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Surgical pearls for a flexible hallux malleus in a 12 year old. Mostly complains of a painful callus on the IP joint. Should I do a FHL release? What are the long term problems with doing a FHL release?

 

I would Have the child wear shoes with larger toe boxes until the growth plates close. Then, if they still want the procedure once the growth plates have closed, I would either do an IPJ arthrodesis or a FHL lengthening procedure so the power of the FHL (ankle joint plantarflexion moment, STJ supination moment, MTJ plantarflexion moment, first ray, 1st MPJ and hallux IPJ plantarflexion moment) is not totally lost.

Sounds like an interesting case. Could you post up photos here since this is not a common clinical scenario?

 

Here are some xrays. Sorry for the poor quality.

 

Hi Tony,
The master knot of Henry is a slip that goes from the FHL tendon to the distal slips of FDL. It is variable. It may go to just the 2nd or the 2nd and 3rd. It's effect can be seen when a subject is trying to plantar flex just the hallux IPJ. When you do this dorsiflex the ankle.

So, cutting and effectivley lengthening the FHL tendon at the toe does not eliminate the pull at the other distal insertions. Post release, you could get a hammertoe of the 2nd and possibly the 3rd from the action of the FHL muscle.

I agree with Kevin's point about conservative measures. If it is still a problem after skeletal maturity you could consider an IPJ fusion.

Eric