Abstract
Background
Checkrein syndrome is a rare condition characterized by dynamic flexion contracture of the hallux interphalangeal joint (IPJ) and extension contracture of the metatarsophalangeal joint (MTPJ) during ankle dorsiflexion. It most often arises secondary to trauma or iatrogenic injury along the course of the flexor hallucis longus (FHL) tendon. Multiple surgical approaches have been described but no consensus exists regarding the optimal technique
Methods
We report the case of a 36-year-old male who developed a painful Checkrein deformity of the hallux following fibular free flap harvest. Conservative measures were unsuccessful. Surgical management consisted of FHL tendon lengthening performed via a medio-plantar forefoot approach. A review of the literature was also performed to summarize available surgical strategies, approaches, and outcomes.
Results
The medio-plantar forefoot approach provided direct access to the FHL tendon proximal to the sesamoid sulcus, enabling precise Z-lengthening under intraoperative dynamic assessment. Postoperative recovery was uneventful, with resolution of big toe deformity and motion. Review of published cases demonstrated that Checkrein deformity most frequently follows post-traumatic and iatrogenic causes involving the leg, ankle, or hindfoot. The predominant surgical technique was FHL Z-lengthening , most often performed through a retro-malleolar approach , followed by midfoot and fracture-site–specific exposures. Overall, outcomes across all techniques were favorable, with high rates of deformity correction, motion restoration, and low recurrence.
Conclusion
The medio-plantar forefoot approach is a safe and effective surgical option in the management of Checkrein deformity. Its advantage is the targeted exposure and avoidance of extensive dissection but does limit associated lesser toe correction. A review of reported cases indicates that favorable outcomes can be achieved across all surgical techniques when appropriately selected.
Introduction
Flexor hallucis longus (FHL) pathology often manifests as a deformity of the great toe. A Checkrein syndrome (also referred to as a “fixed length” deformity), first described by Clawson in 1974, is characterized by a dynamic flexion contracture of the interphalangeal joint (IPJ) and a corresponding extension contracture of the metatarsophalangeal joint (MTPJ) of the hallux during ankle dorsiflexion, resulting from a relative reduction in the functional length of the FHL tendon. ,
This condition most commonly develops following trauma along the course of the FHL muscle-tendon unit, including fractures, dislocations, or iatrogenic insult i.e. fibular graft harvests. ,,,,,,,,,,,,,,,,,,, Several surgical approaches have been described to address the resultant musculotendinous shortening or tethering, including fracture-site, ,, retro-malleolar ,,,,,,, midfoot ,,,,,,, forefoot, and plantar hallux approaches. , However, no consensus exists regarding the preferred method and selection remains dependent on surgeon preference.
We report our experience with FHL tendon lengthening for Checkrein syndrome using a recently described medio-plantar forefoot approach, along with a review of literature on current surgical options.
Case report
We present a case of a 36-year-old male patient who developed a Checkrein deformity of the right hallux following reconstruction of a left hemimandibulectomy defect with a free right fibula osteocutaenous flap ( Fig. 1 ). Post-operatively, he experienced tightness of the right FHL tendon with associated IPJ contracture. He subsequently presented to the foot and ankle clinic with complaints of right hallux contracture with associated pain.
Lateral (left) and anteroposterior (right) radiographs of right leg following harvest of vascularized fibular graft.
On examination, a dynamic flexion contracture of the interphalangeal joint (IPJ) of the right hallux was observed, which became more pronounced with ankle dorsiflexion ( Fig. 2 ). Both the IPJ and first MTPJ were supple, and full extension of the hallux could be achieved when the ankle was in plantarflexion. There was no clinical evidence of FHL impingement at the ankle, and neurovascular assessment was unremarkable. The lesser toes also demonstrated a similar but less severe degree of dynamic contracture.
Checkrein deformity exacerbated with passive ankle dorsiflexion (left) and improved in plantarflexion (right).
Plain radiographs demonstrated a flexion deformity of the right first IPJ without any features of arthritis ( Fig. 3 ). MRI of the ankle and foot showed an intact FHL tendon but revealed a segment of scar tissue in the mid to distal calf measuring approximately 7–14 cm.
Pre-operative plain radiographs of the foot showing contracture of right hallux IPJ.
Initial conservative management including physiotherapy with stretching exercises and splinting resulted in partial improvement. Ultrasound guided hydrocortisone and lignocaine injections with dry needling were attempted but provided limited relief, with hallux dynamic contracture affecting gait. Consequently, the patient was planned for surgical lengthening of the right FHL tendon.
Surgical procedure
Surgery was performed under general anaesthesia with the patient in supine position. With the ankle in plantarflexion and the hallux in full extension, two anatomical reference points (tip of the hallux and the first metatarsophalangeal joint) were marked along the medial border of the hallux and the distance measured. The same measurement was repeated with the IPJ in dynamic flexion with passive ankle dorsiflexion. The difference in length (1.5 cm) represented the approximate FHL lengthening required to restore normal motion ( Fig. 4 )
Distance between two reference points (distal and proximal phalanx) with the hallux interphalangeal joint (IPJ) in flexion (left) and extension (right).
A 4-cm medio-plantar incision was made parallel to the plantar surface, just inferior to the posterior border of the first ray and proximal to the medial sesamoid ( Fig. 5 ). Following careful dissection of the subcutaneous tissue, the abductor hallucis (AbH) tendon was visualized in the operative field. The AbH muscle belly and tendon were retracted anteriorly, which exposed the underlying FHL tendon ( Fig. 5 ). Proximity of AbH to FHL allows it to be a surgical landmark and it s anterior retraction simultaneously protected the medial plantar neurovascular bundle, creating a safe and direct approach ( Fig. 6 ).
Forefoot medio-plantar approach incision with abductor hallucis exposed in the wound bed (left). Anterior retraction of abductor hallucis revealing underlying FHL which is pulled out using a tendon hook (middle). The proximal stump of the FHL is sutured to prevent its retraction (right).
Anatomical relations of abductor hallucis muscle and flexor hallucis longus tendon from the medial (left) and the plantar (right) view.
The exposed segment of the FHL tendon, proximal to the sesamoid sulcus, was safely hooked out for adequate visualization. The amount of lengthening was guided by the difference in distance between the two anatomical reference points described earlier. With the ankle and hallux placed in maximum dorsiflexion for a 1.5 cm Z-tenotomy was performed. Passive dorsiflexion was repeatedly intraoperatively to restore physiological range of motion of the IPJ and MPJ. The distal and proximal ends of the FHL were sutured then sutured using 4–0 Prolene. The incision was then closed in layers with 2–0 Vicryl for subcutaneous tissue and 5–0 Monocryl for the skin. To maintain alignment, a 2 mm Kirschner wire was inserted under intraoperative fluoroscopic guidance, transversing the IPJ to keep the toe straight and prevent excessive tension to the suture and kept for 6 weeks. The ankle was immobilized in a backslab for 2 weeks followed by protected weight bearing with forefoot offloading shoe.
At the 12 weeks follow-up the wound had completely healed and the hallux deformity fully corrected. The adjacent lesser toes had a mild residual deformity which was not symptomatic
Literature review
The available evidence on Checkrein deformity remains limited to case series, case reports, and technical notes ( Tables 1 and 2 ). The predominant etiology is post-traumatic, most commonly following fractures involving the leg ,,,,,,,,, ankle ,,,,,,, or hindfoot. ,,, Surgical management remains the mainstay of treatment, with almost half reported cases were managed through a retro-malleolar approach, followed by midfoot and fracture-site approaches. Forefoot and plantar hallux procedures were least used (Tabel 1). FHL Z-lengthening, often combined with adhesiolysis or tenolysis, represented the predominant surgical strategy—performed in vast majority of reported cases ( Table 1 ). Only a small number described isolated tendon release or indirect correction through fracture reduction. ,,,,,,,
Table 1
Published case series and reports describing surgical management of Checkrein deformity.
| STUDY | DESIGN | N | ETIOLOGY | SURGICAL APPROACH | KEY PROCEDURE | OUTCOME |
|---|---|---|---|---|---|---|
| Polichetti et al., 20,22 | Case series | 14 | Tibia fibular fracture (5), distal tibia fibular fracture (3), ankle fracture (6) | Retro-malleolar | FHL Z-plasty | No complications; no recurrences |
| Lee HS et al., 20,08 | Case series | 11 | Distal tibia fibular fracture (6), tibia fibular fracture (1), ankle fracture (3), soft tissue (1) | Midfoot (6); Fracture-site (5) | FHL Z-plasty ± adhesiolysis | Midfoot: 6/6 no recurrence; Fracture-site: 2/5 partial recurrence, 1/5 complete recurrence |
| Yuan et al., 20,23 | Case series | 11 | Tibia fibular fracture (6), tibia fracture (1), ankle fracture (1), soft tissue (2), atraumatic (1) | Fracture/contracture site (9); Midfoot (1): Non op (1) | Tendolysis ± adhesiolysis ± Z-plasty lengthening (US guided) | Resolution |
| Feeney et al., 20,01 | Case series | 10 | Post-traumatic/Acquired claw toes | Retro-malleolar | Selective lengthening of proximal long flexors | Favorable correction |
| Vadell et al., 20,21 | Case series | 8 | Leg fracture (5), distal tibia fracture (1), ankle fracture (2) | Midfoot (7); Plantar hallux (1) | FHL Z-plasty ± divide FHL–FDL slips ± distal tenotomies | No complications; no recurrences |
| Lee JH et al., 20,16 | Case series | 8 | Distal tibia fibular fracture (6), Ankle fracture (1), leg soft tissue (1) | Retro-malleolar | FHL Z-plasty | No complications; no recurrences |
| Sallent et al., 20,20 | Case series | 2 | Iatrogenic checkrein deformity after fibular flap harvest | Midfoot | FHL Z-plasty | No recurrences |
| Sanhudo et al., 20,02 | Case series | 2 | Distal fibular graft for hip surgery; Weber C ankle fracture | Retro-malleolar, Midfoot | Retro-malleolar FHL lengthening; FHL and FDL lengthening at midfoot | Adhesion recurrence with some loss of extension in retro-malleolar approach case |
| Carr et al., 199,0 | Case series | 2 | Calcaneal fracture | NS | Tendon dislocation reduction | Resolution |
| Chen et al., 202,3 | Case report | 1 | Ankle fracture | Retro-malleolar | Tenolysis of FHL only + hardware removal | Resolution, no recurrence |
| Abolfotouh et al., 201,5 | Case Series | 3 | Intra-articular talar fracture | Fracture site | Fracture reduction and tendon release | Resolution |
| Rodriguez-Collell et al., 2021 | Case report | 1 | Soft tissue trauma | Retro-malleolar | FHL Z-plasty and repair | Resolution, no recurrence |
| Bai et al., 202,0 | Case report | 1 | Iatrogenic after syndesmosis fixation | Midfoot | Remove button; midfoot FHL tenotomy; distal FHL to FDL transfer | Resolution, no recurrence |
| Gadhavi et al., 201,9 | Case report | 1 | Distal tibia fracture | Midfoot | FHL Z-plasty | Resolution, no recurrence |
| de Miranda et al., 201,9 | Case report | 1 | Tibia and fibular fracture | Medial forefoot | FHL Z-plasty | Resolution, no recurrence |
| Tanwar et al., 201,6 | Case report | 1 | Subtalar dislocation | Closed reduction and stabilization | Closed reduction and stabilization | Resolution, no recurrence |
| Sinnet et al., 201,5 | Case report | 1 | Distal tibia fibular fracture | Midfoot | FHL Z-plasty | Resolution, no recurrence |
| Kim et al., 201,5 | Case report | 1 | Ankle sprain with talar fracture | Retro-malleolar | FHL release | Resolution |
| TH Lui et al., 201,4 | Case report | 1 | Tibia and fibular fracture | Retro-malleolar | FHL Z-plasty | Resolution, no recurrence |
| Holcomb et al., 201,4 | Case report | 1 | Distal tibia fracture | Plantar hallux | FHL tenotomy over the IP joint + hallux IPJ arthrodesis | Resolution, no recurrence |
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