Retro-Malleolar Z-Plasty of Flexor Hallucis Longus Tendon in Post-Traumatic Checkrein Deformity: A Case Series and Literature Review

Checkrein deformity (CD) is a dynamic deformity of the hallux characterized by flexion contracture of the interphalangeal (IF) joint and extension contracture of the metatarsophalangeal (MTP) joint, worsened by ankle dorsiflexion. It is due to post-traumatic or ischemic retraction of the long hallux flexor tendon (FHL) following soft tissue trauma, leg fractures, ankle fractures and, more rarely, calcaneal or talar fractures. Diagnosis is essentially clinical, associated with imaging, to rule out unrecognized causes and evaluate fracture healing process. Few cases are reported in literature without univocal treatment. Background and Objectives: To analyze clinical and functional outcomes in patients with CD treated with release and retro-malleolar Z-plasty lengthening of FHL tendon. Materials and Methods: Patients diagnosed with CD treated with retro-malleolar (at tarsal tunnel) Zplasty lengthening of the FHL tendon between January 2016 and August 2020 were included. Clinical and functional outcomes were collected on admission and post-surgery and analysed retrospectively. Patients with a minimum follow-up of 18 months were included. Results: A total of 14 patients, with mean age of 37.4 years old, with CD diagnosis were included in the study. All patients were suffering from post-traumatic CD and the mean time from trauma to onset of deformity was of 7 months (range 1–12). At a mean follow-up of 31.8 months (range 18–48) we found a significant improvement (p < 0.05) in terms of pain relief (VAS), function (AOFAS score) and ROM of the IP and MTP hallux joints. No recurrence, loss of strength, nerve injury or tarsal tunnel syndrome were observed. No patient required revision surgery. Conclusions: In this case series the retro-malleolar FHL tendon Z-plasty proved to be a suitable option for CD correction, allowing a good clinical and functional recovery.