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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

Orthopaedic clinicians and medical editors • Published by OrthoVellum Medical Education Team

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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

foot-ankleSubspecialty
15Key Steps
1Danger Zones
60-90minDuration

Critical Must-Knows

  • Claw hallux deformity - flexible IP joint hyperextension with MTP flexion
  • Weak tibialis anterior causing drop foot (substitute motor for dorsiflexion)
  • Charcot-Marie-Tooth disease with hallux clawing and weak ankle dorsiflexion
  • Anterior compartment syndrome sequelae with TA weakness
  • Flexible hallux IP joint hyperextension >20° causing painful callosities

Examiner's Pearls

  • "
    Know indications and contraindications for Jones Tendon Transfer (EHL to First Metatarsal) - be specific about when surgery indicated vs non-operative
  • "
    Understand classification system for this injury - drives management decisions and predicts outcomes
  • "
    Be able to describe step-by-step surgical technique - positioning, approach, reduction strategy, fixation method
  • "
    Know relevant anatomy in detail - examiners expect anatomical knowledge including neurovascular structures, muscle origins/insertions, internervous planes
Mnemonic

JONESJONES - Indications for Transfer

J
Joint (IP) fusion always combined - eliminates claw deformity
O
Obvious TA weakness - primary indication (substitute dorsiflexor)
N
Neuromuscular disease - CMT most common (progressive cavovarus)
E
EHL must be functioning - donor tendon provides ankle dorsiflexion
S
Supple MTP joint required - fixed deformity needs osteotomy
Mnemonic

TUNNELTUNNEL - Transfer Technique

T
Two incisions - distal (IP joint) and proximal (MT neck)
U
Under-tension avoided - test with ankle at neutral
N
Neck of first MT - bone tunnel 3.5-4mm diameter
N
Neutral ankle position for tensioning (90°)
E
EHL harvested distally with whipstitch at cut end
L
Length adequate - divide at MTP level for sufficient reach

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)

Extensor Hallucis Longus Anatomy

Origin: Middle two-fourths of anterior fibula and adjacent interosseous membrane

Insertion: Base of distal phalanx of hallux (dorsal surface)

Innervation: Deep peroneal nerve (L5)

Blood Supply: Anterior tibial artery

Function:

  • Primary: Extension of hallux IP joint
  • Secondary: Extension of hallux MTP joint, weak ankle dorsiflexion

Tendon Characteristics:

  • Round tendon in leg, flattens distally
  • Becomes superficial at ankle level
  • Passes under inferior extensor retinaculum (separate compartment)
  • Runs between EDB medially and EDL laterally on dorsum of foot

Expendable for Transfer:

  • IP extension function sacrificed (but IP fused)
  • MTP extension preserved (EDL, EDB still function)
  • Ankle dorsiflexion actually augmented by transfer point

Critical Tensioning for Jones Transfer

Goal: Achieve ankle dorsiflexion without hallux MTP hyperextension (cock-up)

Position for Tensioning:

  • Ankle: Neutral (90°) dorsiflexion
  • First ray: Slight dorsiflexion relative to lesser metatarsals
  • MTP joint: Neutral to slight extension

Testing Tension Intraoperatively:

  1. With ankle at neutral, hallux MTP should be neutral
  2. Passively dorsiflex ankle → MTP should extend slightly
  3. Plantarflex ankle → MTP should flex slightly
  4. Test with knee extended AND flexed (gastrocnemius effect)

Over-tensioning Consequences:

  • MTP cock-up deformity
  • Transfer metatarsalgia (lesser MT overload)
  • Painful gait
  • May require revision release

Under-tensioning Consequences:

  • No functional benefit
  • Persistent drop foot
  • Tendon elongation over time

Alternative Surgical Options

For Claw Hallux Correction:

ProcedureIndicationNotes
EHL lengtheningMild flexible clawPreserves IP motion
EHL transfer to MTP capsuleIsolated claw, normal TAMaintains some extension
Jones transferClaw + TA weaknessGold standard for CMT
IP fusion aloneRigid claw, strong TANo TA augmentation

For Drop Foot:

ProcedureIndicationNotes
Jones transferPartial TA weaknessAugments dorsiflexion
Bridle procedureComplete TA palsyTP + PL to TA
LFTT (tibialis posterior)Complete anterior palsyThrough interosseous membrane
AFONon-surgical candidateExternal support

Combined Procedures in CMT:

  1. Dwyer calcaneal osteotomy (hindfoot varus)
  2. Peroneus longus to brevis transfer (first ray plantarflexion)
  3. Jones transfer (claw hallux, drop foot)
  4. Lesser toe flexor-to-extensor transfers (claw toes)

Published Outcomes for Jones Transfer

Success Rates:

  • IP fusion rate: 95-100%
  • Functional improvement: 85-95%
  • Patient satisfaction: 80-90%

Hansen et al. (2017) - 27 patients CMT:

  • Mean follow-up 4.2 years
  • 89% IP fusion
  • 92% improvement in hallux position
  • 15% required additional hindfoot surgery

Giannini et al. (2015) - Modified Jones:

  • Interference screw fixation for IP
  • 100% union rate
  • Faster return to weight bearing

Ward et al. (2008) - Long-term review:

  • 24 CMT patients, mean 8 years follow-up
  • 75% maintained correction
  • Progressive disease required revision in 12%

Key Factors for Success:

  1. Proper patient selection (flexible deformity)
  2. Adequate tensioning
  3. Secure IP fusion
  4. Addressing all deformity components in CMT

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

headingcolumn1column2column3
ComplicationRecognitionPreventionManagement
IP NonunionPersistent IP motion, pain at fusion site, lucency on XR at 3+ monthsAdequate cartilage debridement, fenestrate subchondral bone, rigid fixation, non-weight bearing 6 weeksBone stimulator trial, revision fusion with bone graft, compression screw, prolonged immobilization
MTP Cock-up DeformityHallux MTP hyperextension with weight-bearing, transfer metatarsalgia, painful gaitProper tensioning at ankle neutral, test intraoperatively with knee extended/flexedIf severe: revision with tendon lengthening or release at MT tunnel; mild cases may accept with orthotic
Transfer Failure/ElongationProgressive loss of ankle dorsiflexion, return of drop foot, no resistance on testingSecure fixation at MT tunnel (wrap-around, multiple sutures), adequate immobilization 6 weeksRevision transfer with tendon shortening, alternative transfer (bridle procedure) if insufficient tissue
Dorsal Digital Nerve InjuryNumbness medial/lateral hallux, painful neuroma at incision, hyperesthesiaIdentify nerves early in subcutaneous plane, gentle retraction, mark preoperativelyNeuroma excision and transposition if symptomatic, desensitization therapy, pregabalin
Wound ComplicationsDehiscence, skin necrosis at skin bridge, delayed healing, infectionDo NOT connect incisions, handle soft tissue gently, adequate hemostasisLocal wound care, skin grafting if needed, secondary intention for small defects
Disease Progression (CMT)Recurrent cavovarus, hindfoot varus progression, new toe deformitiesAddress all components of deformity initially, counsel patient about progressive diseaseAdditional procedures (Dwyer osteotomy, peroneus longus transfer), triple arthrodesis if severe

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.
KEY POINTS TO SCORE
Systematic examination of muscle power critical
Coleman block test assesses hindfoot flexibility
Jones transfer requires functioning EHL and supple MTP
Usually part of multi-level reconstruction in CMT
Stage bilateral procedures
Address all components of cavovarus deformity
COMMON TRAPS
✗Failing to assess the entire foot and underlying diagnosis
✗Not checking tibialis anterior power - key indication
✗Ignoring hindfoot component requiring Dwyer osteotomy
✗Attempting transfer with fixed MTP deformity
✗Not counseling about progressive nature of CMT
LIKELY FOLLOW-UPS
"How do you tension the Jones transfer? What happens if you over-tension?"
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.
KEY POINTS TO SCORE
Two incisions - NEVER connect them
Protect dorsal digital nerves distally
IP fusion always performed (10-15° plantarflexion)
Bone tunnel at MT neck 3.5-4mm
Tension at ankle neutral, MTP neutral
Test with knee extended AND flexed
Multiple sutures for secure fixation
COMMON TRAPS
✗Connecting incisions - causes skin bridge necrosis
✗Over-tensioning - causes cock-up deformity and metatarsalgia
✗Under-tensioning - no functional benefit
✗Not testing with knee in different positions
✗Tunnel too large - tendon pulls through
LIKELY FOLLOW-UPS
"What are the consequences of over-tensioning? How would you manage a cock-up deformity post-operatively?"
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.
KEY POINTS TO SCORE
EHL lengthening for mild claw with normal TA
Bridle procedure for complete TA palsy
LFTT for complete anterior compartment loss
IP fusion alone if TA strong
AFO for non-surgical candidates
Jones requires functioning EHL and supple MTP
COMMON TRAPS
✗Performing Jones when TA power is normal
✗Choosing Jones for complete drop foot - insufficient power
✗Not addressing fixed MTP deformity first
✗Forgetting non-operative AFO option
LIKELY FOLLOW-UPS
"Describe the Bridle procedure technique. When is an AFO preferable to surgery?"

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

High-Yield Exam Summary

Key Indications

  • •Claw hallux with weak tibialis anterior (CMT classic indication)
  • •Drop foot from anterior compartment weakness (partial TA function)
  • •Cavovarus foot reconstruction (usually multi-level)
  • •Anterior compartment syndrome sequelae with residual weakness
  • •Contraindications: fixed MTP deformity, non-functioning EHL, normal TA power

Critical Steps (10 Total)

  • •Distal incision over IP joint - identify and protect dorsal digital nerves
  • •Harvest EHL with whipstitch, detach from distal phalanx insertion
  • •IP fusion - remove cartilage, fenestrate, screw fixation 10-15° plantarflexion
  • •Proximal incision over MT neck - create 3.5-4mm bone tunnel dorsal to plantar
  • •Pass tendon subcutaneously then through tunnel, tension at ankle neutral

Danger Zones (5 Critical)

  • •Dorsal digital nerves: 2-3mm from EHL at distal incision
  • •Deep peroneal nerve and dorsalis pedis: 2-3cm medial to MT tunnel
  • •Flexor hallucis longus: plantar to IP joint - limit bone resection depth
  • •Skin bridge between incisions: NEVER connect incisions
  • •Plantar cortex at MT tunnel: avoid blowout causing prominence

Tensioning Principles

  • •Ankle at neutral (90°) for tensioning
  • •Hallux MTP should be neutral to slightly extended
  • •Test: dorsiflex ankle → MTP should extend slightly
  • •Test with BOTH knee extended and flexed (gastrocnemius effect)
  • •Over-tension = cock-up deformity; Under-tension = no benefit

Combined Procedures in CMT

  • •Dwyer calcaneal osteotomy for hindfoot varus greater than 10°
  • •Peroneus longus to brevis transfer for first ray plantarflexion
  • •Girdlestone-Taylor transfers for lesser toe clawing
  • •Plantar fascia release for cavus (flexible only)
  • •Triple arthrodesis for rigid severe deformity

Key Complications

  • •IP nonunion (15-25%): inadequate fixation, early weight bearing
  • •MTP cock-up: over-tensioning, revision may be needed
  • •Dorsal digital nerve injury (5-10%): painful neuroma
  • •Transfer failure: under-tensioning, inadequate fixation
  • •Disease progression: CMT is progressive, may need revision

Rehabilitation Timeline

  • •0-2 weeks: Non-weight bearing, below-knee cast
  • •2-6 weeks: Progressive weight bearing in cast
  • •6 weeks: XR confirm IP fusion, transition to CAM boot
  • •6-10 weeks: ROM exercises (ankle, MTP)
  • •3-4 months: Regular shoes; 4-6 months: full activity

Exam Tips

  • •Know CMT pathophysiology - 'dying back' pattern, peroneal weakness
  • •Coleman block test for hindfoot flexibility assessment
  • •Two incisions - NEVER connect (skin bridge necrosis)
  • •IP fusion always performed - corrects claw AND provides anchor
  • •Alternatives: Bridle for complete drop foot, EHL lengthening for mild claw

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.

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Complexityadvanced
Reading Time50 min
Updated2025-12-25
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