The extensor hallucis longus tendon as the distal reference point in total knee arthroplasty and tibial alignment

Abstract

The use of the EHL tendon as a reference improves coronal tibial alignment. The EHL is a reliable anatomical landmark to use with extramedullary guide systems.

Efficacy Analysis of Selection of Distal Reference Point for Tibial Coronal Plane Osteotomy during Total Knee Arthroplasty: A Literature Review

“…In a study by Bilgen et al, the mean value of the medial angle of the tibial prosthesis was 89.4% (89.17 when the EHLT was used as the distal marker and 88.57 when the second metatarsal was used as the distal marker), there was no significant difference in mean CTA between groups (P = 0.124); however, the authors reported that 69.8% of the cases in the two groups had <2 external and internal valgus, respectively, The number of tibial components with alpha angles in the normal range was significantly higher in the ERT group (P = 0.017) 7 (Table 1).…”

“…In a clinical trial, Sasanuma et al proved that the proximal and distal one-third of the tibia provides good coronal alignment and better accuracy for the posterior tibial slope compared with the conventional method 13 . In a study by Bilgen et al, the EHL tendon is a reliable anatomical landmark to use with extramedullary guide systems and improves coronal alignment 7 . Hino et al proved that using EHLT results in more accurate lower limb alignment than previously reported reference points 8 .…”

“…Therefore, correctly determining the center of the ankle joint is crucial. To align the extramedullary guides to the mechanical axis of the tibia, a number of bony and soft tissue marker points have been proposed as distal tibial reference points; these include the second metatarsal 6 , the extensor hallucis longus tendon (EHLT) 7–9 , the tibialis anterior tendon (TAT) 10 , the Achilles tendon (AT) 11 , the extensor digitorum longus tendon (EDLT) 11 , and the dorsal pedal artery (DPA) 12 . In addition, in recent years, the lines connecting the proximal and distal thirds of the anterior tibial margin 13 or the medial third of the patellar ligament insertion and the distal quarter of the anterior tibial margin have been used a reference axes during tibial osteotomy 14 .…”

Impact of Use of Intramedullary and Extramedullary Guides on Tibial Component Geometry in Total Knee Replacements: A Systematic Review and Meta-Analysis

“…12,34 The use and accuracy of these devices can be affected by patient factors, obesity rendering superficial anatomical landmarks difficult to palpate, 28 wide IM canals allowing toggle of the IM guide, 35 as can a misplaced entry hole on the tibial plateau. 28 EM landmarks used by individual surgeons vary, some using the medial and lateral malleoli to gauge the center point of the ankle, 34 the second metatarsal, 37 palpable tendons, 38 or the dorsalis pedis pulse. 39 There is a paucity of high-quality RCTs in the literature that compare the two alignment systems, with only three dealing with the mechanical alignment systems exclusively.…”

Tibial Cut Accuracy in Mechanically Aligned Total Knee Arthroplasty Using Extensor Hallucis Longus Tendon to Determine Extramedullary Tibial Guide Position

“…Previous reports have highlighted the difficulties and lack of accuracy in finding the center of the ankle using topographic landmarks. 10,11 The use of the extensor hallucis longus (EHL) muscle 12 is a simple anatomical landmark that is marked before the surgery and helps guide the EMTG ankle placement. The objective of our study was to determine the TC accuracy using EHL tendon method and its effect on the postoperative MA of the extremity.…”