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Updated: Jun 13, 2026

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery
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False FHL: a normal variant posing risks in posterior hindfoot endoscopy.

Phinit Phisitkul1, Annunziato Amendola

  • 1Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, Iowa 52242-1009, USA. phinit-phisitkul@uiowa.edu

Arthroscopy : the Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association
|May 4, 2010
PubMed
Summary

Posterior hindfoot endoscopy uses the flexor hallucis longus as a key landmark. A rare muscle variant, the peroneocalcaneus internus, can mimic this structure, posing risks of neurovascular injury during surgery.

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Area of Science:

  • Orthopedic Surgery
  • Anatomy

Background:

  • Posterior hindfoot endoscopy is increasingly utilized for treating various foot pathologies.
  • The flexor hallucis longus (FHL) tendon is a critical medial landmark during these procedures, guiding instruments to prevent neurovascular damage.

Observation:

  • Two cases are presented where the peroneocalcaneus internus muscle mimicked the FHL tendon.
  • This anatomical variation, termed "false FHL," presented a significant risk during initial endoscopic visualization.

Findings:

  • The "false FHL" can be mistaken for the true FHL, potentially leading to inadvertent injury to the tibial nerve and vessels.
  • Preoperative imaging and intraoperative differentiation are crucial for identifying this anomaly.

Implications:

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  • Surgeons must be aware of the peroneocalcaneus internus as a rare but critical anatomical variation.
  • Enhanced preoperative planning and intraoperative vigilance are essential to avoid severe complications in posterior hindfoot endoscopy.