514271

research-articleXXXX
FASXXX10.1177/1938640013514271Foot & Ankle SpecialistFoot & Ankle Specialist

vol. 7 / no. 1 Foot & Ankle Specialist 45

〈 Clinical
Research 〉
Repair of Acute Extensor
Hallucis Longus Tendon Justin C. Wong, MD, Joseph N. Daniel,

Injuries DO, and Steven M. Raikin, MD

A Retrospective Review
Abstract: Background. Extensor Society Hallux questionnaires. Results. digitorum longus may be performed
hallucis longus (EHL) tendon injuries Twenty of 23 patients undergoing EHL if EHL tendon edges are not opposable
may occur with lacerations sustained tendon repair or reconstruction were thus eliminating the need for allograft
over the dorsum of the foot and available for review at an average reconstruction.
lead to hallux dysfunction. Primary clinical follow-up of 12 months
Levels of Evidence: Therapeutic,
repair is performed when tendon (range 3-89 months) and an average
Level IV, Case series
edges are opposable; however, if a telephone follow-up of 5.1 years (range
gap exists between tendon edges, 1-10.4 years). Primary EHL repair Keywords: trauma; soft tissue repair;
then reconstruction with tendon was performed in 80% of cases, with extensor hallucis longus tendon;
graft or tendon transfer may be the remaining patients undergoing lacerations
necessary to restore hallux alignment reconstruction with deep tendon

“
and dorsiflexion. We describe the transfer of the extensor
surgical technique and report the digitorum longus tendon
results on a large series of patients from the second toe. At Most recent studies detailing
having undergone primary repair final follow-up, 19 of
or reconstruction of EHL tendon 20 patients had active operative management have described
lacerations. Methods. We retrospectively hallux dorsiflexion. The
reviewed all patients undergoing average FAAM Activities
either primary repair or secondary
EHL tendon repair or reconstruction of Daily Living score was reconstruction as viable options.”
between January 2005 and May 2012. 94.2% (range 58.3% to
Information on patient demographics, 100%) and the average
mechanism of injury, time to surgery, FAAM Sports score was 94.2% (range
Introduction
intraoperative findings, surgical repair 65.6% to 100%). Conclusion. Primary
or reconstruction technique, and repair or reconstruction of EHL tendon Extensor hallucis longus (EHL) tendon
postoperative function were collected. lacerations is a reliable procedure injuries commonly occur because of
Patients were contacted by telephone that restores hallux alignment and laceration sustained along the dorsum of
for administration of the Foot and function in most patients as measured the foot or ankle. While the true
Ankle Ability Measure (FAAM) and by the validated FAAM questionnaire. incidence of EHL tendon lacerations is
American Orthopaedic Foot and Ankle Deep tendon transfer from the extensor unknown, the largest reported series of

DOI: 10.1177/1938640013514271. From the Department of Orthopaedic Surgery (JCW) and Rothman Institute Orthopaedics (JND, SMR), Thomas Jefferson University,
Philadelphia, Pennsylvania. Each author certifies that our institution has approved the human protocol for this investigation and that all investigations were conducted in
conformity with ethical principles of research. Address correspondence to: Steven M. Raikin, MD, Director of Foot and Ankle Service, Professor of Orthopaedic Surgery,
Thomas Jefferson University, Rothman Institute Orthopaedics, 925 Chestnut Street, Philadelphia, PA 19107; e-mail: steven.raikin@rothmaninstitute.com
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2013 The Author(s)

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46 Foot & Ankle Specialist February 2014

extremity muscle and tendon disruptions been treated surgically for EHL tendon approached through a longitudinal
(1014 cases) found that 11% of lower lacerations, from January 2005 to May extension of the original site of
extremity cases involved toe extensors.1 2012. The clinical records were obtained laceration. In most cases, the traumatic
Although rare, closed injuries have also and reviewed for 23 patients meeting our laceration was horizontally located, and
been described in the setting of extreme criteria. We abstracted demographic these were extended into a “Z” incision
dorsiflexion against resistance,2 as information, including age and gender, in to allow access to the tendon ends. Each
attritional ruptures due to tendon addition to clinical data, including date end of the tendon was mobilized and
degeneration from local steroid of injury, mechanism of injury, location freshened with sharp debridement. The
injections3 or from iatrogenic thermal of laceration, date of surgery, and ankle and hallux were then placed in
injury occurring during ankle concomitant tendon, nerve, or blood neutral position and the tendon ends
arthroscopy.4 vessel injury. The operative reports were were reapproximated and repaired with
There is a paucity of literature on the reviewed and the following data were No. 2-0 Ethibond suture in a Krakow or
optimal treatment for EHL tendon recorded: tendon gap (if present) and Kessler fashion. If tendon ends were
lacerations. Two cases of nonoperative type of surgery (primary repair or significantly retracted, locking stitches
management resulting in recovery of toe reconstruction). Postoperative clinic were placed in each end and gentle,
extension are often cited as evidence notes were reviewed for EHL function steady traction was applied to achieve
that some EHL tendon lacerations may and complications such as failure of apposition followed by tying of the
be treated without surgery.5,6 Most recent surgical repair, surgical scar pain, suture ends. If EHL tendon ends could
studies detailing operative management stiffness, parasthesias, toe deformity, or not be reapproximated, then
have described either primary repair or wound healing problems were noted. reconstruction was performed by
secondary reconstruction as viable Twenty of the 23 patients were transferring the extensor digitorum
options.5,7-10 Only one study attempted to available for follow-up telephone longus (EDL) tendon of the second toe to
determine objective outcomes using assessment. One patient refused to the distal EHL tendon stump as a free
modern scoring systems, such as the participate in the study, and 2 had tendon graft (1 case) or as a deep tendon
American Orthopaedic Foot and Ankle moved and could not be located or transfer (3 cases; Figures 1 and 2).
Society (AOFAS) Hallux scale.7 While contacted. We felt that function was the Second toe extensor function was
operative management would seem to be most relevant modality to assess in preserved by performing tenodesis of the
indicated in most patients, it is important quantifying success of management. As distal second toe EDL tendon to the
to consider potential complications from such we chose the FAAM scores, adjacent third toe EDL tendon.
surgery, such as painful scar formation including subsets for ADL and Sports for Postoperatively, patients were placed in
and joint stiffness from tendon outcomes, which have been previously a short-leg splint with hallux held in
adhesions.5,10 validated. Although the AOFAS Hallux slight dorsiflexion at the
The purpose of this study was to report score has been previously used to metatarsophangeal and interphalangeal
on a large case series of patients with quantify outcomes after EHL repair, it is joints for a period of three weeks.
EHL tendon lacerations, treated by 2 not a validated outcome measure and Patients were kept non–weight bearing
orthopaedic surgeons, using objective requires direct clinician evaluation for for the initial 3-week period to prevent
standardized outcomes to include the reliability. For this reason, AOFAS Hallux potential stress of the tendon repair/
Foot and Ankle Ability Measures (FAAM) scores were obtained in only 14 of 20 reconstruction and limit postoperative
and AOFAS Hallux scales, including patients. Patients were additionally edema, followed by weight bearing in a
assessment of EHL function by clinical questioned about specific symptoms short leg cast for an additional 3 weeks.
exam. We believe that most patients such as scar pain, parasthesias, foot or At 6 weeks, patients were transferred to
undergoing repair of EHL tendons regain toe deformity, ability to lift the hallux off a removable walker boot and enrolled in
a high level of function as measured by the ground while standing, need for physical therapy for gait training,
the FAAM Activities of Daily Living revision surgery, and the presence or strengthening, and range of motion of
(ADL), FAAM Sports, and AOFAS Hallux absence of wound healing issues in the the ankle and toes for an additional 6
scales. postoperative period. weeks.

Materials and Methods Surgical Repair or Results

Reconstruction Technique The average telephone follow-up was 5
Patient Selection Primary repair or reconstruction of the years (range 1-10.4 years) in 20 of the 23
After institutional review board EHL tendons was performed in the patients available for review, with only 2
approval, we reviewed the surgical logs operating room with the patient in patients having less than 2-year
of 2 foot and ankle orthopaedic supine position. A nonsterile calf telephone follow-up. Postoperative
specialists to identify patients that had tourniquet was used. The repair was clinical notes were available for these

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vol. 7 / no. 1 Foot & Ankle Specialist 47

Figure 1.
Reconstructive technique for extensor hallucis longus (EHL) gap. (A) After tendon mobilization, persistent gapping present in EHL
tendon. (B) EHL reconstruction with free tendon autograft from EDL of second toe; second toe extension preserved by proximal and
distal tenodesis between EDL of second and third toes. (C) EHL reconstruction with deep tendon transfer of extensor digitorum longus
(EDL) of second toe, combined with proximal EHL tenodesis; distal EDL of second toe is tenodesed to adjacent EDL of third toe.

Figure 2. Table 1.
Clinical example of extensor Zones of Extensor Hallucis Longus (EHL) Tendon Laceration and Distribution of
digitorum longus (EDL) free tendon Injuries.
autograft: Viewed from medial side
of foot. Extensor hallucis longus Zone Anatomic Description No. of Patients (%)
(EHL) tendon gap has been spanned 1 At EHL insertion 0 (0)
with free tendon autograft from EDL
of second toe; EDL of second toe 2 Between zones 1 and 3 1 (5)
tenodesed proximally (not visible)
3 Over metatarsophalangeal joint 6 (30)
and distally to EDL of third toe.
4 Between zones 3 and 5 6 (30)
5 Under extensor retinaculum 7 (35)
6 Proximal to extensor retinaculum 0 (0)

but were not reachable for survey and location was available in the medical
were excluded. record and classified according to
The average age of the patients at the Al-Qattan7 (Table 1). In almost all
time of injury was 40.1 years (range 9-65 patients, the mechanism of injury
years). The gender distribution of involved laceration to the dorsum of the
same patients with an average follow-up patients was 7 males and 13 females. foot or ankle with a sharp or heavy
of 12 months (range 3-89 months). One There was nearly equal distribution object (glass, knife, mirror, metal object;
patient declined to participate in the between right- and left-sided injuries, Table 2). In 13 of 20 cases (65%),
study and 2 other patients had with 57% of injuries involving the right laceration of the EHL tendon had been
postoperative medical records available foot. In all 20 patients, detailed missed at the time of the patient’s
with an average follow-up of 3 months information about foot laceration emergency room evaluation. In these

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 48

Table 2.
Patient Demographics and Outcomes.
Foot & Ankle Specialist

Time to Initial EHL

Age Other Surgery Retraction FAAM FAAM AOFAS Notes/
Patient (Years) Gender Mechanism Injury Zone Injuries (Days) (cm) Surgical Procedure ADL (%) Sport (%) Hallux (Total) Complication(s)

1 56 M Dropped knife 3 EHB 57 5 #2 EDL transfer to EHL, 100 100 90 Revision EHL
proximal EHL-EDL reconstruction
tenodesis

2 24 F Broken mirror 4 — 24 6 #2 EDL transfer to EHL, 97.6 96.9 85 Hallux IP joint droop
proximal EHL-EDL
tenodesis

3 28 F Dropped knife 4 — 113 6.5 #2 EDL free tendon 100 100 100 Hallux stiffness
interposition graft
to EHL

4 50 F Broken mirror 5 SPN 28 7 #2 EDL transfer to EHL 100 100 100 Parasthesias in SPN
proximal EHL to EDL distribution
tenodesis

5 54 F Broken mirror 5 TA, EDL, 0 0 Primary, Krakow 100 100 90 Emergent initial
DPN, surgical exploration:
anterior Anterior tibial
tibial artery ligated and
artery tendons repaired;
parasthesias in DPN
distribution

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6 38 F Broken glass 5 TA, EDL, 3 0 Primary, Krakow 97.6 95.8 83 Emergent initial
table DPN, SPN, surgical exploration:
anterior Anterior tibial artery
tibial ligated; wound
artery closed. Parasthesias
of SPN and DPN
distribution, ankle
and hallux stiffness

(continued)
February 2014
 Table 2. (continued)
vol. 7 / no. 1

Time to Initial EHL

Age Other Surgery Retraction FAAM FAAM AOFAS Notes/
Patient (Years) Gender Mechanism Injury Zone Injuries (Days) (cm) Surgical Procedure ADL (%) Sport (%) Hallux (Total) Complication(s)

7 47 F Dropped glass 5 — 3 0.5 Primary, Krakow 100 100 — None

8 36 M Dropped metal 5 — 3 0.5 Primary, Krakow 100 65.6 — None

object

9 17 F Dropped glass 3 — 28 0.6 Primary, Krakow 100 100 100 None

10 9 M Cut in bathtub 2 — 8 1 Primary, Kessler-Tajima 100 100 100 None

11 57 F Dropped knife 3 — 9 1 Primary, Krakow 58.3 96.9 — None

12 26 M Dropped metal 5 — 7 1 Primary, Krakow 100 96.9 — None

object

13 36 M Dropped glass 5 — 7 1 Primary, Krakow 97.6 96.9 — None

14 42 F Dropped glass 3 — 16 1.5 Primary, Krakow 82.1 100 — None

15 42 F Dropped glass 3 DM cut, 8 2 Primary, Krakow 100 100 100 Wound dehiscence,
bottle nerve managed with
wound care

16 65 F Dropped knife 4 — 16 4 Primary, Krakow 89.5 75 88 None

17 37 M Dropped slate 3 EHB 4 5 Primary, Krakow 100 100 100 None

18 30 F Dropped knife 4 — 55 6 Primary, Krakow 98.8 93.8 71 None

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19 51 M Dropped glass 4 — 43 7 Primary, Krakow 63.1 65.6 77 None
plate

20 57 F Dropped glass 4 — 16 10 Primary, Krakow 100 100 100 None

  40.1 7 M; 19.9 3.3 (range 94.2 94.1 91.7 (range  

(range 13 F (range 0-10) (range (range 71-100)
9-65) 0-113) 58.3- 65.6-
100) 100)

Abbreviations: M, male; F, female; EHB, extensor hallucis brevis; EHL, extensor hallucis longus; EDL, extensor digitorum longus; SPN, superficial personal nerve; DPN, deep peroneal nerve; TA, tibialis anterior.
Foot & Ankle Specialist
49
50 Foot & Ankle Specialist February 2014

patients, primary repair of the skin portion of EHL was variably tenodesed was based on the experience of a single
laceration was performed and these to the EHB tendon or EDL tendon to the patient whose physician-rated outcome
patients were subsequently referred after second toe. Allograft tendon was not of “satisfactory” result was equivalent to
becoming aware that they could not used for any of the reconstructions. 5 other patients who had undergone
extend their hallux. In the 7 cases where Postoperatively, complications were surgical repair. As highlighted by Kass et
EHL involvement had been recognized, 2 observed in 3 of 20 (15%) patients. One al,11 the location of EHL tendon
had concomitant arterial injury that patient had delayed wound healing laceration is critical to the potential
underwent surgical exploration at initial managed with office-based local care success of nonoperative management. In
presentation. The average time from and subsequently developed stiffness. cases where laceration occurs distal to
injury to surgery was 19.9 days (range Hallux stiffness was additionally seen in the extensor expansion of the EHL,
0-113 days). One of the patients had one other patient. One patient had late hallux dorsiflexion function is preserved
prior EHL tendon repair at another development of hallux droop at the and nonoperative treatment should be
institution, which reruptured 4 weeks interphalangeal joint and reports of the first line of treatment. In cases of
postrepair and was confirmed on occasional toe stubbing when ambulating EHL laceration proximal to the extensor
magnetic resonance imaging. without shoes but did not request a expansion, surgical intervention should
Concomitant tendon laceration revision surgery. Additionally, 3 of the 4 be considered to address the loss of
occurred in 4 of 20 (20%) cases. In 2 of patients who sustained nerve injuries at interphalangeal joint extension. Recently,
these cases, extensor hallucis brevis was the time of their tendon lacerations there has been a trend toward primary
the other tendon injured. In 2 other complained of persistent numbness in surgical repair of acute tendon injuries or
cases, both tibialis anterior and extensor that nerve distribution at final follow-up. surgical reconstruction if tendon
digitorum longus were also injured. Twenty patients were successfully retraction prevents tension-free tendon
Concomitant nerve injury occurred in 4 contacted for administration of the FAAM opposition3,5,7,12; however, few studies
of 20 (20%) cases: isolated deep ADL and FAAM Sports questionnaires. have used patient-rated objective
peroneal nerve in 2 cases; isolated The average FAAM ADL score was 94.2% outcome measures to quantify function
superficial peroneal nerve in 1 case, (range 58.3% to 100%; Table 2) The after repair.7
isolated dorsomedial cutaneous nerve in average FAAM Sports score was 94.2% The largest previously reported case
1 case, and combined deep peroneal and (range 65.6% to 100%). In our series, 18 series of EHL tendon lacerations
superficial peroneal nerves in 1 case. of 20 (90%) patients estimated their included 17 patients with industrial-
Concomitant arterial injury occurred in 2 overall level of foot function and graded related injuries, of which 15 had
of 20 (10%) of cases (anterior tibial artery their foot as “normal” or “nearly normal.” complete tendon disruptions that
in both cases). In both these cases, Only 2 patients graded their overall foot underwent primary repair and
because of profuse bleeding the patients function as “abnormal” despite having postoperative immobilization with
had been taken urgently to the operating active hallux dorsiflexion. No patients transarticular Kirschner-wire pinning of
room where anterior tibial arterial injury considered their foot to be “severely the metatarsophalangeal joint for 6
was identified and the vessel ligated. In abnormal.” weeks.7 In 2 of 17 patients, an
one of these cases, orthopaedic The AOFAS Hallux score was incomplete EHL tendon laceration was
consultation was obtained obtainable in 14 of the 20 patients. For found at time of surgery and patients did
intraoperatively and tendon repair was these patients, the average Hallux pain not have tendon repair; postoperatively,
performed at that time. The other patient score was 34.3 (range 20-40) and the these patients were treated with early
with arterial injury had been stabilized at average Hallux function score was 42.9 mobilization. At a final follow-up of 3
another institution and sent for foot and (range 33-45). The average Hallux months, no patients had any wound
ankle consultation as an outpatient. alignment score was 14.5 (range 8-15). complications and the AOFAS Hallux
At the time of surgery, with the foot The average total Hallux score was 91.7 pain score was 40 of 40, indicating no
and hallux in a neutral resting position, out of a possible 100 points (range pain. The average AOFAS Hallux
18 of 20 (90%) of patients had 71-100). function score was 42.1 (out of possible
measureable extensor hallucis longus 45 points), indicating very little
tendon retraction. The average EHL functional limitation.
tendon retraction encountered at the
Discussion With an average follow-up of 5 years,
time of operation was 3.3 cm (range 0-10 Extensor hallucis longus tendon injuries our patients exhibited AOFAS Hallux
cm). After tendon mobilization, in 16 of are commonly associated with pain and functional scores similar to
20 (80%) cases, direct primary repair of lacerations sustained to the dorsum of those reported by Al-Qattan,7 suggesting
the EHL tendon was possible. In the the foot from dropping a sharp object that EHL tendon repair and
remaining 4 cases, the EDL to the second onto an unshod foot. Prior reconstruction has durable long-term
toe was used to transfer to the distal recommendation for consideration of results. In contrast to Al-Qattan, our
portion of the EHL tendon. The proximal nonoperative management by Griffiths6 postoperative immobilization did not

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vol. 7 / no. 1 Foot & Ankle Specialist 51

involve transarticular Kirschner-wire parasthesias despite no attempt at nerve 3. Poggi JJ, Hall RL. Acute rupture of the
pinning, thereby eliminating the need for repair at the time of surgery. extensor hallucis longus tendon. Foot Ankle
Int. 1995;16:41-43.
pin removal in the postoperative period. Limitations of this study include the
In cases where direct tension-free retrospective design and lack of strength 4. Tuncer S, Aksu N, Isiklar U. Delayed
rupture of the extensor hallucis longus
approximation of tendon edges is not testing of the EHL to grade level of and extensor digitorum communis tendons
possible, case reports have described use function at latest follow up. However, after breaching the anterior capsule with
of interpositional grafts such as fascial from a patient perspective only 2 of the a radiofrequency probe during ankle
lata allograft or semitendinosus autograft 20 patients graded their foot as arthroscopy: a case report. J Foot Ankle
with good results.4,9,12 Additionally, an “abnormal” and only 1 of the 20 patients Surg. 2010;49:490.e1-490.e3.
EHL split tendon lengthening reinforced was noted to have drooping of the 5. Floyd DW, Heckman JD, Rockwood CA.
hallux at the interphalangeal joint that Tendon lacerations in the foot. Foot Ankle.
with dermal matrix has been described
1983;4:8-14.
as an alternative to use of free-tissue interfered with ambulating barefoot.
6. Griffiths JC. Tendon injuries around the
auto- or allograft.13 In our series, the EHL Strengths of the study include the large
ankle. J Bone Joint Surg Br. 1965;47-B:
tendon edges were unable to be series of patients treated with a 686-689.
reapproximated in 4 patients, despite standardized surgical protocol with 7. Al-Qattan MM. Surgical treatment and
tendon mobilization. These patients identification of concomitant injuries and results in 17 cases of open lacerations of
underwent local deep tendon transfer of postoperative complications, as well as the extensor hallucis longus tendon. J Plast
the EDL to second toe to the distal assessment of outcomes with a validated Reconstr Aesthet Surg. 2007;60:360-367.
stump of the EHL tendon. Weakness of functional score, the FAAM. 8. Berens TA. Autogenous graft repair of an
hallux dorsiflexion occurred in 1 of these Extensor hallucis longus tendon injuries extensor hallucis longus laceration. J Foot
are most commonly the result of a sharp Surg. 1990;29:179-182.
4 patients. The perceived benefit of this
procedure is the use of local autogenous object dropped onto the dorsum of the 9. Park HG, Lee BK, Sim JA. Autogenous graft
repair using semitendinosus tendon for a
tissue and avoidance of allograft tissue. foot. Primary repair is preferable when chronic multifocal rupture of the extensor
The most cited complication of EHL tendon edges can be reapproximated hallucis longus tendon: a case report. Foot
tendon repair is painful scar formation, with minimal tension on the repair. Ankle Int. 2003;24:506-508.
which can occur in as many as 38% of However, in cases where tendon 10. Wicks MH, Harbison JS, Paterson DC.
patients.5 In our series, there were few retraction persists after tendon Tendon injuries about the foot and ankle in
complications. Wound complication mobilization, local deep tendon transfer children. Aust N Z J Surg. 1980;50:158-161.
occurred in 1 of 20 patients (5%), but of the EDL tendon from the second toe 11. Kass JC, Palumbo F, Mehl S, Camarinos N.
this case of delayed wound healing was is an effective alternative to allograft Extensor hallucis longus tendon injury: an
in-depth analysis and treatment protocol. J
managed nonoperatively with wound reconstruction. At an average final Foot Ankle Surg. 1997;36:24-27.
care. Hallux stiffness was reported in 2 follow-up of 5 years, 19 of 20 patients
12. Zielaskowski LA, Pontious J. Extensor
of 20 patients (10%) and persistent hallux (95%) had active hallux dorsiflexion. hallucis longus tendon rupture repair using
droop was noted in 1 of 20 patients a fascia lata allograft. J Am Podiatr Med
(5%). Parasthesias in the foot were Assoc. 2002;92:467-470.
reported in 3 of 20 patients (15%), but in
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