Back to Operative Surgery
Foot & Ankle

Jones Tendon Transfer (EHL to First Metatarsal)

Surgical technique guide for Jones Tendon Transfer (EHL to First Metatarsal) - FRCS exam preparation

Core Procedure
advanced
By OrthoVellum Medical Education Team

Reviewed by OrthoVellum Editorial Team

Editorial maintenance, source checking, and correction workflow • Published by OrthoVellum Medical Education Team

Editorial boardMethodologyReview policyReport a correction
High Yield Overview

JONES TENDON TRANSFER (EHL TO FIRST METATARSAL)

Dual incisions: (1) Dorsal longitudinal over hallux IP joint 2-3cm; (2) Dorsal longitudinal over first MT neck 3-4cm | advanced

Mnemonic

JONESJONES - Indications for Transfer

Mnemonic

TUNNELTUNNEL - Transfer Technique

Critical Danger Structures

Dorsal Digital Nerves

Location: 2-3mm medial and lateral to EHL tendon at IP joint incision. Protection: Identify early in subcutaneous plane before tendon sheath opened. Gentle retraction only.

Deep Peroneal Nerve

Location: 2-3cm medial to proximal incision, runs with dorsalis pedis artery. Protection: Stay on dorsal surface of first MT, avoid medial dissection.

Dorsalis Pedis Artery

Location: Runs with deep peroneal nerve medial to proximal incision. Protection: Do not dissect medially from MT neck. Hemostasis with bipolar if encountered.

Flexor Hallucis Longus

Location: Plantar to IP joint, at risk during cartilage debridement. Protection: Limit bone resection depth to 1cm. Do not penetrate plantar cortex aggressively.

Skin Bridge Between Incisions

Location: Dorsal skin between distal and proximal incisions. Protection: Do NOT connect incisions. Subcutaneous tunnel only for tendon passage.

Positioning and Preparation

Patient Position: Supine with bump under ipsilateral hip, foot at end of table for easy access

Surgical Approach: Dual incisions: (1) Dorsal longitudinal over hallux IP joint 2-3cm; (2) Dorsal longitudinal over first MT neck 3-4cm

Incision: First incision centered over hallux IP joint, second incision over first MT neck, both midline dorsal

Charcot-Marie-Tooth Disease and Cavovarus Foot

Pathophysiology of CMT Foot Deformity:

  • Hereditary motor sensory neuropathy (HMSN Type I most common)
  • Progressive distal muscle weakness in "dying back" pattern
  • Intrinsic muscle weakness → claw toes
  • Peroneal weakness (TA, EHL) → drop foot and claw hallux
  • Tibialis posterior relatively preserved → hindfoot varus
  • Peroneus brevis weakness → progressive cavovarus

Classic Cavovarus Triad:

  1. Hindfoot varus (tibialis posterior unopposed)
  2. First ray plantarflexion (peroneus longus unopposed)
  3. Claw hallux and lesser toes (intrinsic weakness)

Jones Transfer Role in CMT:

  • Addresses claw hallux deformity
  • Provides weak dorsiflexion augmentation
  • Usually combined with other procedures (dwyer, peroneus longus transfer, toe flexor transfers)

Operative Technique

Step 1: Patient positioning, incision planning, and tourniquet application

Patient positioning, incision planning, and tourniquet application: Position supine with sandbag under ipsilateral hip. Foot at edge of table. Mark two incisions: (1) 2-3cm longitudinal dorsal incision centered over hallux IP joint, (2) 3-4cm longitudinal incision over first MT neck. Prepare and drape leg. Apply thigh tourniquet and elevate, then inflate to 250-300mmHg.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Avoid connecting incisions - creates at-risk skin bridge. Tourniquet essential for hemostasis and visualization. Mark incisions before inflation to ensure correct placement over bony landmarks.

Step 2: Distal incision - EHL identification and harvest

Distal incision - EHL identification and harvest: Make 2-3cm longitudinal incision centered over hallux IP joint. Deepen through subcutaneous tissue. Identify EHL tendon immediately deep - white glistening structure. Identify and protect dorsal digital nerves medially and laterally (2-3mm from tendon). Open tendon sheath longitudinally. Trace EHL distally to insertion at base of distal phalanx. Use 15 blade to sharply detach tendon from bone insertion, leaving small cuff if possible. Harvest tendon with whipstitch using 2-0 non-absorbable suture at cut end.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Dorsal digital nerve injury (5-10% incidence) - causes painful neuroma and sensory loss. AVOID aggressive retraction. Identify nerves early in subcutaneous plane. If nerve injured, repair primarily with 8-0 or 9-0 nylon under magnification.

Step 3: Interphalangeal joint arthrodesis preparation

Interphalangeal joint arthrodesis preparation: With EHL detached and retracted, expose IP joint capsule. Make longitudinal capsulotomy to expose joint surfaces. Use small rongeur or curette to remove all articular cartilage from proximal phalanx head and distal phalanx base. Create flat, congruent surfaces - proximal head slightly concave, distal base flat to convex. Ensure good bony contact. Fish-scale or fenestrate subchondral bone with small curette to promote bleeding and fusion. Irrigate joint thoroughly to remove debris.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Avoid excessive bone resection - shortens hallux, weakens bone, risks phalangeal fracture. Limit depth to prevent FHL injury plantarly (1cm safe depth). If too much bone removed, may need bone graft or longer screw. Ensure alignment - avoid varus/valgus or rotational malalignment.

Step 4: Interphalangeal joint fixation

Interphalangeal joint fixation: Temporary fixation with K-wire: Insert 1.6mm K-wire from tip of distal phalanx retrograde across fusion site into proximal phalanx. Position hallux in 10-15° plantarflexion, neutral varus-valgus, neutral rotation. Check alignment clinically and with fluoroscopy. Definitive fixation options: (1) Cannulated screw: Ream over K-wire with 3.0-3.5mm reamer. Insert 3.5mm fully threaded cannulated screw, burying head. (2) Non-cannulated screw: Remove K-wire, drill and tap, insert screw. Confirm compression at fusion site. Alternative: Leave K-wire for fixation if screw not available (remove at 6 weeks).

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Screw length critical - measure carefully to avoid plantar cortex penetration and soft tissue irritation. Screw too short - inadequate fixation, nonunion risk. Malalignment in fusion - varus causes medial shoe pressure, valgus causes first web space pain. Excessive plantarflexion limits hallux dorsiflexion for propulsion.

Step 5: Proximal incision - first metatarsal exposure and tunnel creation

Proximal incision - first metatarsal exposure and tunnel creation: Make 3-4cm longitudinal incision over first MT neck dorsally, centered 3-4cm proximal to MTP joint. Deepen through subcutaneous tissue. Identify periosteum over dorsal MT neck. Avoid medial dissection (deep peroneal nerve and dorsalis pedis artery 2-3cm medial). Make small longitudinal periosteal incision 1cm long on dorsal surface. Subperiosteal exposure of MT neck. Using 3.5-4.0mm drill bit, create bone tunnel from dorsal to plantar cortex at MT neck, angled slightly proximal (toward base). Ream tunnel if needed. Ensure smooth tunnel edges.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Deep peroneal nerve and dorsalis pedis artery 2-3cm medial - stay on dorsal surface, avoid medial dissection. Tunnel too large - tendon pull-through, insecure fixation. Tunnel too small - cannot pass tendon. Plantar cortex blowout - weaken tunnel, tendon irritation plantarly. Use fluoroscopy to confirm tunnel position.

Step 6: Tendon passage and transfer

Tendon passage and transfer: Return to distal incision. Divide EHL tendon proximally at level of MTP joint (ensure adequate length for transfer). Create subcutaneous tunnel connecting two incisions using large hemostat or tendon passer. Pass EHL tendon proximally from distal incision to proximal incision through subcutaneous tunnel. At proximal incision, pass tendon end through bone tunnel in first MT from dorsal to plantar using curved hemostat or tendon passer. Pull tendon through until whipstitch visible at plantar tunnel exit.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Tendon too short - inadequate length for secure fixation. Divide more proximally if needed (can harvest to mid-dorsum of foot). Tendon twisting during passage - reduces strength, causes failure. Mark tendon orientation with marker before passage. Subcutaneous tunnel too tight - tendon strangulation, ischemia, adhesions.

Step 7: Tendon tensioning and fixation

Tendon tensioning and fixation: Position ankle in neutral dorsiflexion (90°). Position first ray in slight dorsiflexion relative to lesser metatarsals. Pull tendon tight through bone tunnel to achieve this position. Secure tendon to itself or plantar periosteum using multiple 2-0 non-absorbable sutures (FiberWire or Ethibond). Create tendon weave or wrap-around technique for additional security. Alternative: use suture anchor in plantar MT cortex to anchor tendon. Pull sutures tight while maintaining foot position. Confirm adequate tension - with ankle at neutral, hallux should rest in neutral to slight dorsiflexion at MTP joint.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Over-tensioning most common error - causes hallux MTP cock-up deformity, metatarsalgia, painful gait. Under-tensioning - no functional benefit, tendon failure. Test tensioning intraoperatively: passively dorsiflex ankle - should see hallux extend slightly at MTP. Check tension with knee extended and flexed (gastrocnemius effect on ankle position).

Step 8: Hemostasis, closure, and immobilization

Hemostasis, closure, and immobilization: Release tourniquet. Achieve hemostasis with bipolar cautery. Irrigate both wounds thoroughly. Close periosteum over MT tunnel with 2-0 absorbable suture if possible. Close subcutaneous layer both incisions with 3-0 absorbable suture. Close skin with 4-0 nylon interrupted or 4-0 absorbable subcuticular. Apply sterile dressings. Apply well-padded below-knee cast with ankle in neutral (90°), hallux in slight plantarflexion (10-15°) at MTP, IP fusion site protected. Cast extends to toes to protect IP fusion and transfer.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Inadequate hemostasis - hematoma, increased infection risk. Cast too tight - compartment syndrome risk (rare), vascular compromise. Cast padding insufficient - pressure sores over malleoli, toes. Ensure toes visible for neurovascular monitoring. Instruct patient: elevate leg 48-72 hours, watch for increasing pain (compartment syndrome), toe color changes (vascular compromise).

Step 9: Postoperative rehabilitation protocol

Postoperative rehabilitation protocol: Non-weight bearing in cast for 2 weeks. Wound check at 2 weeks, re-cast if wounds healed well. Progressive weight bearing in cast weeks 2-6. Radiographs at 6 weeks to assess IP fusion. If fusion progressing, transition to CAM boot, begin gentle ROM exercises (ankle and MTP - IP fused). Progressive weight bearing in boot weeks 6-10. Radiographs at 10-12 weeks confirm IP fusion. Transition to supportive shoe with stiff sole. Physical therapy: ankle dorsiflexion strengthening, gait training, proprioception. Return to regular shoes 3-4 months. Full unrestricted activity 4-6 months after confirmed fusion.

Exam Pearl

Technical Tip: EXAM KEY: Critical step in Jones Tendon Transfer (EHL to First Metatarsal) - ensure proper technique and visualization.

Dangers at this step

  • Early weight bearing - IP nonunion (most common complication if protocol violated). Inadequate immobilization - transfer failure, elongation. Delayed rehabilitation - ankle and MTP stiffness, plantar fascia contracture. Patient education critical for compliance. If IP fusion not evident at 12 weeks, consider bone stimulator, prolonged immobilization, or revision fusion with bone graft.

Step 10: Final fluoroscopic confirmation and documentation

Final fluoroscopic confirmation and documentation: Obtain AP and lateral fluoroscopic images of foot. Confirm IP fusion screw position (central, not protruding), bone tunnel intact, foot alignment acceptable. Document hallux position (IP fused in 10-15° plantarflexion, MTP neutral). Record tendon transfer path and tension setting. Note any intraoperative findings (tendon quality, bone quality, neurovascular status).

Exam Pearl

Technical Tip: EXAM KEY: Document tension setting for medicolegal purposes. Take intraoperative photos showing IP fusion hardware and tendon passage for records.

Dangers at this step

  • IP screw too long (plantar prominence) - check lateral view carefully. If screw proud, exchange for shorter. Incomplete documentation - record tension testing and position achieved.

Complications

Jones Transfer Complications - Recognition and Management

Post-operative Care

Below-knee cast with ankle neutral, hallux protected in 10-15° plantarflexion. Non-weight bearing first 2 weeks. Progressive weight bearing in cast weeks 2-6. Radiographs at 6 weeks assess IP fusion. CAM boot transition if fusion progressing, begin gentle ROM (ankle, MTP). Confirm IP fusion at 10-12 weeks radiographically. Supportive shoes with stiff sole, physical therapy for dorsiflexion strengthening and gait training. Return to regular shoes 3-4 months, full activity 4-6 months post-confirmed fusion. Expect permanent IP fusion (no IP motion), improved ankle dorsiflexion, corrected claw deformity. Long-term follow-up yearly for CMT patients to monitor disease progression.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 25-year-old with Charcot-Marie-Tooth disease presents with bilateral claw hallux deformity and foot drop. How would you assess and manage this patient?"

EXCEPTIONAL ANSWER
I would perform a comprehensive evaluation of this patient with CMT. History: disease type and duration, current functional limitations, walking aids, family history, previous interventions. Examination: I would assess muscle power systematically - tibialis anterior (typically weak), EHL (typically weak but functioning), tibialis posterior (relatively preserved), peronei (weakened). I would perform the Coleman block test to assess hindfoot flexibility. The hallux needs assessment for flexibility at both MTP and IP joints - the Jones transfer requires a supple MTP joint. I would assess the cavus component (first ray plantarflexion from unopposed peroneus longus) and hindfoot varus. Investigations include standing AP/lateral radiographs, nerve conduction studies if not already confirmed, and potentially MRI for tendon quality. Management: For bilateral disease I would stage procedures 3 months apart. For a supple claw hallux with weak tibialis anterior, the Jones transfer is indicated - it corrects the claw deformity via IP fusion and augments ankle dorsiflexion. I would likely need to address other components: Dwyer calcaneal osteotomy for hindfoot varus greater than 10 degrees, peroneus longus to brevis transfer for first ray plantarflexion, and possibly Girdlestone-Taylor transfers for lesser toe clawing.
VIVA SCENARIOStandard

EXAMINER

"Describe the key technical aspects of the Jones tendon transfer and how you ensure correct tensioning."

EXCEPTIONAL ANSWER
The Jones transfer involves two dorsal incisions - distal over the hallux IP joint (2-3cm) and proximal over the first metatarsal neck (3-4cm). I never connect the incisions to protect the skin bridge. Distally, I identify and protect the dorsal digital nerves which lie 2-3mm from the EHL tendon. I open the tendon sheath and trace EHL to its insertion on the distal phalanx, detaching it sharply. I whipstitch the tendon end with non-absorbable suture. The IP joint is then fused - I remove articular cartilage from both surfaces, fenestrate subchondral bone, and fix with a retrograde 3.5mm cannulated screw in 10-15 degrees plantarflexion. Proximally, I create a bone tunnel 3.5-4mm in the first MT neck, staying dorsal to avoid the deep peroneal nerve and dorsalis pedis artery medially. I pass the EHL tendon subcutaneously then through the bone tunnel dorsal to plantar. For tensioning, I position the ankle in neutral dorsiflexion and tension the tendon until the hallux MTP is neutral to slightly extended. I test by dorsiflexing the ankle - the MTP should extend slightly. I test with knee extended and flexed to account for gastrocnemius effect. I secure the tendon with multiple non-absorbable sutures in a wrap-around fashion.
VIVA SCENARIOStandard

EXAMINER

"What alternative procedures exist for claw hallux and drop foot? When would you choose alternatives over the Jones transfer?"

EXCEPTIONAL ANSWER
For claw hallux specifically, alternatives include: EHL lengthening for mild flexible deformity with normal tibialis anterior - this preserves IP motion; EHL transfer to the MTP capsule for isolated claw with normal TA - maintains some extension function; IP fusion alone for rigid claw with strong TA where dorsiflexion augmentation not needed. For drop foot, the Jones transfer only provides weak dorsiflexion augmentation so is suitable for partial TA weakness. For complete anterior compartment palsy, I would consider the Bridle procedure - this uses tibialis posterior and peroneus longus transfers routed to the TA insertion, providing stronger dorsiflexion. The LFTT (lateral flexor-to-extensor tendon transfer of tibialis posterior through the interosseous membrane) is another option for complete anterior compartment loss. An AFO remains appropriate for non-surgical candidates or as a temporizing measure. I would choose alternatives to Jones when: TA power is normal (no dorsiflexion augmentation needed), EHL is non-functioning (no donor tendon), the MTP is fixed (requires osteotomy first), or the patient needs only drop foot management without claw hallux correction.

Jones Tendon Transfer (EHL to First Metatarsal) - Exam Summary

High-Yield Exam Summary

References

  1. Jones R. The soldier's foot and the treatment of common deformities of the foot. BMJ 1916;1:749-753.

  2. Hansen ST. Functional reconstruction of the foot and ankle. Lippincott Williams & Wilkins 2000.

  3. Beals TC, Nickisch F. Charcot-Marie-Tooth disease and the cavovarus foot. Foot Ankle Clin 2008;13:259-274.

  4. Sammarco GJ, Taylor R. Cavovarus foot treated with combined calcaneus and metatarsal osteotomies. Foot Ankle Int 2001;22:19-30.

  5. Ward CM, Dolan LA, Bennett DL, et al. Long-term results of reconstruction for treatment of a flexible cavovarus foot in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 2008;90:2631-2642.

  6. Giannini S, Faldini C, Pagkrati S, et al. Modified Jones procedure for pes cavovarus. Foot Ankle Int 2008;29:892-897.

  7. Krause FG, Wing KJ, Younger AS. Neuromuscular issues in cavovarus foot. Foot Ankle Clin 2008;13:243-258.

  8. Holmes JR, Hansen ST. Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14:476-486.

  9. Schwend RM, Drennan JC. Cavus foot deformity in children. J Am Acad Orthop Surg 2003;11:201-211.

  10. Chan G, Sampath J, Miller F, et al. The role of the dynamic pedobarograph in assessing treatment of cavovarus feet in children with Charcot-Marie-Tooth disease. J Pediatr Orthop 2007;27:510-516.