Dual Purpose Use of Flexor Hallucis Longus Tendon for Management of Chronic Achilles Tendon Ruptures

Abstract

Background: Chronic Achilles tendon ruptures are uncommon and increase long-term morbidity when untreated. There is no standard treatment for this condition. Methods: Chronic Achilles tendon rupture was repaired in 10 patients by harvesting the flexor hallucis longus tendon (FHL) using a minimally invasive technique. It was then transferred to the calcaneus and the remnant used to bridge the gap for reconstructing the Achilles tendon itself. The patients were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot Scale. Results: Patients were evaluated postoperatively to assess pain, function, and alignment of the ankle and hindfoot. Average follow-up time was 30.9 months (range = 17-43 months). The average postoperative AOFAS score was 78.5 (range = 54-94). The average postoperative score for pain was 33.5 out of 40; for function, 38.7 out of 50; and for alignment, 6.3 out of 10. A single surgical site infection requiring Incision and Drainage (I&D) was the only operative complication noted. No patient developed a significant deformity of the hallux after transfer. Conclusions: FHL transfer using a minimally invasive harvest for the treatment of chronic Achilles tendon ruptures produces good to excellent outcome measures as judged by an AOFAS score of 75 or greater while minimizing risk to the medial neurovascular bundle. Levels of Evidence: Case series, Level IV: Retrospective

Surgical Management of Chronic Achilles Tendon Ruptures: A Systematic Review and Proposed Treatment Algorithm

“…Seven studies performed flexor hallucis longus (FHL) tendon transfer on 141 patients. 13 , 20 , 25 , 31 , 37 , 46 , 48 The decision to perform an FHL transfer was determined by the senior surgeon’s preference. The AOFAS score was the scoring system that was most frequently utilized in 6 studies.…”

“…Flexor hallucis longus (FHL) transfer is a frequently used tendon transfer technique as it fires in-phase with the Achilles, but is associated with reduced plantarflexion strength of the first ray. 13 , 20 The semitendinosus tendon can be harvested as an autograft as it is a robust, strong tendon that can bridge large gaps between the tendon stumps. 7 , 28 The gastrocnemius tendon is an easily accessible tendon that is in the same line of pull as the Achilles tendon and thus can restore normal ankle biomechanics.…”

Neglected tendoachilles tear treated with flexor hallucis longus tendon transfer

“…All cases had history of trauma and duration between day of injury and presentation to our institution is greater than 4 weeks. All cases were closed during presentation, but 2 patients had history of open injuries, was treated elsewhere and the diagnosis of tendoachilles injury was missed and presented to our institution after 4 weeks [16] . The average gap of the tendon after removing the fibrosed tissue with ankle in 30 degree plantar flexion is about 7.8 cm.…”

“…It is the most commonly injured tendon in the lower limb [13] . The most common cause of tendoachilles injuries in developed nations is due to trauma during sports activities [16] . The common cause of tendoachilles injuries in Indian setting is lavatory pan injury and due to road traffic accident.…”

Achilles tendon reconstruction combining a modified Dresden technique and endoscopic flexor hallucis longus transfer

“…In terms of tendon fixation, a myriad of techniques has been described with more or less popularity (14) . Interference screw is an increasingly used technique because it decreases donor site morbidity, and less tendon length is needed for transfer, reducing the need of auxiliary incisions (14,15) . To the authors´ knowledge, no clinical studies have described interference screw failure in FHL transfer.…”