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

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 • Textbook royalties- Elsevier

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

Acute vs. old ruptures

Bridging the gap Delay of a week may make repair difficult

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

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

Complications

Do you have a good plastic surgeon available?

Eradicate infection • Antibiotics • Debridement • Skin graft • Wound vac But you still have a tendon defect?? What now??

Major turn down flap!! Courtesy J. DeOrio MD

“ V-Y ” plasty (can get 3-5 cm)

Flexor Hallucis Longus • S. Hansen-1991 • K. Wapner-1993,1995

Open FHL transfer? • TWO WAYS TO DO IT!

Pulled proximal Free up at knot-of- Henry

Insert guide pin Make a small incision around the pin site

Separate incision for exit of drill and tendon

Single incision technique

Harvest the tendon, just above the tunnel

Using the fiber loop to secure the tendon

Size the tendon

Drill pin out the plantar aspect

Drilling hole with ACL reamer

Passing the suture, and then the tendon

Secure with appropriate tendon with biotenodesis screw

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

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 of chronic Achilles tendon disorders with FHL transfer. FAI 2000

Can you transfer FHL alone? Near normal gait pattern Wong M, Ng V. Modified FHL transfer for Achilles insertion • rupture in elderly patients CO 2005

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

Exposing the FHL

Grasping FHL

Releasing FHL

Bringing tendon out and placing Krakow suture

Drill calcaneal hole

Checking position of the fixation drill hole

Pulling suture out the heel, tensioning the transfer

Fixing tendon with interference screw

Placing screw

Post op 6 weeks

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

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

FHL transfer • Good strength • Best of all tendons to transfer (Hansen) • Choices on technique: – Two incision – One incision – endoscopic