paoloni J.
        • De Vos R.J.
        • Hamilton B.
        • Murrell G.A.
        • Orchard J.
        Platelet-rich plasma treatment for ligament and tendon injuries.
        Clin J Sport Med. 2005; 21: 37-45
        • Al-Qattan M.M.
        • Posnick J.C.
        • Lin K.Y.
        Triggering after partial tendon laceration.
        J Hand Surg Br. 1993; 18: 241-246
        • Maitland G.D.
        Manipulation—mobilisation.
        Physiotherapy. 1966; 52: 382-385
        • Refshauge K.M.
        • Taylor J.L.
        • McCloskey D.I.
        • Gianoutsos M.
        • Mathews P.
        • Fitzpatrick R.C.
        Movement detection at the human big toe.
        J Physiol. 1998; 513: 307-314
        • Demirel M.
        • Turhan E.
        • Dereboy F.
        • Yazar T.
        Augmented repair of acute tendo Achilles ruptures with gastrosoleus turn down flap.
        Indian J Orthop. 1998; 45: 45-52
        • Takao M.
        • Ochi M.
        • Naito K.
        • Uchio Y.
        • Matsusaki M.
        • Oae K.
        Repair of neglected Achilles tendon rupture using gastrocnemius fascial flaps.
        Arch Orthop Trauma Surg. 2003; 123: 471-474
        • Maquirrriain J.
        Achilles tendon rupture: during surgical repair and rehabilitation.
        Yale J Biol Med. 2011; 8: 289-300
        • Oei T.S.
        • Klopper P.J.
        • Spaas J.A.
        • Buma P.
        Reconstruction of the flexor tendon sheath: an experimental study in rabbits.
        J Hand Surg Br. 1996; 21: 72-83
        • Liu A.M.
        • Lu S.B.
        Reconstruction of sheath with fascial graft in flexor tendon repair: an experimental study.
        J Hand Surg Br. 1991; 16: 179-184
        • Eiken O.
        • Holmberg J.
        • Ekerot L.
        • Sälgeback S.
        Restoration of the digital tendon sheath: a new concept of tendon grafting.
        Scand J Plast Reconstr Surg. 1980; 14: 89-97
        • Burkhead Jr., W.Z.
        • Krishnan S.G.
        • Lin K.C.
        Biologic resurfacing of the arthritic glenohumeral joint: historical review and current applications.
        J Shoulder Elbow Surg. 2007; 16: S248-S253
        • Bhatia D.N.
        • van Rooyen K.S.
        • du Toit D.F.
        • de Beer J.F.
        Arthroscopic technique of interposition arthroplasty of the glenohumeral joint.
        Arthroscopy. 2006; 22: 570
        • Adams J.E.
        • Merten S.M.
        • Steinmann S.P.
        Arthroscopic interposition arthroplasty of the first carpometacarpal joint.
        J Hand Surg Eur. 2007; 32: 268-274
        • Panchal J.
        • Mehdi S.
        • O'Donoghue J.M.
        • O'Sullivan S.T.
        • O'Shaughnessy M.
        • O'Connor T.P.
        The range of excursion of flexor tendons in zone V: a comparison of active vs passive flexion mobilisation regimes.
        Br J Plast Surg. 1997; 50: 517-522
        • Chesney A.
        • Chauhan A.
        • Kattan A.
        • Farrokhyar F.
        • Thoma A.
        Systematic review of flexor tendon rehabilitation protocols in zone II of the hand.
        Plast Reconstr Surg. 2011; 127: 1583-1592
        • Newport M.L.
        • Tucker R.L.
        New perspectives on extensor tendon repair and implications for rehabilitation.
        J Hand Ther. 2005; 18: 175-181
        • Howell J.W.
        • Merritt W.H.
        • Robinson S.J.
        Immediate controlled active motion following zone 4–7 extensor tendon repair.
        J Hand Ther. 2005; 18: 182-190
      1. Milner C, Russel P. Upper limb: focus on extensor tendon injury. Bone and Joint Website. Available at: http://www.boneandjoint.org.uk/content/focus/extensor-tendon-injury. Accessed May 21, 2012.

      2. Gott M. Tendon phenotype should dictate tissue engineering modality in tendon repair: a review. Discovery Medicine Website, July 26, 2007. Available at: http://www.discoverymedicine.com/Michael-Gott/2011/07/26/tendon-phenotype-should-dictate-tissue-engineering-modality-in-tendon-repair-a-review/. Accessed August 7, 2011.

        • Wolfgang M.
        • Alexander O.
        • Friedriech F.
        Combined rupture of the tibialis anterior and extensor hallucis longus tendons—functional reconstruction.
        Arch Orthop Trauma Surg. 2005; 125: 277-280
        • Silfverskiold K.L.
        • May E.J.
        • Tornvall A.H.
        Gap formation during controlled motion after flexor tendon repair in zone II: a prospective clinical study.
        J Hand Surg Am. 1992; 17: 539-546