Cortical button fixation is a simple, reproducible, and biomechanically strong method that allows surgeons to reliably seat the tendon against the cortex of the bone socket, maximizing the surface area for tendon-to-bone healing.1 For tendon or ligament transfers, the Tenodesis Graft Sizing Kit can be used to determine which implant system to open. Using Arthrex's Tension Slide Technique, surgeons can tension the tendon into the tunnel and then add a BioComposite Tenodesis screw for aperture fixation to complete the construct. Cortical button fixation can be used for FDL tendon transfers, FHL tendon transfers, anterior tibialis tendon transfers, and posterior tibialis tendon transfers.
References
1. Arthrex, Inc. Data on file (APT-04032). Naples, FL; 2019.

Foot and Ankle

Product

The FDL Implant System is used for posterior tibial tendon dysfunction. Arthrex has developed the Tenodesis Tension-Slide Technique for FDL tendon transfer. The flexor digitorum longus tendon is traced to the master knot of Henry and harvested. It is then transferred to the navicular and stabilized with the DX button on the dorsal cortex as well as with a Tenodesis screw for aperture fixation. This procedure can be done in conjunction with the InternalBrace™ spring ligament augmentation.

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Flatfoot Repair With the InternalBrace™ Ligament Augmentation Procedure

The Arthrex internal brace. Spring Ligament Augmentation Repair is a surgery for people who have flat foot due to weakness or rupture of the spring ligament or posterior tibial tendon. Spring ligament is the connecting tissue located under the foot that connects the calcaneus and navicular bone. This ligament is often repaired in people that have a condition called flat foot. It is when the arch of the foot collapses coming into contact with the ground. The repair begins with the surgeon making a cut on the side of the ankle, where the calcaneus, navicular bone, and medial cuneiform are located. Next, the surgeon will create a bone tunnel by drilling into the sustentaculum tally of the calcaneus using a guidewire and drill guide. The bone tunnel is made in the calcaneus to prepare for a SwiveLock suture anchor loaded with FiberTape. The SwiveLock anchor is screwed into place. Next, the FTL tendon, also known as flexor digitorum longus, located on the medial side of the leg, is identified, cut, and then tagged with a FiberLoop stitching technique. A bone tunnel is made in the navicular to prepare for an additional SwiveLock anchor. The ankle structures are tensioned and fixed into place by taking one part of the FiberTape and passing it from top to bottom with a suture passing wire. Then take the other part of the FiberTape with the sutures from the FTL tendon, and passing it from bottom to top. The surgeon then holds it in place by inserting the SwiveLock from bottom to top. The remaining sutures are cut. The supporting structures of the arch of the foot are now repaired and held together, with the internal brace, causing the arch of the foot to be restored.

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Flexor Digitorum Longus Tendon Transfer With DX Button and Tension-Slide Technique

The FDL Implant System comes in two size offerings of 4.75 mm × 15 mm and 5.5 mm × 15 mm with everything included for an FDL tendon transfer in association with the tension-slide technique. The addition of the Spring Ligament InternalBrace™ procedure completes this simple and reproducible method of fixation that reliably seats the tendon against the cortex of the bone socket, maximizing the surface area for tendon-to-bone healing as well as augmenting the repair of the superior and inferior band of the spring ligament complex.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

FDL Tendon Transfer Using Tension-Slide Technique and InternalBrace™ Spring Ligament Augmentation

Flexor digitorum longus tendon transfer using the DH button and tension slide technique with spring ligament. Internalbrace ligament augmentation. Make a 5cm to 6cm incision from the posterior aspect of the medial malleolus to just below the palpable navicular tuberosity. Use a combination of blunt and sharp dissection to identify the posterior tibial tendon sheath just distal to the medial malleolus. Open the sheath. Expose and debride, or excise the posterior tibial tendon. Insert the 1.35mm K-wires in the sustentaculum tali at 15 degrees palatally and slightly posterior, avoiding the subtalar joint. Shaverdrill with a 2.7mm cannulated drill. Then use the 3.5mm. Tap down to the laser line. Insert a 3.5mm SwiveLock anchor loaded with collagen coated FiberTape suture. Hold the paddle and turn the paddle clockwise until the black line is slightly countersunk. Then move the FiberTape SutureTak to the side. Identify the FDL tendon and open the sheath and dissect into the plantar medial foot. Making sure there is enough length for insertion into the navicular. Then cut the FDL tendon at that point. Place a traction stitch through the tendon using a number two FiberWire or number two. Fiberloop suture. Size the tendon through the tenodesis graft sizer based on the tendon diameter. Open either the 4.75mm or 5.5mm FDL implant system. At the most plantar point of insertion of the posterior tibial tendon on the plantar medial navicular tuberosity. Drill the 3.2mm spade tip pin bicortical across the body of the navicular from plantar to dorsal. Note it is recommended to use fluoroscopy to confirm spade tip pin is centered and just breaches the dorsal cortex with the foot in maximum plantar flexion and inversion. Pull the traction stitch so the FDL is tensioned appropriately at the interface of the bone and drill pen. Use a marking pen and mark the entry point of the tendon. Then make a second mark 15mm distal to the entry point. Use an Allis clamp to secure the end of the tendon. Speedwhip stitch with the FiberLoop SutureTape and lock the construct by making the final pass proximal to the previous pass and having the needle exit through distal tip of tendon. Remove the traction stitch and any excess tendon past the second mark. Use the reamer in the implant system based on the size of the tendon. Drill 20mm or just up to the dorsal cortex, but do not breach the cortex. Remove the spade. Tip. Drill pin. Irrigate to remove bone debris. It is important for surgeons to do a primary repair or imbrication of the spring ligament before the spring ligament. Internalbrace ligament augmentation is Is completed at this point. Take one lib of the FiberTape from the SwiveLock and pass it dorsal to planter using the nitinol wire. Passer and repeat with the other FiberTape limb planter to dorsal confirm concentric reduction of the talonavicular joint. Thread one suture limb from the tendon. Whip stitch through one side of the eight millimeter DX button and back through the opposite side with a straight needle. Thread the other suture limb in the same manner, starting on the opposite side. Make sure the suture limbs are not tangled, pulling each limb to ensure the button slides freely. Hold tension on the suture limbs and insert the tip of the button inserter into the button. Now hold tension on the sutures and insert the button through the navicular under fluoroscopy, ensuring it is deployed through both cortices. Pull lever back on the inserter handle to release the button. Note leave the button inserter in the hole when pulling tension back on button. Pull on the free ends to seat the button against the against the dorsal navicular cortex. Confirm with fluoroscopy that the button is in appropriate position resting against cortical bone. Remove the button. Inserter. Grasp each suture limb and slowly apply axial tension on each suture limb to dock the tendon into the bone tunnel. Once the tendon is fully seated, use the free needle and pass one suture limb through the tendon and tie 3 to 4 knots to complete the construct. Hold one limb of the FiberTape under tension from dorsal to planter, and the second limb under tension from planter to dorsal. Then insert the tenodesis screw next to the tendon and FiberTape sutures, securing it so it is flush with the cortex. Cut the excess suture and fixation is complete.

FDL Implant System

Child (D)

The FHL Implant System is used for reinforcement of an Achilles repair. Arthrex has developed the Tenodesis Tension-Slide Technique for FHL tendon transfer. The flexor hallucis longus tendon is traced to the calcaneus and harvested. It is then transferred to the posterior calcaneus and stabilized with the DX button on the plantar cortex, as well as a Tenodesis screw for aperture fixation.

Joshua Nadaud, MD, (St. Louis, MO) presents his technique for Arthroscopic Flexor Hallucis Longus Tendon Transfer utilizing the Arthrex® Tenodesis Screw™ System.

Arthroscopic FHL Tendon Transfer

Hello, my name is Doctor Joshua Nadaud from Saint Louis, Missouri. And today we're going to perform an arthroscopic flexor hallucis longus tendon transfer. The rationale for doing the surgery is a patient who lacks plantar flexion strength after undergoing an Achilles repair. Two years post-operatively. We start by establishing medial and lateral portals in the standard technique to gain access to the retro calcaneal bursal space. Using a 4.0mm shaver to clear off some of the subcutaneous fat, the flexor hallucis longus tendon is found. The great toe can be flexed and extended to assure that the correct tendon is localized. The FHL is then freed of any surrounding soft tissue with a shaver to assure maximum visualization and excursion. Additionally, the retro calcaneal Bursa is cleared of soft tissue to allow for later implantation of the FHL into the calcaneus. The camera is then switched to the medial portal. The next step is to tag the FHL tendon using the Fastpass Scorpion and a number two FiberLink suture to load the Fastpass appropriately. The looped end or lasso of the FiberLink suture is placed over the jaws and shaft of the Fastpass Scorpion. The non looped end is manually loaded into the jaws of the device. Insert the Fastpass Scorpion into the lateral portal. Grasp a large bite of the FHL tendon with a Scorpion and fire the device. The device then grabs the suture through the trap door, and the loop slides off the Fastpass Scorpion over the tendon, creating a locking stitch. To then be able to control the tendon. Pull proximally in the suture to maximize the length of the FHL to be harvested. Switch the camera to the lateral portal and insert an arthroscopic scissor medially. Pull tension on the number two FiberLink and cut the tendon from medial to lateral under direct visualization. Next, pull the tendon out of the of the medial portal. Use an Allis clamp to maximize the externalization of the tendon. Remove the FiberLink. Proceed to whip stitch the tendon using a number two FiberLoop. The distal aspect of the harvested tendon is contoured to allow for easy passage through the bone tunnel, using the tenodesis driver to determine the size of the tendon. In this instance, the tendon measured to be just under seven millimeters in diameter. Next, reintroduce the tendon back into the retro calcaneal space and shuttle the suture and tendon out of the lateral portal using a looped grasper. It is important to debride any soft tissue from the calcaneus with arthroscopic shaver to allow for easy visualization of the following procedural steps under direct visualization, laterally insert a 2.4mm K-wires through the medial portal and drill the K-wires all the way through the through the calcaneus. K-wires should be oriented anterior to the Achilles. Next, while holding tension on the whipstitch suture laterally to keep the FHL out of harm's way. Drill with the appropriate sized cannulated tenodesis reamer to a depth of approximately 25 to 30mm, while making sure not to penetrate the far cortex of the calcaneus. In this instance, we used a seven millimeters cannulated reamer. The superintendent is then shuttled back to the medial portal and passed through the open end of the K wire. Using a mallet, the k wire and the whipstitch suture is shuttled out of the planter aspect of the foot. Pull tension on the suture planter lee to tension the tendon into the prepared bone tunnel. The tension can be held with a coker on the planter aspect of the foot. Finally, secure the tendon into the bone tunnel using a biocomposite tenodesis screw. In this instance, we use a seven by 23 millimeter biocomposite Tenodesis screw. Insert the driver and screw into the medial portal until the distal aspect of the screw comes into contact with the calcaneus. While holding the thumb pad, turn the driver clockwise and advance the screw until the screw is flush with the bone tunnel. Appropriate tension is checked both arthroscopically with a probe and manually. In this case, the patient is able to get back to neutral dorsiflexion manually, which is ideal. This concludes the procedure. The plantar sutures can be cut flush with the skin and scoped portals closed appropriately. The benefits of doing arthroscopic flexor hallucis longus tendon transfer is less risk of wound infection and wound complication, and smaller incisions. Post-operative protocol will be no weight bearing for two weeks, followed by protected weight bearing and a boot brace for four weeks.

Joshua Metzl, MD, (Denver, CO) demonstrates his technique for an Insertional Achilles Tendon Rupture Repair utilizing Bio-Tenodesis™ set for a Flexor Hallucis Longus (FHL) tendon transfer and Achilles SpeedBridge™ implant system for reattachment of the distal Achilles tendon. The Achilles SpeedBridge is a knotless four anchor construct that creates a large hourglass pattern of FiberTape® suture securing the distal Achilles tendon to the calcaneus.

Insertional Achilles Rupture Repair With Achilles SpeedBridge™ Repair System and FHL Tendon Transfer

Insertional Achilles ruptures are relatively rare injuries, but when you do encounter them, it can be helpful to have the foot off the end of the bed. You're going to incise posteromedial staying off the Achilles and then you come down distally. This is the typical distal Achilles tendon rupture. You can see here. This is the calcaneal insertion. So it's very important to reflect full thickness flaps at the calcaneus distally both medially and laterally. So next we will excise the haglund's deformity. Any distal spurs. So you're going to finish it with a thin osteotomy. If a flexor hallucis longus tendon transfer is going to be performed you then reflect the Achilles tendon proximally and dissect anteriorly. You excise the retro calcaneal Bursa. You can see the tendon comes into view here. You can confirm that through range of motion of the halex. I have my assistant place a retractor, just interior and we'll free up the FHL tendon proximally. Typically we'll have the assistant flex the halex to decrease tension and give us as much tendon excursion as possible. Again, we will then dissect distally into the fiber osseous tunnel, resect the tendon as distal as possible to give us as much length as we can possibly get for our tendon transfer. Good. So I prefer to use the FiberLoop especially for this tendon transfer, because I think it cuts down on time and certainly provides you adequate fixation, and it does have excellent strength. So now that we have the FHL tendon secure, I then actually mark out the remaining five spots one two the distal row kind of distal aspect of the calcaneus. And then for the tendon transfer you want to try to cheat that just the anterior. So again you don't have any confluence of your bone tunnel. So I'll then use a K-wires to try to make sure that I like my trajectory. Yeah, that looks really nice. Then we'll go ahead and size the tendon. I think six would be fine, especially in this softer bone. We'll just go ahead and take the appropriate size. Reamer I'm going to get to a depth of at least 20. Typically I go two, but not through the plantar cortex. So we're already at a depth of 30, which should be plenty. So then we'll go ahead and pass our tendon transfer through the The calcaneus. The sutures will exit plantar. The tendon is going to glide into the tunnel appropriately. So we'll place a clamp plantar to make sure that it keeps our our tension on the tunnel. And then we'll go ahead and secure the tendon transfer. This is size six two, five by 15. Even in this softer bone you still get a sense that this is very adequate fixation. We will proceed with the Achilles tendon reconstruction. So I like to make sure that the tunnels are not going to be convergent distally. And I'm going to drill three out of the four tunnels, then remove the K-wires and drill the fourth. And again I'm going to use this K-wires that I've placed as my guide. So I'm going to match the trajectory of that K-wires. Perfect. So now we have all four of our tunnels placed. I like to tap all four, so we will place the proximal row first. Gentle taps. Advance the anchor down. And place the second anchor. Sure. We get it down below the surface. Now it's at the point where we want to test and see if we feel like our Achilles tendon is going to have appropriate excursion to reach down to the calcaneus. So in this case, actually, it looks it looks fairly reasonable. If you needed additional length, you can perform a v y lengthening. So what you can do is extend your incision proximally. You really have to be careful of the surreal nerve here more proximally. So we'll make a mark in the most central aspect of the tendon. And then both medially and laterally. I often will use a bovie for this. But I think in this context we'll use a knife. You want to have your assistant just pull gentle traction. You're just incising through the tendinous portion but not the underlying muscle. Good. So you can see. With limbs of two centimeters, we're going to be able to lengthen the Achilles approximately one centimeter. And that would really help be able to excise any diseased portion of the distal Achilles tendon. So we can do that here just because we have that extra length. Which is great. So we will then Secure the the Achilles with the proximal row anchors and suture. So then we'll pass the medial suture. Excellent. And we can just test to make sure that we're going to get a nice healthy bite distally. So then we'll cut our sutures. Perfect. And then we will take one suture from each anchor to get our distal fixation. So we'll take the SwiveLock pass our suture through the eyelet at this point is when you're going to set your tension in the Achilles. Once you have achieved the appropriate tension, you can then implant the distal SwiveLock. We then remove the additional suture. This one I do not use. Identify the lateral drill hole. So we then pass the sutures through the eyelet. You're going to set your tension. You then are going to impact the second anchor. You remove the additional suture leaving the second anchor in place. We're going to cut the FiberTape as close to the calcaneus as we can to not leave any prominent suture. Excellent. So at this point, you can see we have the V lengthening proximally. I do like to use these additional sutures for extra points of fixation. So we will come here again through the distal achilles just proximal to where we placed the FiberTape with one limb of the suture. So once you have these sutures passed you can then tie them again for an additional point of fixation. You can see how it really does help to reinforce that distal tendon. Excellent. So now that we have the distal tendon re approximated. The last thing that we need to do is close our more proximal v lengthening. Again we're going to protect the neurovascular structures. We're going to secure our v to y lengthening proximally. Perfect. And the last thing we would do is cut our FHL tendon transfer sutures the FiberLoop. [00:09:06] And that's it.

A Flexor Hallucis Longus Tendon transfer is used to aid in chronic Achilles tendonopathy. An FHL transfer is performed to augment an Achilles reconstruction utilizing Arthrex Tenodesis Screw™ technology. The tendon is excised either medially or laterally and transferred into a bone tunnel in the calcaneus bone. Final fixation is achieved with a screw from the Bio-Tenodesis™ Screw System.

Flexor Hallucis Longus (FHL) Tendon Transfer

Flexor hallucis longus tendon transfer utilizing Arthrex tenodesis screw technology to aid in chronic Achilles tendon arthropathy and FHL transfer is performed to further solidify an Achilles repair construct. Begin by making a 5 to 7 centimeter longitudinal incision just medial to the Achilles tendon. Appropriate dissection is performed to locate the FHL tendon and muscle belly. Release the tendon as distal as possible and place a number two FiberWire traction stitch at the distal tip of the tendon. Measure the diameter of the tendon using the appropriate tenodesis driver handle. It is important to use a reamer that is 0.5mm to one millimeter larger than the measured tendon diameter. Place a 2.4mm tenodesis guidewire into the dorsal medial aspect of the calcaneus. Drill with the appropriate reamer to a depth of 25mm with the foot in slight plantar flexion. Tension. The FHL and mark the tendon at the insertion point of the bone tunnel. Then measure a 0.25mm distal to the insertion site and make a second mark. Cut any excess tendon and whipstitch appropriately using a number two FiberLoop. Load the appropriate tenodesis. Screw onto the driver and shuttle a number two suture through the Bio-Tenodesis driver, using the nitinol passing pin to make a suture loop at the distal tip of the screw driver. Capture the tendon with the suture loop and insert the tendon and driver into the calcaneal tunnel with the foot in mild plantar flexion. Hold the thumb pad on the Bio-Tenodesis driver and turn the handle clockwise until the screw is fully seated and flush with the cortical bone. Cut the remaining sutures and the tendon transfer is complete.

Flexor Hallucis Longus Tendon Transfer With DX Button and Tension-Slide Technique

Anterior Tibialis Tendon Transfer Using DX Button and Tension-Slide Technique

The FHL Implant System comes in two size offerings of 6.25 mm × 15 mm and 7 mm × 23 mm with everything included for an FHL tendon transfer in association with the Tension-Slide Technique. This simple, reproducible, and biomechanically strong method of fixation1 reliably seats the tendon against cortex of the bone socket, maximizing the surface area for tendon-to-bone healing. The BioComposite Tenodesis screw adds strength to the final construct with an aperture interference fit and provides a scaffold for bony ingrowth.
Reference
1. Arthrex, Inc. Data on file (APT-04032). Naples, FL; 2019.

FHL Tendon Transfer Using the DX Button and Tension-Slide Technique

Flexor hallucis longus tendon transfer with DH button and tension slide technique. Make a 5cm to 7cm longitudinal incision through the midline of the Achilles tendon. Use fine scissors to make the incision deeper until the FHL tendon and its muscle belly are identified. Confirm by flexion and extension of the helix. Retract the neovascular bundle and expose tendon, then cut FHL as distal as possible. Place a traction stitch through the tendon using two FiberLoop suture. Size the tendon through the tendon graft sizer based on the tendon diameter. Open either the 6.2 5mm or 7mm. Fhl implant system on the superior calcaneus, approximately one centimeter anterior to the Achilles insertion. Drill the 3.2mm spade tip drill pin bicortical, aiming one centimeter anterior to exit the plantar surface in the midline of the calcaneus and centered medial to lateral. Note fluoroscopy is recommended to ensure the 3.2 spade tip pin just breaches the plantar cortex. It is important to make sure the drill does not exit along the plantar posterior tuberosity plant, or flex the foot and pull the traction stitch so the FHL is tensioned appropriately at the interface of the bone and drill pin. Use a marking pen and mark the entry point of the tendon. Determine the length of the tendon that will pass into the tunnel. This will be either 15 or 23mm and make a second distal marking. Use an Allis clamp to secure the end of the tendon. Speedwhip stitch with the FiberLoop SutureTape and lock the construct by making the final pass proximal to the previous pass and having the needle exit through distal tip of tendon. Use the reamer in the implant system. Drill either 20 or 30mm based on screw length. Note when reaming over the 3.2mm spade tip pin, make sure the pin does not push through the plantar fascia and skin. Remove the spade tip. Drill pin. Irrigate to remove bone debris. Remove the traction stitch and any tendon past the second mark. Thread one suture limb from the tendon. Whipstitch through one side of the 12 millimeter DX button and back through the opposite side with a straight needle. Thread the other suture limb through in the same manner, starting on the opposite side as the first limb. Make sure the suture limbs are not tangled. Pulling each limb to ensure the button slides freely. Hold tension on the suture limbs and insert the tip of the button inserter into the button. Hold tension on the sutures and insert the button through the calcaneus under fluoroscopy, ensuring it is deployed through both cortices. Pull lever back on the inserter handle to release the button. No leave button Inserter in the hole when pulling tension back on button. Pull on the free ends to seat the button against the plantar calcaneal cortex. Confirm with fluoroscopy that the button is in appropriate position resting against cortical bone. Remove button inserter. Grasp each suture limb and slowly apply axial tension to dock the tendon into the bone tunnel. Once the tendon is fully seated, use the free needle and pass one suture limb through the tendon and tie 3 to 4 knots. Insert a 6.2 5 millimeter or 7 millimeter tenodesis screw for aperture fixation. The screw should sit flush with the cortex. Cut the excess suture, and fixation is complete.

Thomas O. Clanton, MD (Vail, CO), demonstrates an FHL tendon transfer using the Arthrex FHL Implant System with Tension-Slide Technique and Achilles SpeedBridge™ repair.

FHL Implant System With Tension-Slide Technique

I'm using the Arthrex FL implant system in a patient with recurrent insertional Achilles Tendinopathy from failed prior surgery. His MRI shows degenerative change at the Achilles insertion with recurrent spurring and retro calcaneal bursitis. The patient is prone and we are operating on his right heel. The hagland deformity has already been resected, and the Achilles debrided with at least 50% of the Achilles involved in degenerative change. So I'm using an FHL transfer. It's important to plan or flex the ankle and great toe, including the IP joint. The dissection just medial to the talus exposes the FHL tendon in order to get the maximum distance of the tendon before cutting it. While holding the tendon, it can be sized through the tenodesis graft sizer. I'm using the 6.25, in this case, a 3.2mm spade tip drill is started one centimeter anterior to the posterior calcaneus in the midline, centered from medial to lateral, and aim to exit the plantar calcaneus. One centimeter anterior to the plantar tuberosity. And then I confirm this on fluoroscopy. The FHL tendon is sutured with the number two FiberLoop SutureTape. Having done this previously, I knew that I had the right length of tendon to go into the dead end tunnel and get fixation with a 15mm Bio-Tenodesis screw, and the graft is trimmed at the end, so it goes into the tunnel more easily. Under normal circumstances, you will measure your graft going into the tunnel and be sure you have adequate length, but not excessive length for the tunnel that is created. So that length is normally about 20mm. Using the appropriate size reamer, I drilled over the spade tip to a depth of 20 to 25mm, being careful not to penetrate the planter cortex. The sutures are threaded through the X button first going in one direction and then the second suture goes in reverse direction. Hold tension on the suture. Limbs. Insert the tip of the button inserter into the button, and then insert the button into the bone tunnel in the calcaneus. Visualize with fluoroscopy that the button penetrates through the plantar cortex of the calcaneus. Then deploy the button by pulling the lever back on the inserter, but be sure to keep the inserter in the bone tunnel to prevent the button from pulling back into the tunnel. Then pull the free suture ends to seat the button and toggle the sutures. Pulling the FHL into the bone tunnel and the button firmly against the plantar calcaneus. You can then confirm the position with fluoroscopy. Use the free needle from the kit and pass one suture limb through the tendon and tie 3 to 4 knots prior to inserting the 6.25mm biocomposite tenodesis screw for aperture fixation with the screw head sitting flush with the cortex. The green drill guide is used with the 3.5. Drill bit to make the proximal 4.75mm SwiveLock holes slightly posterior into the medial and lateral sides of the FHL tunnel. The power tap is used to tap the holes. Taking it back out on reverse, and the 4.75mm swivel locks are then inserted into the holes. The needle on each SwiveLock is passed through the Achilles tendon on each side, and the single portion of the SutureTape on each side is cut to leave two FiberTape coming through each side of the Achilles. I then cross one of those suture limbs from each side to the other side, creating the criss crossed pattern that holds the Achilles tendon down flat against the calcaneus. The Achilles split is closed with an absorbable suture. Then the distal holes are prepped in the same manner as we did the proximal holes, but at the distal insertion of the tendon the power tap is used and as always, it is reversed out. The two sutures from the two different proximal SwiveLock are loaded into the 4.75mm SwiveLock for the distal holes, and the tension is adjusted prior to inserting the SwiveLock into the distal holes. The suture tails are cut and the incision is closed. Once you've done this, the dressings applied, followed by a posterior splint and stirrup splint. The patient is in this splint non-weight bearing for 10 to 14 days. When we see the patient back in the office to remove the splint and remove sutures, they then go into a walking boot with heel lifts in the walking boot so that their comfortable weight bearing as they progress from partial weight to full weight over the next 2 to 4 weeks.

Thomas O. Clanton, MD (Vail, CO), describes the surgical treatment of a patient with chronic insertional Achilles tendinopathy using the FHL Implant System with the Tension-Slide Technique.

Chronic Insertional Achilles Tendinopathy - FHL Tendon Transfer Using the Tension-Slide Technique

Hello. My name is Tom Clanton. I'm an orthopedic foot and ankle specialist at the Steadman Clinic in Vail, Colorado. I'm going to give a presentation on one of our cases. That's a relatively recent case using the Arthrex FHL tendon transfer with the tension slide method. This is a 46 year old male. He's has a seven year history of posterior heel and Achilles pain. He had had previous surgery five years previous without significant improvement. And his pain is specifically at his Achilles insertion in the posterior heel area, both at rest and with activity. And when he increases his activity, he gets to a point where he can't even walk. He's had no improvement with multiple prior treatments, including physical therapy, dry needling, all of these things. You see pretty much the gamut of non-operative treatment for this problem. Therefore, we saw him I'm in the office. He's tender over his posterior heel and his distal Achilles. The distal Achilles is a little thick. He does have normal ankle range of motion, some tenderness in the retro calcaneal Bursa area, with pain on heel rise and with stair climbing. We did imaging studies, but he had previously had an ultrasound at another facility that showed significant degenerative changes in his distal Achilles, even from a couple of years ago. So we did X-rays, followed by an MRI. His X-rays showed that he has a prominent posterior superior tuberosity or a hagland deformity. There's no clear evidence of prior resection of bone there, even though he did give the indication that he had had surgery there, and they had done something to his heel while they removed an trigonum. And then his MRI definitely shows some degenerative changes in the distal Achilles and insertion. That really looks like it's over 50% of the total volume of the Achilles in that location. He has a prominent posterior superior calcaneal tuberosity and mild retro calcaneal bursitis. Here's what it looks like in a little more close up view. You can see a signal change in the Achilles, the thickness of the Achilles, the Haglund deformity there. And so this is what it looks like on the T2 imaging. Once again you can see the same things in these views. And so our treatment was a posterior midline incision. We dissected through his prior scar which was somewhat difficult. His resection of the Bursa was pretty straightforward. And then we debrided the degenerative Achilles tendon area. And it did come to what I considered more than 50% of the Achilles tendon. So we resected the Haglund deformity, and then did the FHL tendon transfer and repaired the Achilles tendon. This is the tension slide method. So you attach the inserter to the button after you've placed the sutures through it. And then we place that through the bone tunnel. And you can see that is in proper position. So once we have it in place, then we do the toggling of the sutures to pull the tendon into the tunnel, and then we can seat the button on the bottom of the planter aspect of the calcaneus. So once we have it fully seated, we confirm that with a fluoroscopic image. This shows it in proper position on the bottom of the calcaneus. We place a suture using the the free needle going through the through the FHL tendon right at the dorsal aspect of the calcaneus, where it goes into the bone tunnel, suture that down, tie the knots. And then once we've done that, then we place the interference fit screw in place in the tunnel in order to get aperture fixation within the tunnel. So this gives us a very strong reconstructive method. And we can begin a range of motion immediately. And and early weight bearing. And this really seems to have improved the outcomes of our patients with this particular problem. Postoperatively. This patient was splinted for the postoperative course until he came to the office 14 days later. We do that so that the patient will have a healed wound and decreased swelling. And then we remove the splint and as bandages take the sutures out. And then he goes into a cam boot. He's touched down weight bearing in the boot with crutches. He then begins removing the boot several times a day for range of motion, and starts his physical therapy to work on motion balance and gradual strengthening. The patient was from a fair distance away, so I spoke with him just this past week. He's five weeks post-op and he has minimal pain. He's ambulating full weight bearing in his boot at five weeks post-op and has full ankle range of motion. His physical therapist is happy which makes me happy.

David I. Pedowitz, MD (Philadelphia, PA), demonstrates a tibialis anterior reconstruction using the Tension-Slide Technique with the newly released Tension-Slide Tenodesis System.

Tibialis Anterior Reconstruction

My name is David Pedowitz. I am a foot and ankle surgeon at the Rothman Institute in Philadelphia. And today we're going to talk about tibialis anterior tendon reconstruction. This case is a 78 year old male who plays tennis three times a week and golfs every weekend. He relays a new four week history of having tripped while playing tennis, and he's felt weak ever since. His wife states that he drags his toe and he's tripped many times, although he's not fallen. As you can see in the clinical photograph, he inverts when he attempts dorsiflexion, recruiting both the perineal tendons and the extensor digitorum longus. He has a palpable mass right below the extensor retinaculum, and all other muscle groups are five out of five strength without pain. And he really has no palpable tibialis anterior tendon, as you can see here in the MRI. He has a tibialis anterior tendon tear. It sort of disappears as we go down a little bit further. He does have a complex tear of the Peroneus brevis, but it's clinically silent regarding his options. The patient was unhappy with his function, and he wanted to be able to resume tennis and golf. So we presented to him the possibility of using a plastic ankle foot orthosis or a brace or surgical reconstruction, and he elected to go ahead with surgical reconstruction. So the overview of the plan, and this is really important because the actual order of the steps helps prevent additional errors. So the first step was just exposure and tendon debridement. Then the pin for the bony tunnel preparing part of the graft, repairing the extensor retinaculum, determining the length of the graft needed. Preparing the distal graft, passing that graft with a tension slide technique and then securing it with a screw. So here's our exposure. It's an anterior medial incision along the course of the tibialis anterior tendon. And we then debride the proximal tibialis anterior to get down to healthy tendon and then remove the non salvageable distal tendon. We then go towards the bone and find the mid portion of the medial caniform. This is an important step. One might think that we were just working with the tendon. Why are we now going to the bone? We'll start doing this step at this point allows us to not tangle up sutures in the wires. We're passing the wire in the reamer. The concept here is we're going to advance the pin through the plantar cortex of the Cartiform. Then we're going to ream over that pin, too, but not through the plantar cortex. The next step is we prepare the tibialis anterior tendon allograft with a locking stitch at one end. I used a number two FiberWire, and we were really only preparing the proximal end of the graft at this point. Here you can see the pin in the medial cuneiform. Right below that is the native distal tendon with a locking stitch and then the graft with a locking stitch proximally. We then sew the native tendon to the graft itself. And then what we do is we repair the extensor retinaculum. It's important to understand that you need to repair the extensor retinaculum under no tension, because once the tendon has been repaired, the retinaculum will be under too much tension and will just rupture. This prevents bowstringing. Next step is we dorsiflex the ankle in order to prepare the distal graft. So what we're doing here is we want to determine the length needed for the distal end of the graft. And when it goes into the bony tunnel. And I generally think of this as about one centimeter longer than the distance of the graph to the bone. And we mark that distance with a pen. We then place a FiberLoop in the distal graph for transfer, and we sort of trim down the graph so that it's almost bullet shaped. So it will go into the bony tunnel very nicely. We then paste a suture button on the distal sutures. And this is just a graphic of that. And the suture button is passed through the pinhole. And you can see it going through there. It is then flipped and then brought back up against the planar aspect of the medial cuneiform. And you can see where we're passing the needle with our graft sutures through the button. There is a suture passer where we pass the button. We then dorsiflex the ankle and pull the tendon into the bony tunnel. You can see that I have a bump against my chest pushing this into dorsiflexion. And as this next video shows, you can show us tensioning and really shimmying the tendon graft into the bony tunnel. And then subsequently it's fixed using an interference screw, and you can hear the interference screw, making that bony contact and reassuring us that we have good strength for our time. Zero fixation on the AP. You can see that the button has been placed through the bony tunnel, and it's subsequently been flipped. And on the lateral x ray you can see it's on the plantar cortex of the medial cuneiform. When you take away this bump, the ankle should not plantar flex. And this is a good example of how our repair is nice and strong. This is that patient nine months post-operatively. You can see he's walking without any great difficulty. As you can see, this tension slide technique allows me to get suture button fixation underneath the cuneiform, which gives me reassurance as well as the cortical fixation of the interference screw, allowing this patient to rehabilitate quicker and really get an outstanding result that he was expecting after this surgery. Thank you very much.

Cortical Button Fixation

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