title: Alternative to the modified jones procedure: outcomes of the flexor hallucis longus (FHL) tendon transfer procedure for correction of clawed hallux.
abstract: BACKGROUND
  The modified Jones procedure is the traditional operative procedure for correction of a clawed hallux, although the deformity may be caused by overpull of one of three different muscles. In this study we present the radiographic and functional outcomes of flexor hallucis longus (FHL) tendon transfer as treatment for clawed hallux. The transfer is performed by drawing two thirds of the FHL tendon up through a drill hole in the proximal phalanx and then suturing it medially back to the remaining third.
  
  
  METHODS
  We retrospectively identified 19 patients (22 feet) who had FHL tendon transfer for correction of clawed hallux over a period of 5 years. Followup was an average of 51.0 (range 6 to 74; +/- 3.8) months after the procedure. Outcome and patient satisfaction were determined using the Long-Form Musculoskeletal Function Assessment (MFA) score. Patients were asked whether they were satisfied, somewhat satisfied, or dissatisfied with the overall outcome and were asked about shoewear limitations. Preoperative and postoperative radiographs were evaluated in 15 patients (17 feet). We measured the hallux valgus and interphalangeal (IP) angles on the anteroposterior (AP) radiographs. On the lateral view we measured the angle of the IP joint, the metatarsophalangeal (MTP) joint, and the talometatarsal angle. Statistical analysis was done using a repeated measures ANOVA (p < 0.05).
  
  
  RESULTS
  On the lateral radiographs, the hallux IP joint angle (p < 0.0012; n = 15) and hallux MTP joint angle (p < 0.0265; n = 15) were significantly reduced postoperatively. On AP radiographs, the hallux valgus angle (p < 0.0334) was significantly reduced; however, the IP angle and the talometatarsal angle were not significantly different after surgery. Patients had an average MFA score of 14.6 (+/-3.8 standard error, range 1 to 35; n = 19). Thirteen patients were fully satisfied and six were somewhat satisfied with the overall result of the surgery. Four patients thought that their hallux limited the types of shoes they could wear, while 15 did not.
  
  
  CONCLUSIONS
  It has been shown that clawed hallux can result from excessive motor function in one of three muscles: FHL tendon, peroneus longus (PL), and extensor hallucis longus (EHL). This study suggests that transfer of part of the tendon of the FHL is an effective alternative operative procedure for correction of clawed hallux.
authors.affiliation: University of Washington, Orthopaedics and Sports Medicine, 1959 NE Pacific St., Box 356500, Seattle, WA 98195, USA. kadel@u.washington.edu
authors.forename: Nancy J
authors.initials: NJ
authors.lastname: Kadel
authors.forename: Emily A
authors.initials: EA
authors.lastname: Donaldson-Fletcher
authors.forename: Sigvard T
authors.initials: ST
authors.lastname: Hansen
authors.forename: Bruce J
authors.initials: BJ
authors.lastname: Sangeorzan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006215:Hallux Valgus / Q000000981:diagnostic imaging; D037801:Hammer Toe Syndrome / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011859:Radiography; D012189:Retrospective Studies; D013709:Tendon Transfer / Q000379:methods*; D013710:Tendons / Q000601:surgery*; D014033:Toe Joint / Q000000981:diagnostic imaging; D016896:Treatment Outcome