Dynamic Splinting After Extensor Hallucis Longus Tendon Repair A

Dynamic Splinting After Extensor Hallucis Longus
Tendon Repair
A Case Report
HILLEL SKOFF
Surgery often is recommended to prevent the symptomatic hallux flexus and
equinus deformity that may result from traumatic laceration of the extensor
hallucis longus (EHL) tendon. Surgical repair of the EHL tendon, however, may
cause scarring and adhesion formation that results in a loss of EHL tendon
function. Dynamic splinting may be used during rehabilitation to prevent these
complications. The purpose of this case report is to describe the use of dynamic
splinting in the treatment of a patient after EHL tendon laceration and surgical
repair.
Key Words: Lower extremity, ankle and foot; Orthotics/splints/casts, lower extremity;
Tendon injuries.
Disruption of the extensor hallucis longus (EHL) tendon is
uncommon and usually results from traumatic laceration.
Unlike the long extensor tendons to the digits, which can be
sacrificed with near impunity, surgical repair of the EHL
tendon is recommended to prevent symptomatic hallux flexus
and equinus deformity.1,2 An important complication of EHL
tendon repair, however, is postsurgical scarring and adhesion
formation that results in a loss of great toe function.3 The
purpose of this case report is to describe how dynamic splinting can be used to prevent complications of EHL tendon
repair.
ASSESSMENT
The patient was a 25-year-old woman who reported pain
in her right hallux and an inability to extend her great toe as
a result of a laceration caused by a wedge of sharp glass. A
physical examination revealed a clean transverse laceration
over the dorsum of her right first metatarsophalangeal (MTP)
joint. The severed ends of the EHL tendon were visible at the
base of the wound. Sensory examination response distal to
the laceration was within normal limits. Vascular examination
findings were also within normal limits. A motor examination, conducted with the ankle joint at 90 degrees, revealed
an inability to extend the interphalangeal joint of the right
great toe, although 15 degrees of active MTP joint extension
was demonstrated. The extensor hallucis brevis muscle was
tested at Fair muscle strength, with pain. The EHL muscle
could not be graded but was noted to be contractile. The
patient's gait was antalgic to the right.
TREATMENT
The patient was taken to the operating room, where the
wound was irrigated, the EHL tendon primarily repaired, and
H. Skoff, MD, is Instructor of Orthopaedic and Plastic Surgery, Beth Israel
Hospital/Harvard Medical School, 330 Brookline Ave, Boston, MA 02215
(USA). He was Hand and Orthopaedic Fellow, Princess Margaret Rose Hospital, Edinburgh, Scotland, and Instructor of Orthopaedic Surgery, School of
Medicine, Yale University, New Haven, CT, when this report was written.
This article was submitted June 25, 1986; was with the author for revision 23
weeks; and was accepted March 30, 1987. Potential Conflict of Interest: 4.
Volume 68 / Number 1, January 1988
the skin sutured. The patient's limb was placed postoperatively in a short-leg plaster of Paris cast with toe plate, the
ankle at 90 degrees, the MTP joint in about 10 degrees of
extension, and the interphalangeal joint in 0 degrees of extension. One week after surgery, the patient requested the removal of the cast because her employment precluded the
wearing of a cast while on duty. Because the EHL tendon
repair required further protection, a dynamic splint was fashioned to allow active hallux flexion while maintaining the
first MTP and interphalangeal joints in passive extension. The
splint was worn under the patient's regular clothing and
therefore was acceptable in her work place.
The technique for splint application was similar to that of
dynamic splinting in the upper extremity. A metal clip was
glued to the dorsal nail plate of the hallux. A second clip was
sewn to the anterior strap of a Velcro anklet. A rubber band
then was suspended between the two clips with sufficient
tension to restrict active plantar flexion of both MTP and
interphalangeal joints to 0 degrees of extension, with the ankle
at 90 degrees (Fig. 1).
The patient was instructed to wear the splint full time for
three weeks and to refrain from activities other than walking
or standing. Her gait pattern during the early splinting period
showed a shorter stride length, decreased velocity, right-sided
antalgia, increased right hip and knee flexion (mild steppage
gait), decreased forefoot ground clearance, and decreased
deceleration from heel-strike to foot flat. After the pain subsided in the hallux, the patient returned to an essentially
normal gait pattern. Beginning with postoperative week five,
the patient was instructed to remove the rubber band for
exercise periods of active right hallux extension supervised by
a physical therapist. Use of the dynamic splint was discontinued after postoperative week six. The patient then was
instructed to restrict her activity to walking and standing
without any type of immobilization for six more weeks.
Follow-up examination at three months after surgery revealed
that active extension of the right hallux was equal to that of
the left hallux: 50 degrees at the MTP joint and 10 degrees at
the interphalangeal joint, with the ankle at 90 degrees. Muscle
testing revealed the right EHL muscle to be at Good strength
compared with Normal strength for the left EHL muscle. The
patient's gait was normal. She was allowed to resume jogging
75
and noncontact sports as desired. A follow-up examination at
six months revealed the patient to be without pain or deformity. The right EHL muscle was at Normal strength on muscle
testing. The patient demonstrated full range of motion at the
MTP and interphalangeal joints and ambulated with a normal
gait. She was discharged without activity restriction.
DISCUSSION
Dynamic splinting has become an accepted mode of
rehabilitation after tendon laceration and surgical repair.4
Although Bunnell recommended dynamic splinting 40
years ago, to prevent postoperative and postinjury adhesion
formation,5 the use of dynamic splints did not become
widespread until the biology of tendon healing was better
delineated. Researchers in the 1950s and 1960s stressed the
importance of adhesions to injured tendons from surrounding
soft tissue as a necessary source of fibroblasts and tendon
nutrition.6,7 This extrinsic pathway of tendon healing requires
immobilization and creates a susceptibility to permanent
limitation of tendon excursion, particularly where tendons
glide through fibrous pulleys. More recently, the intrinsic
pathway of tendon healing has been promulgated. This concept stresses the importance of postinjury tenoblastic proliferation, nourished by synovial fluid.8,9 The intrinsic pathway
does not require immobilization and has been used to support
the application of early mobilization. Both pathways currently
are thought to contribute to tendon healing, modulated by
the severity of the injury, the added surgical trauma, and the
rapidity of postoperative mobilization.
Although not accepted universally,10 the reported benefits
of early tendon mobilization, such as improved tendon healing and superior clinical results,1112 serve as the basis for
dynamic splinting. The clinical relevance of tendon healing
and mobilization traditionally has been associated with surgery of the hand; nevertheless, its relevance to surgery of the
foot should not be overlooked.13 On the dorsum of the foot,
for example, the EHL tendon passes under fourfibrouspulleys
before its insertion (Fig. 2).2 In the largest series of reported
EHL tendon lacerations, surgical repair was advised.14 The
trauma of both EHL tendon disruption and surgical repair,
however, might cause adhesions that restrict tendon gliding.3
Dynamic splinting is a more physiologic alternative to postoperative immobilization of the EHL tendon.5
Fig. 1. Application of dynamic splint after extensor hallucis longus
tendon repair.
CONCLUSION
In this case report, a patient's EHL tendon was repaired
surgically and mobilized early with dynamic splinting. The
patient achieved a good clinical result. Dynamic splinting
after EHL tendon repair had not been reported previously,
but it should be considered as an alternative mode of rehabilitation after tendon surgery in the foot.
REFERENCES
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the Foot, ed 5. St. Louis, MO, C V Mosby Co, 1986, pp 255-256
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3. Jahss MH: Disorders of the Foot. Philadelphia, PA, W B Saunders Co,
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by immediate controlled mobilization. J Hand Surg [Am] 2:441-455,1977
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1946
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Reconstr Surg 34:223-232,1964
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Fig. 2. Anatomy of the extensor hallucis longus tendon and the
dorsal pulleys. (Reprinted with permission from M. O. Tachdjian and
W B Saunders Co2)
7. Skoog T, Persson BT: An experimental study of the early healing of
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PHYSICAL THERAPY