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All-Inside Endoscopic Zone 1 Flexor Hallucis Longus Transfer: A Cadaveric Feasibility Study.
Kevin D Martin1, Yi Wei1, Adam G F Smith1
1Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
Foot & Ankle Orthopaedics
|May 11, 2026
Summary
This study explored a new endoscopic technique for flexor hallucis longus (FHL) tendon transfer in Achilles tendon rupture repair. The all-inside zone 1 approach proved feasible and safe in cadavers, avoiding plantar incisions and neurovascular damage.
Area of Science:
- Orthopaedic Surgery
- Minimally Invasive Procedures
- Tendon Transfer Techniques
Background:
- Chronic Achilles tendon ruptures often require flexor hallucis longus (FHL) tendon transfer.
- Traditional methods involve plantar incisions, posing risks of neurovascular injury.
- An all-inside endoscopic zone 1 FHL tenotomy and transfer technique aims to mitigate these risks.
Purpose of the Study:
- Evaluate the feasibility of an all-inside endoscopic FHL zone 1 tenotomy and transfer.
- Assess if the technique provides adequate tendon length for fixation.
- Determine if the technique avoids neurovascular damage and tunnel blowout.
Main Methods:
- Ten cadaveric specimens underwent all-inside endoscopic zone 1 FHL tendon transfers.
- Procedures were performed without fluoroscopic guidance.
- Post-procedure analysis by two orthopedic surgeons assessed tendon length, anchor placement, tunnel integrity, and neurovascular preservation.
Main Results:
- No instances of neurovascular injury or calcaneal tunnel blowout were observed.
- The mean FHL tendon length achieved for fixation was 17.5 mm (±3.7 mm).
- Suture material was visible above the biotenodesis screw in two specimens.
Conclusions:
- The all-inside endoscopic zone 1 FHL tenotomy and transfer technique is feasible, reproducible, and preliminarily safe.
- Cadaveric findings support further clinical investigation for Achilles rupture repair.
- This minimally invasive approach shows promise for treating Achilles tendon injuries.
