FHL and ultrasound-guided surgery: towards office surgery?
This lecture explores the prospects for minimally invasive ultrasound-guided FHL release. Dr. Vallotton discusses technical advances, ongoing research, potential complications, and the feasibility of office-based foot surgery. A rich discussion explores current tools, ultrasound surgery, and minimally invasive innovations.
Doctors
Topics
Treatments
Advice
- Dr Jacques Vallotton
- FHL Research Project
- Release under echo
- Office surgery
- Neurovascular risks
- Anatomical dissection
- Release of FHL under ultrasound
- Office surgery
- Needle arthroscopy
- Minimally invasive ultrasound-guided
- Vasculonervous complications
- Surgery possible in consultation
- Research in progress
- Importance of imaging and appropriate tools
FHL Release: Why be interested in ultrasound?
The flexor hallucis longus (FHL) can become locked under the retrotalar pulley and desynchronize the terminal phase of stance. Standard endoscopic release is effective, but interest is growing in even less invasive, ultrasound-guided approaches. The goal: targeted treatment with minimal incision, potentially in office surgery, in carefully selected patients.
This approach requires excellent imaging skills and a detailed understanding of local vascular and nervous anatomy. It is part of the general trend towards more precise surgery, focused on function.
Technical feasibility and safety
Studies on anatomical specimens assess the feasibility of partial or complete sections of the pulley under ultrasound guidance. Complete releases are more likely to expose the patient to vascular and nervous system injuries; partial releases appear to be better tolerated. Ultrasound guidance requires reliable landmarks and a learning curve. The choice of instruments (dedicated blades, retractable knives) determines safety.
Alternatively, needle arthroscopy (2 mm arthroscope) allows direct visual control, at the cost of specific analytical and technical requirements.
This is one of the ways forward if this surgery has to be done often.
Directions and route organization
The ultrasound-guided indication is intended for patients with proven functional Hallux limitus, documented by a positive clinical test and a characteristic podiatric analysis, after failure of methodically conducted conservative treatment. Planning includes imaging, identification of vascular and nervous bundles and anticipation of rehabilitation.
The patient pathway must remain focused on safety: informed consent, exclusion criteria (risky vascular-nervous terrain, low echogenicity), and the possibility of escalation to an endoscopic approach if necessary.
Expected benefits and current limitations
Potentially, ultrasound surgery reduces access morbidity, accelerates recovery, and makes the procedure more organizationally accessible. However, the variability of echogenicity, the risk of injury in the event of complete release, and the lack of standardized dedicated instrumentation currently limit its widespread deployment. Intraoperative pain in the office must be anticipated and controlled (adapted anesthesia).
The priority remains reproducibility and safety, before generalization.
This is a new paradigm for FHL surgery.
Perspectives and training
Dissemination of this approach will involve clinical protocols, tools designed for FHL, and training programs dedicated to surgical ultrasound. Collaborations between orthopedists, radiologists, and engineers will help refine targeted release strategies and clarify their indications. Feedback will guide the standardization of critical steps and the prevention of complications.
In the meantime, the classic endoscopic approach retains its place as the benchmark.
For the patient: a promise conditioned by safety
For a patient, the benefits of minimally invasive release are clear: reduced incision, faster recovery, and potentially outpatient procedures. However, case selection, team expertise, and imaging quality take precedence over technical novelty. A personalized discussion allows for the safest path to restoring a smooth and lasting gait.
The goal remains the same: release the tendon, resynchronize gait and regain function.
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