Home Functional Hallux Limitus Surgical treatment Surgical technique
Surgical treatment
Endoscopic tenolysis, step by step
The operation restores the proper gliding of the tendon by opening the fibrous sling at the back of the ankle, through two incisions of less than one centimeter. A high-definition camera guides the procedure; the operation usually takes less than an hour, and recurrence is exceptional.
Freeing the tendon, without cutting it
Surgical treatment is offered when conservative treatment fails. It consists of restoring the proper gliding of the FHL tendon by opening the fibrous sling at the back of the ankle. This operation, called FHL tenolysis, frees the tendon; to be complete, the release sometimes requires “shaving” a bony prominence if it contributes to the impingement.
The operation is performed endoscopically, with a camera transmitting live images to a screen. The patient lies face down, as the portals are posterior. The procedure usually takes less than an hour.
Arthroscopy: two incisions and an HD camera
Through two small incisions, arthroscopy provides a clear view of the FHL tendon, the pulley, and the joints of the ankle and hindfoot. The arthroscope is a tube five millimeters in diameter, fitted with an optical system and a light source; it is coupled to a miniaturized video camera, itself connected to a high-definition screen.
The arthroscope is introduced through a portal on the lateral side of the Achilles tendon. Through this portal, the subtalar joint can be observed and the retro-talar pulley of the flexor hallucis longus identified.
Surgical portals (here a left foot). The arthroscope is introduced parallel to the long axis of the foot until it contacts the bone; “blunt” dissection on the medial side down to contact with the trocar.
Incising the pulley, until the tendon glides freely
Through a portal on the medial side of the Achilles tendon, the instruments used to incise the pulley at its contact with the talus are introduced, until free tendon gliding is achieved. This maneuver also frees the hindfoot, which is locked by the blocked tendon. At the end of the operation, the skin incisions are closed with a single stitch each.
Endoscopic tenolysis in the operating room: the procedure is guided live on a high-definition screen.
Arthroscopic views showing the FHL tendon (blue arrow) and the fibrous pulley constricting the tendon posteriorly (red arrow).
Lasting results
The results of surgical treatment are lasting. Once the gliding of the tendon has been restored, recurrence is exceptional — fewer than 5% of cases. Rebalancing during walking is thus durably restored.
Practical tip
After surgery, buying new shoes is recommended: this avoids returning to the bad patterns linked to the deformation of the old shoes under the effect of the tendon blockage.
The operation in video
Three videos give a concrete view of the technique, from the general presentation to the endoscopic maneuver and the complete procedure.
Functional Hallux Limitus: the surgical technique
Endoscopic tenolysis of the flexor hallucis longus for FHL
The complete endoscopic procedure, narrated by Dr Vallotton
Scientific reference
The technique has been fully described in an international publication, which details the methodology, the portals, and the results of the Centre du pied series.
Reference article
Endoscopic tenolysis of the Flexor Hallucis Longus tendon, surgical technique
Olden TR., Vallotton J., Journal of Arthroscopy, The Journal of Arthroscopic and Related Surgery, 2020
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Your questions about the operation
Duration, anesthesia, scars, return to sports: the answers to patients’ most frequent questions.
In practice
Duration
under one hour
Positioning
face down
Incisions
2, either side of the Achilles
Maneuver
incision of the pulley
Recurrence
under 5%
Weight-bearing
immediate