Arthroscopic technique of the flexor hallucis longus pulley
Dr. Jacques Vallotton presents in detail an arthroscopic technique targeted at resection of the flexor hallucis longus pulley. The procedure is explained step by step, with recommendations on setup, anatomical landmarks, equipment adjustments, and precise surgical procedures to ensure optimal tendon glide. A valuable resource for foot surgeons.
Doctors
Topics
Treatments
Advice
- Dr Jacques Vallotton
- Presentation of the material
- Adjusting the arthroscopy tower
- Patient installation
- Anatomical landmarks
- Technical description
- Subtalar arthroscopy
- Pulley resection
- use a 90 degree arthrocaria
- respect the horizontality of the instruments
- protect the nerves during suturing
- avoid continuous suction during milling
- always check the tendon glide
Posterior impingement and FHL pulley: when arthroscopy is necessary
Posterior ankle impingement is sometimes accompanied by blockage of the flexor hallucis longus (FHL) at its pulley. This impediment alters tendon glide and disrupts propulsion. In selected cases, targeted arthroscopic resection restores the tunnel space and returns the tendon to free kinematics.
The intervention is aimed at patients who are in pain despite well-conducted conservative treatment, in whom clinical examination and imaging suggest mechanical conflict and braking of the FHL glide.
Installation, equipment and benchmarks: the rigor of the axes
The patient is positioned in the prone position. Preparation includes a standard arthroscopy tray (optical, shaver, cold light) and a thermocoagulation generator. Irrigation pressure remains moderate, and continuous suction is avoided during reaming to protect soft tissue.
The portals are set up so as to work perpendicular to the Achilles tendon, maintaining strict horizontal alignment of the instruments to avoid any disorientation. This discipline of the axes conditions the safety and readability of the gesture.
You really must always respect the horizontality of the instruments.
Essential operating times: release and check the glide
After identifying the subtalar joint, dissection progresses from lateral to medial to minimize neurovascular risk. The pulley is sectioned in contact with the bone, from top to bottom and from front to back, until sufficient space is obtained in the tunnel.
A hook passed in front of the tendon allows the sliding to be tested and the release of residual low fibers to be assessed. The final check confirms satisfactory fluid circulation and free tendon glide.
Points of vigilance and prevention of complications
Protection of the nerve structures guides the choice of working angles and rotation of the instruments near the posterolateral corner of the talus. If there is any lingering doubt about fluidity, sparing bone retouching is preferable to incomplete release.
At the time of closure, the suture should only encompass the skin to avoid nerve inclusion, which can cause paresthesia. Systematic intraoperative monitoring of glide reduces revisions.
Be very careful to only suture the skin.
Indications, limitations and alternatives
The indication is based on a concordant clinical and radiological bundle: posterior pain, signs of FHL blockage and compatible imaging. Arthroscopy is preferred in active patients when symptoms persist despite optimization of conservative treatment.
Alternatives include shoe adaptation, targeted physiotherapy, and rational infiltration. The decision is discussed on a case-by-case basis, based on the functional impact and the patient's goals.
Functional recovery and realistic expectations
The gradual recovery is organized around pain control, ankle mobility, and posterior chain rehabilitation. Success criteria include resolution of the blockage, improved propulsion, and a return to activities without apprehension.
This minimally invasive surgery aims to faithfully restore tendon glide, ensuring an effective and long-lasting procedure.
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