Surgical treatment
Twenty-five years of surgical history
From the first open tenolyses in 1999 to today’s standardized arthroscopic technique, the history of this procedure is that of expertise patiently built — more than 1,660 operated feet, and an anatomy of the impingement documented over the course of the series.
1999, the first open tenolyses
Dr Jacques Vallotton operated on his first patients in 1999 through a 4 to 5 cm medial retro-malleolar open approach. Access to the tendon at depth is awkward, and care must be taken to spare the calcaneal branch of the saphenous nerve. Some twenty cases were operated on this way, with very encouraging results.
The FHL tenolysis is limited to the retro-talar pulley: it is not extended to the calcaneal retinaculum as in the technique described by Hamilton. The indications mainly involve FHL tenosynovitis, but also some chronic Achilles tendinitis and knee pain of the patellofemoral or iliotibial band syndrome type, in patients whose improvement with conservative treatment did not last. The correlation between FHL tendon impingement and knee pain was already known at the time.
2000, the arthroscopic turning point with Prof. van Dijk
In 2000, Dr Vallotton traveled to the Academic Medical Center in Amsterdam to meet Professor Niek van Dijk. This foot specialist had developed arthroscopy of the ankle and hindfoot, describing its portals and its surgical technique.
From then on, FHL tenolyses were performed arthroscopically, using two portals located on either side of the Achilles tendon — more than 1,660 feet operated on to date. Over this long series, the anatomy of the FHL and the configuration of the retro-talar tunnel have been studied and documented, which today allows a better understanding of the origins of the impingement and a refinement of the surgical treatment.
What the series taught about the anatomy of the impingement
Several anatomical factors can contribute to the impingement and must be taken into account to restore physiological gliding of the FHL tendon.
factor
Muscular hypertrophy of the FHL
An oversized muscle belly crowds the retro-talar tunnel and impedes the gliding of the tendon.
factor
Low-lying musculotendinous junction
When the muscle extends too far down the tendon, it enters the pulley with every step.
factor
Prominent posterolateral talar tubercle
A bony prominence of the talus can narrow the tunnel and pinch the tendon.
factor
Os trigonum
This accessory ossicle, present in some patients, reduces the space available behind the talus.
factor
Tenosynovitis
Inflammation of the sheath thickens the tendon and perpetuates the impingement within the tunnel.
Continue
The surgical indications
Who FHL tenolysis is for, from hallux rigidus to painful knee syndromes.
At a glance
First tenolysis
1999
Open approach
some twenty cases
Arthroscopy
since 2000
Series
1,660 feet (2020)
Reference
Prof. N. van Dijk, AMC
Target
retro-talar pulley