Surgical and Radiologic Anatomy

, Volume 40, Issue 9, pp 1031–1038 | Cite as

Anatomical feasibility study of flexor hallucis longus transfer in treatment of Achilles tendon and posteromedial portal of ankle arthroscopy

  • Haijiao Mao
  • Linger Wang
  • Wenwei Dong
  • Zhenxin Liu
  • Weigang Yin
  • Dachuan Xu
  • Keith L. Wapner
Original Article



The aim of this study was to evaluate the occurrence of anatomical variations of the musculotendinous junction of the flexor hallucis longus (FHL) muscle, the relationship between FHL tendon or muscle and the tibial neurovascular bundle at the level of the posterior ankle joint in human cadavers.


Seventy embalmed feet from 20 male and 15 female cadavers, the cadavers’ mean age was 65.4 (range from 14 to 82) years, were dissected and anatomically classified to observe FHL muscle morphology define the relationship between FHL tendon or muscle and the tibial neurovascular bundle. The distance between the musculotendinous junction and the relationship between FHL tendon or muscle and the tibial neurovascular bundle was determined.


Three morphology types of FHL muscle were identified: a long lateral and shorter medial muscle belly, which was observed in 63 specimens (90%); equal length medial and lateral muscle bellies, this variant was only observed in five specimens (7.1%); one lateral and no medial muscle belly, which was observed in two specimens (2.9%). No statistically significant difference was observed according to gender or side (p > 0.05). Two patterns were identified and described between FHL tendon or muscle and the tibial neurovascular bundle. Pattern 1, the distance between the neurovascular bundle and FHL tendon was 3.46 mm (range 2.34–8.84, SD = 2.12) which was observed in 66 specimens (94.3%); Pattern 2, there was no distance which was observed in four specimens (5.7%).


Knowing FHL muscle morphology, variations provide new important insights into secure planning and execution of a FHL transfer for Achilles tendon defect as well as for the interpretation of ultrasound and magnetic resonance images. With posterior arthroscopic for the treatment of various ankle pathologies, posteromedial portal may be introduced into the posterior aspect of the ankle without gross injury to the tibial neurovascular structures because of the gap between the neurovascular bundle and FHL tendon.


Arthroscopy anatomy Flexor hallucis longus Neurovascular tibial bundle Achilles tendon 



This project was supported by Zhejiang Medical Science and Technology Projects Grant (2014RCA025) and Nature Science Foundation of Ningbo city (2016A610133).

Author contribution

Haijiao Mao did this research and wrote the main manuscript text. Wenwei Dong and Linger Wang did date collection. Zhenxin Liu performed the study. Weigang Yin and Dachuan Xu offered the cadaver bodies. Keith L Wapner reviewed and revised the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


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Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, The Affiliated Hospital of Medical schoolNingbo UniversityNingboChina
  2. 2.Department of AnatomyMedical School of Ningbo UniversityNingboChina
  3. 3.Department of AnatomySouthern Medical UniversityGuangzhouChina
  4. 4.Department of Orthopaedic Surgery, Pennsylvania HospitalUniversity of Pennsylvania School of MedicinePhiladelphiaUSA

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