Journal of Orthopedics and Joint Surgery
Volume 5 | Issue 2 | Year 2023

Neglected and Large Defect of Extensor Hallucis Longus Tendon Injuries reconstructed by Double looping with Extensor Digitorum Longus by an Improvised Surgical Method

Makesh Ram Sriraghavan1, Poornima Kumararja2, Pavalan Louis3

1,3Department of Orthopaedics, Government Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India

2Department of Pathology, ACS Medical College, Chennai, Tamil Nadu, India

Corresponding Author: Makesh Ram Sriraghavan, Department of Orthopaedics, Government Thoothukudi Medical College, Thoothukudi, Tamil Nadu, India, Phone: +91 9841617765, e-mail: ram23ortho@yahoo.com

Received on: 10 April 2023; Accepted on: 10 May 2023; Published on: 07 July 2023


Introduction: Laceration to the dorsum of the foot is usually associated with injury to the extensor hallucis longus (EHL) tendon. But in chronic cases or neglected EHL injuries, the patient develops EHL dysfunction causing a flexion deformity of the great toe at the level of the IP joint. There are various methods (autograft and allograft) for the treatment of large defects in EHL tendons. Tendon diameter mismatch and diminished resistance are common issues in other tendon transfers.

Materials and methods: This study had 12 patients with EHL injuries—reconstructed by double looping with extensor digitorum longus (EDL) done from 1st September 2019 to 28th February 2023. But intraoperatively, there was a defect of up to 4–6 cm and so in all cases, EDL of the second toe was rerouted and double looping done, and transferred to EHL. The distal part of EDL was tenodesed with extensor digitorum brevis (EDB). In the case of associated fractures, they were anatomically reduced and the EHL defect was repaired.

Results and discussion: This is a surgical technique where rerouting of EDL of the second toe along with the EHL and to improve the results further both the tendons were enclosed in the paratenon to promote good tendon healing and to prevent adhesions. This technique provides greater tensile strength and better function. At the final follow-up, all patients recovered with good active hallux extension with good functional results. No reruptures or other complications were reported in this group of patients.

Conclusion: Second EDL-to-EHL double loop transfer for EHL reconstruction is a safe, reproducible, and low-cost technique to address EHL ruptures when a primary repair is not possible.

How to cite this article: Sriraghavan MR, Kumararja P, Louis P. Neglected and Large Defect of Extensor Hallucis Longus Tendon Injuries reconstructed by Double looping with Extensor Digitorum Longus by an Improvised Surgical Method. J Orth Joint Surg 2023;5(2):50-55.

Source of support: Nil

Conflict of interest: None

Keywords: Allograft, Autograft, Lisfranc injury, Metatarsal fracture, Paratenon, Rehabilitation, Tenodesis, Tendon reconstruction.


Extensor tendon injuries of the foot account for approximately 1% of all foot injuries. Isolated EHL tendon occurrence is reported rarely. Lacerated injuries and compound fractures to the dorsum of the foot, sometimes may be associated with injury to the EHL tendon.1,2 Direct end-to-end repair is the preferred method of treatment in isolated acute lacerations (small defects) of EHL, but in large defects—autograft is usually preferred.3,4 If there is any associated fracture, it has to be treated along with EHL injury. In chronic cases or neglected EHL defects, the patient can develop EHL impairment and it can lead to a flexion deformity of the great toe. Often this injury is neglected or sometimes left unnoticed and finally, the EHL injury can affect the normal gait pattern in later stages. In most patients, it’s defined as the hallux catching (toe grip) on the ground or occasionally they can they have a weakened grip of all other toes.5

There are various methods to treat these EHL tendon injuries (small to large defect) with a satisfactory outcome like—fascia lata autograft or tenodesis with EDL tendon. Sometimes a free tendon autograft reconstruction has been used.6-9

Merits of tendon allograft:

But it has many demerits, like:

Al-Qattan zone Classification for EHL Lacerations10

  • Zone 1: At the level of the EHL insertion site to the distal phalanx of the great toe.

  • Zone 2: Area between zones 1 and 3.

  • Zone 3: At or over the first meta-tarso-phalangeal (MTP) joint.

  • Zone 4: Dorsum of the foot—the area between zones 3 and 5.

  • Zone 5: Injury of the EHL tendon underneath the extensor retinaculum.

  • Zone 6: Distal part of the leg, proximal or above the extensor retinaculum.

Lipscomb and Kelly Scale for EHL Repairs11

Scale Range
Good Good and full movement of the great toe.
No pain (compared to the normal side).
Fair Recovery of active extension of the big toe.
No pain or tripping of the big toe while walking barefoot.
Poor Nil active extension of the great toe.
Persistent pain or tripping of the big toe while walking barefoot.

Aim and Objective

This study is about how we treated neglected and large defect of EHL laceration was reconstructed by double looping with EDL.

This surgical technique offers a reconstruction of EHL double looped with EDL—with a greater advantage, where the EDL of the second toe is rerouted to a defect in EHL, and also the paratenon suturing offers better healing without any adhesions and thus avoiding donor site complications.


Inclusion Criteria

  • Age 20–55 years.

  • Primary reconstructable skin flaps.

  • End-to-end repair is not possible.

  • Neglected EHL injuries.

  • Acute large defect of isolated EHL injuries with foot fractures/dislocations.

  • Al-qattan zone 3,4 and 5 EHL injuries.

Exclusion Criteria

  • Extensor hallucis longus (EHL) tendinopathy.

  • Chronic EHL dysfunction.

  • Motor neuron disease.

  • Neurological disorders.

  • The patient is not willing to study.

The cases were subdivided based on whether it’s isolated or any associated injuries/fractures sustained. As our institution is located in Southern most part of Tamil Nadu, India, we were able to get cases with this type of tendon injuries referred from other peripheral hospitals (Fig. 15).

Distribution of Cases

Sex Male—11 cases Female—one case
Side Right—10 Left—two
Injury sustained RTA—seven cases Laceration without#—four cases
Laceration with#—three cases (Lisfranc one case and first metatarsal#—two cases)
Accidental injury (sutured elsewhere) —five cases Sickle cut injury—three cases
Glass injury—two cases

Cases with associated fractures presented immediately to the hospital, but had EHL weakness with pain in the foot. The American Orthopedic Foot and Ankle Society (AOFAS) system of scoring was used to assess the patient’s impairment in the preoperative (pre-op) and postoperative (post-op) follow-up period. Lipscomb and Kelly’s score is used to assess the status of the hallux function in the post-op period. The mean measured gap between the proximal and distal stump of EHL intraoperative was 4.1 cm, and where we couldn’t approximate the cut ends.

At 28–40 months follow-up, all cases recovered with good active and passive great toe extension except in one case with lisfranc injury there was poor hallux extension, but no great toe drop was observed at the final follow-up. There was no functional deformity in the hallux IP joint at the final follow-up. No abnormality or impairment of movement of the second toe was observed in any of the patients. Overall all the patients were fully satisfied, in their last follow-up.

At this point, patients were evaluated by:

  • American Orthopedic Foot and Ankle Society (AOFAS).

  • Lipscomb and Kelly grading system for EHL tendon repairs.

Surgical Procedure

Under spinal anesthesia with tourniquet control, parts were painted and draped. On case to case basis, the EHL defect was addressed.

In the case of isolated EHL injury, the defect was reconstructed. In case of associated fractures—the lisfranc fracture was fixed with a 4 mm cannulated cancellous screw and K-wires and in metatarsal fracture—K-wire was used.

Step 1—over the plane of the first metatarsal by dorsal approach, through the previous scar or wound in the foot or through the lacerated wound, the distal end of cut EHL is first visualized (usually found at the level of injury or sometimes partially contracted). Usually, the injured proximal stump was found retracted to midfoot or up to below the ankle due to the extensor muscle contracture, and the same was explored. EHL gap was measured (Figs 1 to 4).

Fig. 1: Hallux toe drop

Fig. 2: Incision over the previous scar

Fig. 3: Distal cut end of EHL

Fig. 4: Proximal cut end of EHL

Step 2—another 1–1.5 cm incision is made over the MTP joint of the second toe, EDL, and EDB tendons of the second toe were identified. A tenotomy of the EDL is performed proximal to its extensor expansion, usually at the level of the neck of the second metatarsal (Figs 5 to 7).

Fig. 5: Intra-op gap

Fig. 6: Distal end of EDL and EDB of the second toe exposed

Fig. 7: Proximal end of EDL of the second toe

Step 3—distal end of the EDL is then tenodesed to EDB with 4–0 nonabsorbable suture for maintenance of extension of the second toe. The proximal end of the EDL is then directed subcutaneously and brought through the first wound (Fig. 8).

Fig. 8: Cut EDL tenodesed to EDB

Step 4—a slit is created in the distal end of the EHL stump and the EDL is passed through it from the lateral to the medial direction then the defect is closed by making another slit in the proximal stump and thus EHL continuity is fashioned (Fig. 9).

Fig. 9: Triple loop of EDL defect EHL ends

Step 5—the created proximal triple bundle union (one bundle of proximal EHL and a double bundle of EDL) is completed and anchored with a 4–0 nonabsorbable suture. Then the distal triple bundle is now repaired similarly for good strength.

Step 6—reconstruction of the paratenon is done to enhance good tendon healing and to prevent adhesion at the site of triple bundle level-proximally and distally. Wound closure is done in layers (Fig. 10).

Fig. 10: Double loop of EDL in middle

Below knee splint is applied with the great toe in extension to relax the reconstructed EHL tendon defect.

Follow-up Protocol

Immediate post-op—a well and soft-padded, below-knee splint with great toe in extension is applied (Figs 11 and 12).

Fig. 11: Hallux drop

Fig. 12: Immediate post-op

Late post-op—strict nonweight bearing: (# signifies fracture)

  • After 6 weeks of isolated injury.

  • After 8 weeks in metatarsal#.

  • After 12 weeks in lisfranc#.

Follow-up—partial weight-bearing started:

  • After 6 weeks of isolated injury.

  • After 8 weeks in metatarsal#.

  • After 12 weeks in lisfranc#.

The full weight gradually:

  • After 10 weeks of isolated injury.

  • After 12 weeks in metatarsal#.

  • After 16 weeks in lisfranc#.

Physiotherapy is started for good passive and active range of motion of the hallux from 12 weeks after surgery. Intrinsic foot muscle exercise is also started simultaneously. Return to daily activities was observed at 3 months post-op in isolated injuries, but delayed by 2–3 weeks in associated fracture cases. Regular periodic follow-up at 1 and 3 months then once every 3 months up to a full extension of the hallux is achieved at 1 year (Fig. 13) and returns to normalcy at 2 years (Fig. 14).

Fig. 13: At 1-year follow-up

Fig. 14: At 2-year follow-up

Fig. 15: Showing the distribution of injuries sustained


The tabular column shows in detail about age-group, Al-qattan zone of injury, type of injury, presentation of the wound status to our institute, the timing of the initial injury, intra-op tendon gap, pre-op AOFAS, post-op AOFAS score, and Lipscomb and Kelly. There were 10 cases of zone 4, one case of zone 3, and one case of zone 5 EHL injury (Table 1).

Table 1: Showing the results and outcome of all the cases
Age/gender Al-Qattan zone of injury Injury type Presentation Timing from the initial injury (days) Intraoperative tendon gap in cms Pre-op AOFAS Post-op AOFAS Lipscomb and Kelly
32/M 4 Isolated—No # Primary unreconstructable 0 6.2 48 88 Good
27/M 3 Metatarsal # referred 1 5.0 41 85 Fair
42/M 4 Isolated—No # Primary unreconstructable 0 4.1 49 89 Good
29/M 4 Isolated neglected—sickle injury Sutured elsewhere 15 5.7 48 88 Good
23/M 4 Isolated neglected—glass injury Sutured elsewhere 21 5.1 41 90 Good
30/F 4 Isolated neglected—glass injury Sutured elsewhere 20 6.4 49 89 Good
47/M 4 Metatarsal # Referred 2 5.9 51 90 Fair
28/M 4 Compound lisfranc Primary 4 5.5 50 76 Fair
43/M 5 Isolated neglected—sickle injury Sutured elsewhere 17 6.3 49 91 Good
36/F 4 Isolatedneglected—glass injury Sutured elsewhere 24 6.1 42 90 Good
22/M 4 Isolated—No # Primary unreconstructable 2 5.6 52 74 Good
52/M 4 Isolated—No # Primary unreconstructable 0 5.9 47 87 Good


In all the cases wound healed well with no infections except in one case of a lisfranc injury. One patient developed a painful neuroma at the end of 18 months and an injection of tricort was given with ultrasound (USG) therapy. Now he is pain-free and under observation. Two patients experienced prolonged mild aching pain in the forefoot on walking, but the pain eventually resolved in both patients at the end of 1 year. Two patients had difficulty gripping slippers but resolved in 14 months.

Case Example

A 31-year-old male with a lacerated injury (glass cut) to the dorsum of his right foot for which suturing was done at a nearby hospital with weakness of extension of great toe 4 weeks after injury. On evaluation by USG, there was an EHL defect of 4 cm. But preoperatively the defect was 6.1 cm.


Clinically, patients with isolated neglected EHL injury had persistent and progressive weakness of great toe extension. It is due to undiagnosed EHL injury because most of them were unaware of it. The strength and continuity of the hallux are necessary to attain and maintain balance, during push-off in the stance phase of the gait cycle. Usually, the width of the grafted tendon should match the native tendon to prevent poor healing or adhesion which can develop at both the ends of the grafted tendon.12

Tendon mismatch can decrease the strength and dexterity of the toe or limb function. Few available tendon autografts are smaller in diameter like plantaris and peroneus tertius. To overcome this problem many surgeons, use semitendinosus autograft, due to its same width of EHL.13-15 There is another free tendon autograft available for reconstruction—gracilis and palmaris longus.7,9,16. We have analyzed the results of our cases based on Lipscomb and Kelly and AOFAS grading.17

Our technique had no graft tendon mismatch, hence thereby it increased the transfer extension force of the great toe and reduced the risk of adhesion formation.

Reconstruction of paratenon helps in preventing post-operative adhesions. Hallux stability is provided due to uniform coherence of the great toe extensor and flexor as it is very essential to meet the demands of bipedal and unipedal balances and activities in the gait cycle. This surgical method demonstrates the success of the best technique to repair the defective EHL and its rehabilitation.


This technique of second toe EDL to EHL reconstruction is:

All cases had favorable, functional, and satisfactory outcomes with active extension of the great toe in all patients at final follow-up. This technique reconstructs the defective EHL using both stumps by creating a middle double bundle and thus withstands all the forces.


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