Flexor Hallucis Longus Tenosynovitis and First Metatarsophalangeal Synovitis After Penetrating Nail Prick Injury: Treated by Zone 3 Flexor Hallucis Longus Tendoscopy and Metatarsosesamoid Arthroscopy

Abstract

Pedal penetrating nail prick injury around the first metatarsal head can result in persistent synovitis of the first metatarsophalangeal joint and tenosynovitis of the flexor hallucis longus tendon. Exploration and debridement is indicated if the condition does not improve with antibiotics. Open surgery requires extensive dorsal and plantar incisions. The purpose of this Technical Note is to report the combined arthroscopic and tendoscopic approaches to address the first metatarsophalangeal joint and flexor hallucis longus tendon pathologies. Because it is a result of a pedal injury, the layerby-layer exploration and debridement is from plantar dorsally. It starts with zone 3 flexor hallucis longus tendoscopy, followed by arthroscopy of the metatarsosesamoid compartment, and finally arthroscopy of the metatarsophalangeal compartment.

Effect of extensive tenosynovectomy on diffuse flexor hallucis longus tenosynovitis combined with effusion

“…Most of the previously reported cases are just local lesions, and most of the patients have a history of big toe trauma or special occupations such as ballerinas or professional athletes, who have tendon sheath stenosis and wedge pressure-caused tendon sliding disorder, so it can be easily diagnosed. 4,9,10 Another type of easily identifiable case is the case combined with os trigonum and posterior malleolus impact, in which FHLT-E may be found coexisting during treating the posterior malleolus impact. 11,12…”

“…3 Its clinical manifestations are diverse, and some cases manifest inaccurate ankle discomfort and pain. Michelson and Dunn 1 reported 81 patients with diffuse pain in the middle and posterior foot, most of whom were misdiagnosed as "plantar fasciitis" and then underwent erroneous treatment; some cases manifest local symptoms; Lui 4 once reported a group of patients with nail prick injury-caused FHLT and the first metatarsophalangeal synovitis, which manifested swelling and pain at the distal end of the first metatarsophalangeal joint; some cases have no clinical symptoms. Lohman et al 5 used magnetic resonance imaging (MRI) and observed asymptomatic sheath effusion of FHL after long-distance running in healthy people.…”

Metatarsosesamoid Arthroscopy for Management of Plantar Pain of the First Metatarsophalangeal Joint After Surgical Correction of Hallux Valgus Deformity

“…Extra-articular causes should be managed by other appropriate procedures such as metatarsal osteotomy 11 or flexor hallucis longus tendoscopy. 12 , 13 , 14 To provide effective treatment of the intra-articular causes, complete arthroscopic adhesiolysis with synovectomy and debridement of the damaged cartilage of the metatarsosesamoid compartment should be performed. If there is fragmentation of the sesamoid bone signifying severe sesamoiditis, arthroscopic sesamoidectomy should also be performed.…”

“…If there is fragmentation of the sesamoid bone signifying severe sesamoiditis, arthroscopic sesamoidectomy should also be performed. 9 , 10 , 14 …”

Septic acute Tenosynovitis of the Flexor Hallucis Longus Tendon Complicating a Lower Limb Erysipelas

“…Lui T H described in the context of minimally invasive approach, the combined arthroscopic and tendoscopic procedure to manage FHL septic tenosynovitis and first metatarsophalangeal (MTP-1) synovitis after prick injury [36]. According to the author, the advantages of this technique include small incisions which provides better cosmetic results, less chance of painful scar formation and thorough exploration and debridement of the FHL tendon and the MTP-1 joint [36].…”