Anatomical Variations of the Flexor Hallucis Longus and Flexor Digitorum Longus

NewsBot · Jun 23, 2013

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Anatomical Variations of the Flexor Hallucis Longus and Flexor Digitorum Longus in the Chiasma Plantare.
Plaass C, Abuharbid G, Waizy H, Ochs M, Stukenborg-Colsman C, Schmiedl A.
Foot Ankle Int. 2013 Jun 20.

BACKGROUND:
The flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendon are routinely used in reconstructive foot and ankle surgery. The tendons cross in the chiasma plantare and show variable interconnections. This can complicate harvesting of the tendons. Previous anatomical studies were inconclusive and did not reference the connections to surgically relevant landmarks. The purpose of this study was to integrate these conflicting results, introduce a thorough classification system, and analyze the position of the interconnections relative to the surgically relevant bone landmarks.
METHODS:
Sixty embalmed feet of 30 cadavers were analyzed anatomically with respect to the individual cross-links in the planta pedis. All feet were photo documented. The interconnections were classified in a modified classification system and distances to surgically relevant anatomic landmarks measured.
RESULTS:
A proximal to distal connection from the FHL to the FDL was found in 95% of the feet (types I and III), in 3% there was a proximal to distal connection from the FDL to the FHL (type II) tendon only, and in 30% a crossed connection (type III) was found. The average point of branching of the FHL and FDL tendon was 5.3 and 4.6 cm distal to the medial malleolus, respectively.
CONCLUSION:
Our modified classification system accommodated all found variations. In over 90% of the feet, a proximal to distal connection from the FHL to the FDL was found, which might contribute to the residual function of the lesser toes after FDL transfer.
CLINICAL RELEVANCE:
The exact knowledge of the anatomy of the crossing of FDL and FHL in the plantar foot is essential to facilitate tendon harvesting, reduce morbidity and explain possible postoperative functional loss.
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NewsBot · Dec 19, 2015

Anatomical study of toe flexion by flexor hallucis longus
Mutsuaki Edama et al
Annals of Anatomy - Anatomischer Anzeiger; 15 December 2015

Because connections exist between the flexor hallucis longus (FHL) and flexor digitorum longus (FDL), the FHL is surmised to exert a flexion action on the lesser toes, but this has not been studied quantitatively. The objectives of this study have thus been to clarify the types of FHL and FDL connections and branching, and to deduce the toe flexion actions of the FHL. One hundred legs from 55 cadavers were used for the study, with FHLs and FDLs harvested from the plantar aspect of the foot, and connections and branches classified. Image-analysis software was then used to analyze cross-sectional areas (CSAs) of each tendon, and the proportion of FHL was calculated in relation to flexor tendons of each toe. Type I (single slip from FHL to FDL tendon) was seen in 86 legs (86%), Type II (crossed connection) in 3 legs (3%), and Type III (single slip from FDL to FHL tendon) or Type IV (no connection between muscles) in 0 legs (0%). In addition, Type V (double slip from FHL to FDL tendon) was seen in 11 legs (11%), representing a new type not recorded in previous classifications. In terms of the various flexor tendons, the proportion of FHL showing tendons to toes 2 and 3 was high, at approximately 50-70%. Consequently, considering the branching type and proportion of CSA, the FHL was conjectured to not only act to flex the hallux, but also play a significant role in the flexion of toes 2 and 3. These results offer useful information for future clarification of the functional roles of tendinous slips from the FHL.
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NewsBot · Sep 22, 2019

Communications between the tendons of flexor hallucis longus and flexor digitorum longus: a cadaveric study.
Vasudha TK et al
Surg Radiol Anat. 2019 Sep 20

INTRODUCTION:
Tibialis posterior tendon insufficiency in adult acquired flat foot deformity (AAFFD) is treated by reinforcing the posterior tibial tendon (PTT) using grafts from flexor hallucis longus (FHL) and flexor digitorum longus (FDL). The communication between FHL and FDL will influence the length of the graft that can be harvested from FHL and FDL. In this study, we aim to study the patterns of communications between FHL and FDL tendons and the location of Master Knot of Henry (MKH) and point of division of FDL tendons in Indian population.

MATERIALS AND METHODS:
In this observational descriptive study, 36 formalin-fixed cadavers were sourced from Subbaiah Institute of Medical Sciences, Shimoga, Karnataka, India, and JIPMER, Puducherry, India, during the period of 2017-19. Various parameters of the foot to locate the MKH and point of division of FDL tendons and various types of communications between FHL and FDL were observed.

RESULTS:
Among the various types of communications between FHL and FDL tendons, type I was present in 61.76% of cases, type II in 2.94% of cases, type III in 7.35% of cases, type IV in 14.70% of cases, type V in 8.82% of cases, type VI in 0% of cases, type VII in 1.47% of cases and an unusual type in 2.94% of cases.

CONCLUSION:
In the present study done in Indian population, we found that type I variety is present more commonly followed by type IV. FHL and FDL tendon grafts can be lengthened based on the communications between them. In type I variety, the communication can be severed at the FDL end to lengthen the tendon graft for harvest.
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NewsBot · Nov 22, 2022

Anatomy of Flexor Hallucis Longus and Its Relationship with Hallux Valgus: A Cadaveric Study
Cristian A. Ortiz, MD, Ana I. Butteri, […], and Manuel J. Pellegrini, MD
Source

Introduction/Purpose:
The first ray is an inherently unstable structure that relies on a fine balance between its static and dynamic stabilizers to maintain its alignment. Multiple risk factors have been associated with hallux valgus development. The dynamic stabilizers, particularly the flexor hallucis longus (FHL), has been mentioned as a potential deforming force that could contribute and accentuate hallux valgus deformity due to its spatial situation and insertion morphology. The aim of this study is to describe FHL distal insertion morphology and it spatial relationship with interphalangeal (IP) and metatarso-phalangeal (MTTP) joint.
Methods:
10 fresh frozen cadaver hallux were dissected up to the MTT-F joint, exposing FHL and bony structures, leaving in situ ligamentous attachments. We evaluated FHL distal insertion morphology in terms of width of insertion and distance between insertion borders of the FHL and medial-lateral phalangeal borders. The spatial relationship of the FHL with IP and MTTP joint was measured by the position of the FHL long axis width midpoint in relation to the phalangeal and metatarsal width 1cm proximal to the joint.
Results:
The FHL mean width of insertion was 12,1mm (range 10-15) SD (+-1,5). All specimens showed a lateral tendon fascicle that was inserted more lateral and distal than the tendon main insertion. Mean lateral distance of insertion to phalangeal border was 3mm (range3-4) SD (+-0,7), mean medial distance of insertion to phalangeal border 5,2mm (range 4-7) SD (+-1,1). FHL long axis width midpoint was on average 12.36% laterally deviated from the osseous midpoint at MTTP joint and 14.07% lateral deviated at IP joint.
Conclusion:
The FHL has a closer insertion to the lateral phalanx border and it long axis midpoint is laterally located in relation to IP and MTTP joint, creating a laterally directed force vector over both joints that could be involved in the pathogenesis of hallux valgus.
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NewsBot · May 29, 2023

MRI evaluation of interconnections between flexor hallucis longus and flexor digitorum longus around the Master knot of Henry
Seung-Hwan Park et al
Eur Radiol. 2023 May 25

Objectives: To demonstrate the magnetic resonance imaging (MRI) findings of interconnections between flexor hallucis longus (FHL) and flexor digitorum longus (FDL) around the Master knot of Henry (MKH).

Methods: Fifty-two MRI scans of adult patients were retrospectively analyzed. The types and subtypes of interconnections between the FHL and FDL were evaluated using the classification suggested by Beger et al based on the direction and number of the tendon slips and contributions to the lesser toes. The layering organization formed by the FDL, quadratus plantae, and tendon slip from the FHL was evaluated. The distance between bony landmarks and the branching site of tendon slips and the cross-sectional area (CSA) of the tendon slips were measured. Descriptive statistics were reported.

Results: MRI scans revealed that type 1 interconnection was the most common (81%), followed by type 5 (10%) and types 2 and 4 (4% each). All tendon slips from the FHL contributed to the second toe, and 51% of the tendon slips contributed to the second and third toes. For the layering organization, the two-layered type was the most common (59%), followed by the three-layered (35%) and single-layered (6%) types. The mean distance between the branching site and bony landmarks was longer in the FDL to FHL cases than that in the FHL to FDL cases. The mean CSA of the tendon slips from the FHL to FDL was larger than that of the FDL to FHL.

Conclusions: MRI could provide detailed information about the anatomical variations around the MKH.

Clinical relevance statement: In lower extremity reconstruction surgery, the flexor hallucis longus and flexor digitorum longus tendons serve as donor tendons. A preoperative MRI scan could provide information on anatomical variations around the Master knot of Henry, which can help predict postoperative functional outcomes.

Key points: • Normal anatomical variations around the Master knot of Henry were not extensively studied in the radiology literature before. • MRI identified the various types, sizes, and locations of interconnections between the flexor digitorum longus tendon and the flexor hallucis longus tendon. • MRI is a useful noninvasive tool for evaluating the interconnections between the flexor digitorum longus tendon and the flexor hallucis longus tendon.
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NewsBot · Nov 9, 2023

Flexor hallucis longus. A cadaveric study of its distal insertion
Felipe Chaparro Ravazzano et al
Journal of the Foot & Ankle, 17(2), 99–102.

Objective: Describe flexor hallucis longus (FHL) distal insertion.
Methods: Ten cadaver feet were dissected to evaluate FHL distal insertion, the width of insertion, and the distance between insertion borders and medial-lateral phalangeal borders.
Results: All specimens showed a lateral tendon fascicle inserted more lateral and distal than the main insertion. The mean lateral and medial insertion distance to the phalangeal border was 3 mm and 5.2 mm. The FHL long axis was 12.36% laterally deviated at the metatarsophalangeal (MTP) joint and 14.07% at the interphalangeal (IP) joint.
Conclusion: The FHL has a closer insertion to the lateral phalanx border, and its long-axis midpoint is laterally located in relation to the IP and MTP joint. The detailed knowledge of the FHL true anatomy. The discovery of a lateral deviated axis, a lateral fascicle, and a lateral footprint.
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