Arthroscopically assisted Z-lengthening of extensor hallucis longus tendon

Extensor hallucis longus tendon contracture can lead to hyperextension deformity of the big toe. We describe an endoscopic approach of Z-lengthening of the tendon. Extensor hallucis longus tendoscopy is performed with a distal portal at the level of the metatarsal neck and a proximal portal at the level of the navicular. At the distal portal, the medial half of the extensor hallucis longus tendon is cut and a stay stitch of No. 2 ethibond is applied. It is then stripped proximally with a tendon stripper to the proximal portal. A stay stitch of No. 2 ethibond is applied to the lateral half of the tendon at the proximal portal and it is cut proximal to the stitch. With the ankle plantarflexed and the big toe kept in the similar position as the lesser toes, the tendon segments are kept in tension through the stay stitches via the proximal and distal portals. The stay stitches of distal tendon segment are sutured to the proximal segment at the same level of the cut end of the distal fragment with the aid of an eyed needle under arthroscopic visualization through the distal portal. The needle is passed through the tendon and then the skin. The suture is also passed through the skin and then retrieved to the proximal portal by a hemostat. It is then sutured to the proximal tendon segment at the proximal portal. Similarly, the proximal tendon end is sutured to the distal tendon segment at the corresponding level and the endoscopic Z-lengthening of the extensor hallucis longus tendon is then completed.