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Systematic review of tendon transfers in the foot and ankle using interference screw fixation: Outcomes and safety of early versus standard postoperative rehabilitation. Foot Ankle Surg 2022; 28:166-175. [PMID: 33766498 DOI: 10.1016/j.fas.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/31/2020] [Accepted: 03/15/2021] [Indexed: 02/04/2023]
Abstract
AIMS To compare the outcomes of early and standard rehabilitation protocols following tendon transfers in the foot and ankle using interference screw fixation (ISF). METHODS A systematic review was performed for relevant articles (1998 to 2020) reporting foot tendon transfer using ISF in adults. The primary outcome was early tendon failure. Secondary outcomes included function and complications. RESULTS In total, 21 studies met the inclusion criteria, totalling 494 patients. Seven studies reported early rehabilitation protocols. The rate of early tendon failure was zero for each protocol and studies consistently reported a significant improvement in function. No differences were found comparing different rehabilitation protocols for tendon transfer for Achilles tendon pathology and foot drop. CONCLUSION Both early and standard rehabilitation protocols are associated with high patient satisfaction and low complication rates, but currently there is a lack of evidence to support early loaded activities or motion. LEVEL OF EVIDENCE IV Systematic review including case series.
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Batista JP, Abdelatif NMN, Del Vecchio JJ, Diniz P, Pereira H. Endoscopic Flexor Hallucis Longus Transfer for the Management of Acute Achilles Tendon Ruptures: A Prospective Case Series Report With a Minimum of 18 Months' Follow-Up. J Foot Ankle Surg 2021; 59:927-937. [PMID: 32527698 DOI: 10.1053/j.jfas.2019.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 02/03/2023]
Abstract
Acute Achilles tendon rupture can be treated either surgically or nonsurgically. The flexor hallucis longus (FHL) has been used successfully in patients with large chronic Achilles tendon defects. The aim of this study was to describe the clinical outcomes of isolated endoscopic FHL transfer in patients with acute Achilles tendon ruptures at a minimum follow-up of 18 months. Fifty-six male patients with an average age of 36.3 years who underwent endoscopic FHL transfer as a treatment for acute Achilles tendon ruptures were included. Follow-up was for a mean (± standard deviation) of 27.5 ± 7.29 months. At 18 months postoperatively, the Achilles tendon total rupture score mean was 95 ± 4.26, and the American Orthopaedic Foot and Ankle Society score was a mean of 96.4 ± 4.31. The median value for FHL tendon dynamometry on the surgical side was 95.72 (range 70.1 to 142), and 100.7 (range 68 to 161) for the nonoperated side. Mean ankle plantarflexion strength at 18 months was 19.19 ± 2.55 kg • m compared with the uninjured side of 19.27 ± 2.16 kg • m. Relative Achilles tendon resting angle showed a mean of -0.25° ± 2.43°. Magnetic resonance imaging performed at a minimum of 18 months postoperatively showed a homogeneous continuous Achilles tendon signal for 43 patients and heterogeneous signal intensity in 13 patients (23.21%). No patients reported any great toe complaints or symptomatic deficits of flexion strength. No neurovascular or skin complications were encountered. The current study demonstrated satisfactory and comparable results with minimal complications when using the endoscopic FHL tendon transfer in surgical management of acute Achilles tendon ruptures, compared with the currently used methods.
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Affiliation(s)
- Jorge Pablo Batista
- Head, Ankle and Knee Section, Orthopaedics Department, Centro Artroscópico Jorge Batista SA, Buenos Aires, Argentina; Head, Soccer Medical Department, Department of Sport Medicine, Club Atlético Boca Juniors, Buenos Aires, Argentina
| | | | - Jorge Javier Del Vecchio
- Head, Foot and Ankle Section, Orthopaedics Department, Fundación Favaloro. Hospital Universitario, Buenos Aires, Argentina; Professor, Department of Kinesiology and Physiatry, Universidad Favaloro, Buenos Aires, Argentina
| | - Pedro Diniz
- Orthopaedic Surgeon, Hospital de Sant'Ana, Parede, Portugal; PhD Student, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Portugal
| | - Helder Pereira
- Orthopedic Surgeon, Orthopedic Department of Póvoa de Varzim, Ripoll y De Prado Sports Clinic, Murcia-Madrid, Spain; Orthopedic Surgeon, FIFA Medical Centre of Excellence; ICVS/3B's, PT Government Associate Laboratory, Porto, Portugal; Orthopedic Surgeon, ICVS/3B's, PT Government Associate Laboratory - Minho University, Braga, Portugal
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Jain M, Tripathy SK, Behera S, Das SS, Rana R, Gantaguru A. Functional outcome of gastrocnemius advancement flap augmented with short flexor hallucis longus tendon transfer in chronic Achilles tear. Foot (Edinb) 2020; 45:101704. [PMID: 33038661 DOI: 10.1016/j.foot.2020.101704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength. METHODOLOGY Fifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS). RESULTS The mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4-10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13-24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62-83) to 98.4 ± 2.03 (94-100) and 61.73 ± 8.16 (52-70) to 98 ± 1.85 (94-100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture. CONCLUSION The functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.
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Affiliation(s)
- Mantu Jain
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sudarsan Behera
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India.
| | - Sudhanshu Sekhar Das
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
| | - Rajesh Rana
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
| | - Amrit Gantaguru
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubanewar, Odisha 751019, India
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Lee JI. Endoscopic Flexor Hallucis Longus Tendon Transfer for Reconstruction of the Achilles Tendon Rupture in High-Risk Patients: A Case Series. J Foot Ankle Surg 2019; 58:1257-1261. [PMID: 31679678 DOI: 10.1053/j.jfas.2019.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/30/2019] [Indexed: 02/03/2023]
Abstract
The neglected Achilles tendon rupture requires surgical reconstruction for the best functional outcome. According to the current literature, there are many reconstructive options available that demonstrate acceptable functional results in most cases. These procedures require large incisions, leading to potential wound-healing complications. Therefore, these procedures may not be suitable for patients who are at high risk for wound-healing problems. A minimally invasive approach is desirable in this situation to decrease the risk of this potential complication. Endoscopic transfer of the flexor hallucis longus tendon is described in this series as an alternative to reconstruct the Achilles tendon in 2 such high-risk individuals. Both patients had a successful outcome with no wound-healing problems and regained acceptable functional status.
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Affiliation(s)
- Jake I Lee
- Senior Physician, Department of Orthopedic Surgery, Kaiser Foundation Hospital, Redwood City, CA.
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Alhaug OK, Berdal G, Husebye EE, Hvaal K. Flexor hallucis longus tendon transfer for chronic Achilles tendon rupture. A retrospective study. Foot Ankle Surg 2019; 25:630-635. [PMID: 30321934 DOI: 10.1016/j.fas.2018.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/31/2018] [Accepted: 07/09/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The transfer of Flexor Hallucis Longus Tendon (FHL) is an established method for the treatment of chronic Achilles tendon ruptures. An extensive examination of power, strength, endurance and complications related to this procedure is presented. METHODS 21 patients treated with open FHL transfer for chronic Achilles tendon rupture were studied retrospectively. Medical records were reviewed. The patients were examined with a test battery for triceps surae strength, functional tests and PROMs. RESULTS The median maximal concentric strength was equal,1300 vs 1336W, comparing affected with unaffected side. The endurance tests showed a larger difference, 219J vs. 2398J, respectively. The median AOFAS score was 87. 11 of 21 patients sustained one or more complications; the most common were infection, disturbed wound healing, and clawing of small toes. CONCLUSIONS Patients achieve almost normal maximal strength after open FHL transfer, but endurance is notably lower. The complication rate was high.
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Affiliation(s)
| | - Gøran Berdal
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Kjetil Hvaal
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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Abstract
Chronic ruptures of the Achilles tendon are often missed injuries, which is challenging for the surgeon. The complications from reconstruction are a considerable concern. Primary repair may be attempted, but the missed injury often presents later than 4 weeks with gaps greater than 4 cm, necessitating more complex reconstructions using local tissues such as turn-down flaps and VY plasty, requiring large incisions in an unfavorable area of the body. We describe a step-by-step technique of endoscopic flexor hallucis longus reconstruction for chronic Achilles rupture, which decreases local complications. This article reviews the available literature for endoscopic flexor hallucis longus reconstruction.
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Arthroskopischer Transfer der Flexor-hallucis-longus-Sehne zum Ersatz der Achillessehne. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-0297-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ozer H, Ergisi Y, Harput G, Senol MS, Baltaci G. Short-Term Results of Flexor Hallucis Longus Transfer in Delayed and Neglected Achilles Tendon Repair. J Foot Ankle Surg 2019; 57:1042-1047. [PMID: 29784532 DOI: 10.1053/j.jfas.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Indexed: 02/03/2023]
Abstract
Flexor hallucis longus (FHL) tendon transfer to the calcaneus in the repair of delayed or neglected Achilles tendon (AT) injuries is a viable and dynamic option. Nineteen patients (18 males, 1 female; mean age 47.4 ± 12.4, range 24 to 74, years; body mass index 27.5 ± 4.5, range 23.2 to 38.9, kg/m2; interval from injury to surgery 40.8 ± 11.6, range 28 to 60, days) with delayed or neglected repair of AT rupture were included in the present study. FHL transfer to the calcaneus through a single incision and repair of the defect with native tendon lengthening or a tendinous turndown flap was performed. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot and hallux scale scores, balance and jump performance, ankle dorsiflexion range of motion, and lower extremity concentric and eccentric strength were evaluated 6 months postoperatively. Student's t test was used to compare the outcomes between the operated and nonoperated sides. AOFAS hindfoot and hallux scale scores were 93.83 and 86.9, respectively. No significant difference was found in vertical jump (p = .60), forward jump (p = .68), or balance performance (p > .05). However, less ankle dorsiflexion on the operated side was recorded compared with the nonoperated side (p = .008). Concentric/eccentric muscle strength between the operated and nonoperated side was similar (p > .05). The concentric strength of the operated side reached 92% and eccentric strength reached 101.7% of the nonoperated side's strength. All the patients were satisfied with their results and return to preinjury daily activities. AT repair of a delayed and neglected injury using FHL transfer to the calcaneus in a dynamic fashion provided excellent outcomes.
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Affiliation(s)
- Hamza Ozer
- Professor, Department of Orthopaedics and Traumatology, University of Gazi, Ankara, Turkey.
| | - Yilmaz Ergisi
- Medical Doctor, Department of Orthopaedics and Traumatology, Sungurlu Hospital, Corum, Turkey
| | - Gulcan Harput
- Assistant Professor, Department of Physiotherapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Mehmet S Senol
- Medical Doctor, Department of Orthopaedics and Traumatology, Gazi University, Ankara, Turkey
| | - Gul Baltaci
- Professor, Department of Physiotherapy and Rehabilitation, Private Guven Hospital, Ankara, Turkey
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Husebye EE, Molund M, Hvaal KH, Stødle AH. Endoscopic Transfer of Flexor Hallucis Longus Tendon for Chronic Achilles Tendon Rupture: Technical Aspects and Short-Time Experiences. Foot Ankle Spec 2018; 11:461-466. [PMID: 29338333 DOI: 10.1177/1938640017754234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Chronic Achilles tendon ruptures can lead to reduced power of plantar flexion in the ankle with impaired gait ability. The open 1- or 2-incision technique for flexor hallucis longus transfer has proven good functional outcome but has the disadvantage of relatively extensive surgery performed at a vulnerable location. To reduce the risk of soft tissue problems, the flexor hallucis longus transfer can be performed endoscopically. MATERIAL AND METHOD An endoscopic technique for flexor hallucis longus transfer is presented together with the experiences from the first six patients operated with this method. RESULTS No wound healing problems or infections. Five of 6 patients managed single leg heel raise on the affected side 12 months after surgery. CONCLUSION The functional results are promising. The soft tissue dissection is minor, and no patients had postoperative wound healing problems or infection. Endoscopic flexor hallucis longus transfer may be an operative procedure that can be considered also in patients with potential wound healing problems. LEVELS OF EVIDENCE Level IV: Technical note/case series without controls.
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Affiliation(s)
- Elisabeth Ellingsen Husebye
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway (EEH, KHH, AHS).,Department of Orthopaedic Surgery, Ostfold Hospital, Grålum, Norway (MM)
| | - Marius Molund
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway (EEH, KHH, AHS).,Department of Orthopaedic Surgery, Ostfold Hospital, Grålum, Norway (MM)
| | - Kjetil Harald Hvaal
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway (EEH, KHH, AHS).,Department of Orthopaedic Surgery, Ostfold Hospital, Grålum, Norway (MM)
| | - Are Haukåen Stødle
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway (EEH, KHH, AHS).,Department of Orthopaedic Surgery, Ostfold Hospital, Grålum, Norway (MM)
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Mohamed A, Oliva F, Nardoni S, Maffulli N. Failed synthetic graft after acute Achilles tendon repair. Muscles Ligaments Tendons J 2017; 7:396-402. [PMID: 29264352 DOI: 10.11138/mltj/2017.7.2.396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The present case report aimed to determine the results of Flexor Hallucis Longus (FHL) transfer as a second surgery after synthetic tissue reinforcement graft (Artelon®) implanted to a primary repaired Achilles tendon (AT), that was undertaken by another orthopedic. One year post-operative the patient was referred to us with retrocalcaneal pain and difficulty in walking, associated with stiffness and significant impairment of daily living activities. Methods MRI and full clinical examination were the outcome measures applied before and 1 year after surgery. Removal of the synthetic graft and subsequent FHL autologous transfer was undertaken and the graft was sent for histology examination. After removing the below knee leg cast, patient started rehabilitation program supervised by a trained physiotherapist. Results The patient was allowed to return to his normal activities at the sixth post-operative month, 1 year post-surgery MRI showed correct position of the autograft in the calcaneous bone and in the centre of the native AT plus reduced oedema of the AT body, with clinical improvement of the patient who reported no pain and was able to walk on tiptoes. Conclusion Synthetic patch augmentation to enhance tendon healing should be subjected to proper investigation before using it in routine parctice, as it may act as a barrier against proper tendon healing. Level of evidence V.
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Affiliation(s)
- Asmaa Mohamed
- Department of Physical and Rehabilitation Medicine, School of Medicine, University of Rome "Tor Vergata", Italy Physical medicine, Rheumatology and rehabilitation Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Francesco Oliva
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Italy
| | - Stefano Nardoni
- Department of Pathology "San Filippo Neri Hospital" Rome, Italy
| | - Nicola Maffulli
- Head of Department of Orthopaedics and Traumatology, Azienda Ospedaliera San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
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Flexor hallucis longus tendon transfer in the reconstruction of extensive insertional Achilles tendinopathy in elderly: an improved technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25:583-90. [DOI: 10.1007/s00590-014-1569-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
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Lui TH. A minimally invasive "overwrapping" technique for repairing neglected ruptures of the Achilles tendon. J Foot Ankle Surg 2014; 53:806-9. [PMID: 25128913 DOI: 10.1053/j.jfas.2014.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Indexed: 02/03/2023]
Abstract
About 10% to 25% of acute ruptures of the Achilles tendon go undiagnosed for some time beyond what would be optimal for repair and a return to optimal function. Managing these chronic or neglected ruptures is a surgical challenge, because the tendon ends retract and atrophy and could develop a short, fibrous distal stump. In the present report, a patient with a ruptured right Achilles tendon, neglected for approximately 10 years, is described. The chronically injured tendon was successfully treated by overwrapping the interposed scar at the rupture site. This minimally invasive technique restored tension to the tendon, a prerequisite for which was the presence of functional triceps surae, confirmed by identification of gross contraction of the muscle during tiptoeing. The procedure is contraindicated when the scar tissue is not intact and does not have sufficient laxity to allow adequate dorsiflexion of the ankle after overwrapping the tendon or when the triceps surae are nonfunctional.
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Affiliation(s)
- Tun Hing Lui
- Consultant, Department of Orthopaedics and Traumatology, North District Hospital, New Territories, Hong Kong Special Administrative Region, Sheung Shui, People's Republic of China.
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Rahm S, Spross C, Gerber F, Farshad M, Buck FM, Espinosa N. Operative treatment of chronic irreparable Achilles tendon ruptures with large flexor hallucis longus tendon transfers. Foot Ankle Int 2013; 34:1100-10. [PMID: 23624909 DOI: 10.1177/1071100713487725] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Transfer of the flexor hallucis longus (FHL) tendon aims to restore function and relieve pain in chronic Achilles tendon (AT) disease. The goal of the present study was to investigate the clinical and radiographic outcomes of FHL transfer to the AT and to compare the transtendinous technique to the transosseous technique. We hypothesized that the type of technique would have a notable impact on outcome. METHODS Forty patients (42 ankles) were retrospectively reviewed and divided into group 1 (transtendinous technique, 22 patients/24 ankles) and group 2 (transosseous technique, 18 patients/18 ankles). Outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Foot Function Index (FFI), and Short Form-36 (SF-36) scores. Magnetic resonance imaging of the lower leg was performed preoperatively to assess muscle quality and fatty infiltration. Postoperatively, isokinetic plantar flexion strength was assessed using a Con-Trex dynamometer. RESULTS In group 1 (follow-up, 73 months; age, 52 years), the AOFAS score improved from 66 points to 89 points (P < .001) with average values for the VISA-A of 76 points, FFI-D pain 15%, and FFI-D function 22%. In group 2 (follow-up, 35 months; age, 56 years), the AOFAS score increased from 59 points to 85 points (P < .001) with mean values for the VISA-A 76 points, FFI-D pain 25%, and FFI-D function 24%. At follow-up, the average SF-36 score in group 1 was 66% and in group 2 was 77%. Isokinetic testing at 30 deg/s in group 1 revealed notable weakness in the operated ankle averaging 54.7 N·m (75% of normal), and in group 2 the average was 58.2 N·m (77% of normal). No statistically significant differences were found between the groups. CONCLUSION The hypothesis was disproved. Both techniques for FHL transfer to AT, intratendinous and transosseous, provided good to excellent clinical and functional outcome in the treatment of irreparable AT disease. LEVEL OF EVIDENCE Level III, retrospective comparative series.
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