Endoscopic Flexor Hallucis Longus Tendon Transfer for Chronic Achilles Tendon Rupture

Endoscopic Flexor Hallucis Longus Tendon Transfer for the Treatment of Chronic Achilles Tendon Defects

Background

An all-inside endoscopic flexor hallucis longus (FHL) tendon transfer is indicated for the treatment of chronic, full-thickness Achilles tendon defects. The aim of this procedure is to restore function of the gastrocnemius-soleus complex while avoiding the wound complications associated with open procedures.

Description

This procedure can be performed through 2 endoscopic portals, a posteromedial portal (the working portal) and a posterolateral portal (the visualization portal). The FHL tendon is identified, and the joint capsule is debrided to identify the subtalar joint. A shaver is utilized to circumferentially debride the FHL at the level of the subtalar joint, allowing for full visualization of the tendon. Care is taken to avoid the posteromedial neurovascular bundle by keeping the shaver against the tendon. An endoscopic suture-passing device is utilized to pierce the FHL tendon and shuttle a nonabsorbable suture through the tendon; this step is done 2 times. The tendon is then cut at its distal-most aspect (adjacent to the subtalar joint) with an endoscopic cutter. The tendon is then brought through the posteromedial portal and prepared for transosseous passage with nonabsorbable suture. Next, the anterior insertion of the Achilles tendon is endoscopically identified and debrided. With use of needle endoscopy-targeted pin placement, a Beath pin is placed at the anterior footprint of the Achilles via the posteromedial portal. The pin is advanced dorsal to plantar and out the bottom of the foot and is confirmed on fluoroscopy. With use of an appropriately sized reamer, the Beath pin is loaded with the 2 grasping sutures and shuttled plantarly. The needle endoscope is then placed in the posterolateral portal to visualize the FHL tendon, advancing into the tunnel with the foot held in 15° of plantar flexion. An appropriately sized interference screw is then placed in the tunnel, using direct endoscopic visualization to confirm placement and depth of the screw.

Alternatives

Chronic Achilles tendon ruptures with symptomatic weakness often necessitate operative treatment; however, high-risk patients may be better managed nonoperatively with an ankle-foot orthosis. These patients often demonstrate improved gait and function with this orthosis1. The choice of operative technique for the treatment of chronic Achilles tendon defects is primarily based on tendon gap length; options include end-to-end repair, fascial advancement, and turn-down procedures with or without transferring the FHL, peroneus brevis, or flexor digitorum longus tendons. These techniques require substantial incisions and violation of the posterior compartments and Achilles paratenon, creating substantial postoperative scarring.

Rationale

Chronic Achilles tendon ruptures with defects or gaps leave the patient with weakness and biomechanical loss of the gastrocnemius-soleus complex. The gold standard algorithm in which the gap length determines the type of fascial advancement requires lengthy incisions and violation of the posterior compartments and paratenon. These reconstruction procedures do restore gastrocnemius-soleus complex tension, but also result in diminished gliding and substantial scarring and thickening. These incisions are also prone to wound complications, sural nerve injury, and painful scarring. An all-inside endoscopic FHL tendon transfer has several advantages over the standard approach. The all-inside approach prevents violation of the compartments and the Achilles, avoiding painful scars and hypertrophic tissue changes. The use of an FHL tendon transfer is advantageous as it is an in-phase transfer that maximizes neuromuscular control. The anatomic position of the flexor hallucis longus muscle also creates optimal force vectors allowing for optimal gait propulsion. The FHL also has a robust muscle belly that can hypertrophy and strengthen over time. The endoscopic approach allows for immediate weight-bearing as part of an accelerated rehabilitation, which helps to reduce muscle wasting, deep vein thrombosis, and wound complications, and facilitates an earlier return to work3.

Expected Outcomes

This procedure provides excellent clinical outcomes with decreased complication rates, as compared with open treatment. In a study of 22 patients with chronic Achilles tendon rupture with a large tendon gap who underwent endoscopic FHL tendon transfer, the mean American Orthopaedic Foot & Ankle Society score improved from 55 preoperatively to 91 at the time of final follow-up4. All patients in this cohort returned to daily activities. In another study, a total of 42 patients with chronic Achilles tendon rupture underwent either endoscopic (18 patients) or open treatment (24 patients). Patients in the endoscopic cohort demonstrated better functional outcomes and decreased complication rates compared with the open treatment cohort3. Patients undergoing the endoscopic procedure also had a significant increase in American Orthopaedic Foot & Ankle Society scores postoperatively and a lower rate of complications. One patient in the open treatment cohort had a wound dehiscence. There were no wound-healing complications in the endoscopic group.

Important Tips

Utilize a low-flow straight-forward viewing endoscope.Utilize an endoscopic suture passer to avoid iatrogenic injury.Visualize the bone tunnel prior to passing the tendon in order to confirm that the wall is intact.Plantar flex the ankle and great toe when performing the tenotomy to allow for adequate tendon length for transfer.If a low-lying FHL muscle belly is present, it can be taken back to the level of the tibial talar joint. We have found that cutting the FHL at the level of the subtalar joint is optimal for transfer.Inadequate visualization of the tendon of the subtalar joint can prevent tenotomy from being distal enough for transfer.Avoid soft-tissue bridging by minimizing utilization of the posteromedial portal and by passing a looped grasper down the suture to confirm that no soft-tissue bridges are present.Failure to utilize both endoscopy and fluoroscopy can lead to inadequate tunnel placement.

Acronyms and Abbreviations

FHL = flexor hallucis longusHPI = history of present illnessPMH = past medical historyNSAIDs = nonsteroidal anti-inflammatory drugsPT = physical therapySH = social historyPE = physical examinationMRI = magnetic resonance imagingCAM = controlled ankle motionAOFAS = American Orthopaedic Foot & Ankle Society.

Surgical management of chronic Achilles tendon rupture: evidence-based guidelines

BACKGROUND

Chronic Achilles tendon ruptures (CATR) often require surgical intervention to restore function. Despite numerous treatment modalities available, the optimal management strategy remains controversial given the limited high-quality evidence available. This article aims to provide evidence-based guidelines for the surgical management of CATR through a comprehensive systematic review of the available data. The consensus reached by synthesizing the findings will assist clinicians in making informed decisions and improving patient outcomes.

METHODS

A group of 9 foot surgeons in three continents was consulted to gather their expertise on guidelines regarding the surgical management of CATR. Following the proposal of 9 clinical topics, a thorough and comprehensive search of relevant literature published since 1980 was conducted for each topic using electronic databases, including PubMed, MEDLINE, and Cochrane Library, to identify relevant studies published until 1 October 2023. All authors collaborated in drafting, discussing, and finalizing the recommendations and statements. The recommendations were then categorized into two grades: grade a (strong) and grade b (weak), following the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) concept. Additionally, feedback from 21 external specialists, who were independent from the authors, was taken into account to further refine and finalize the clinical guidelines.

RESULTS

Nine statements and guidelines were completed regarding surgical indications, surgical strategies, and postoperative rehabilitation protocol.

CONCLUSION

Based on the findings of the systematic review, this guideline provides recommendations for the surgical management of CATR. We are confident that this guideline will serve as a valuable resource for physicians when making decisions regarding the surgical treatment of patients with CATR.

Endoscopic peroneus brevis tendon transfer for chronic ruptures of the Achilles tendon: surgical technique

Chronic Achilles tendon rupture is usually defined as a rupture diagnosed 4-6 weeks after injury. The management of chronic Achilles tendon rupture (CATR) is a topic of hot debate, and no consensus has been achieved. Surgical management of CATR is recommended. Several approaches, techniques, and grafts have been described. Open techniques carry a high risk of wound breakdown, infection, and necessitate long rehabilitation times. Surgical techniques with smaller incisions to reduce the risk of scar fibrosis, pain, and infection are becoming common. The ipsilateral tendon of the hallux flexor longus and the peroneus brevis is commonly used. Endoscopic transfer of the peroneus brevis tendon is an innovative alternative to other procedures, with comparable results of other autografts even in elite athletes. The tendon of the peroneus brevis is harvested by tendoscopy before performing a calcaneal tendon endoscopy and fixing the graft in a calcaneal tunnel using an interference screw. After surgery, an anterior splint is placed for 3 weeks with immediate forefoot weight bearing. The rehabilitation starts on the 15th postoperative day.

One Step Double Augmentation with Human Dermis Allograft and Homologous PRP in Misdiagnosed and or Chronic Achilles Tendon Ruptures

OBJECTIVE

Misdiagnosed/chronic Achilles tendon injuries are rare and disabling for patients. The surgical treatment of these rare injuries aims to ensure the tendon heals mechanically and biologically. This is the prerequisite for a good clinical and functional outcome and reduces recurrences. The main aim of the study is to present a surgical technique that has proven to be original, reproducible, and capable of guaranteeing solid tendon repair and optimal tissue regeneration.

METHODS

We treated five patients, four males and one female, with the one-step double augmentation technique. All patients of this study complained of pain, but above all severe functional limitation that Achilles tendon injury had been causing for more than a month. In this study, we widely described the surgical technique, original and not found in the literature, which provides a biological graft (allograft of decellularized dermis) and homologous, thrombin-activated, platelet-rich plasma (H-PRP) in a single step. Surgical approach, always used by the first author, respected predefined steps: careful dissection and preparation of the peritendinous tissues from suture to the end of the procedure, tenorrhaphy, and augmentation with allopatch to obtain a mechanically effective repair to avoid recurrences, and finally "biological" augmentation with a unit of homologous, thrombin activated, PRP. We offered to all patients a regenerative rehabilitation program post-operatively.

RESULTS

All patients were evaluated clinically (functional clinical tests and questionnaires) and instrumentally (elastic-sonography and perfusion MRI). The obtained results have been evaluated at a minimum follow-up of 18 months and a maximum of 24 months. In all patients pain was resolved, and district function and kinetic chains improved with resumption of daily activities, work, and sports.

CONCLUSION

The present study confirmed the regenerative potential of decellularized dermis allograft and PRP (homologous and thrombin-activated). The same approach can also be exploited in cases of severe tendon destructuring and limited "intrinsic" regenerative potential at any age. The proposed one-step surgical technique of a double augmentation therefore appears useful, safe, reproducible, and applicable in all chronic tendon lesions with low regenerative potential.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.

Primary augmentation of percutaneous repair with flexor hallucis longus tendon for Achilles tendon ruptures reduces tendon elongation and may improve functional outcome

PURPOSE

Achilles tendon ruptures (ATR) result in loss of strength and function of the gastrosoleus-Achilles tendon complex, probably because of gradual tendon elongation and calf muscle atrophy, even after surgical repair. Flexor hallucis longus (FHL) augmentation not only reinforces the repair and provides new blood supply to the tendon, but also protects the repair, internally splinting the repaired Achilles tendon, maintaining optimal tension. We prospectively compared the clinical outcomes of patients with acute ATR, managed with either percutaneous repair only or percutaneous repair and FHL augmentation.

METHODS

Patients with acute ATR undergoing operative management were divided into two groups. Thirty patients underwent percutaneous repair under local anesthesia, and 32 patients underwent percutaneous repair augmented by FHL tendon, harvested through a 3 cm longitudinal posteromedial incision, and transferred to the calcaneus, under epidural anesthesia. All patients were treated by a single surgeon between 2015 and 2019 and were followed prospectively for 24 months.

RESULTS

The percutaneous only group was younger than the augmented one (35.4 ± 8.0 vs 40.4 ± 6.6 years, p = 0.01). In the augmented group, 25 patients stayed overnight and only 5 were day cases, whereas in the percutaneous only group 4 patients stayed overnight and 28 of them were day cases (p < 0.001). The duration of the procedure was significantly longer in the augmented group (38.9 ± 5.2 vs 13.2 ± 2.2 min, p < 0.001). At 24 months after repair, the Achilles tendon resting angle (ATRA) was better in the augmented group (-0.5 ± 1.7 vs -4.0 ± 2.7, p < 0.001), as was Achilles tendon rupture score (ATRS) (91.7 ± 2.2 vs 89.9 ± 2.4, p = 0.004). Calf circumference of the injured and the non-injured leg did not differ between the groups, as did the time interval to single toe raise and the time interval to walking in tiptoes. Although plantarflexion strength of the operated leg was significantly weaker than the non-operated leg in both groups, the difference in isometric strength of the operated leg between the groups was not significant at 24 months (435 ± 37.9 vs 436 ± 39.7 N, n.s.).

CONCLUSION

Percutaneous repair and FHL tendon augmentation may have a place in the management of acute Achilles tendon ruptures, reducing tendon elongation and improving functional outcome.

LEVEL OF EVIDENCE

Level II.

Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures

PURPOSE

Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective.

METHODS

A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range.

RESULTS

For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments.

CONCLUSION

Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness.

LEVEL OF EVIDENCE

Level III.

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

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.

Arthroscopic, Single-Incision, and Double-Incision Approaches to Flexor Hallucis Longus Tendon Transfer Following Achilles Tendon Rupture: A Literature Review

Achilles tendon rupture is a common athletic injury that results in a painful and antalgic gait. Flexor hallucis longus tendon transfer through arthroscopic, single-incision, or double-incision techniques is used as a treatment approach to address this rupture; however, no studies have compared postoperative complications between these three techniques. A systematic search of published articles was conducted using keywords "Achilles rupture," "flexor hallucis tendon," "transfer," and "recovery." Articles were then selected based on their title, abstract, and content following full-text review. From each article's reported surgical outcomes, a comparison was made between arthroscopic and single- and double-incision postoperative complications using a χ2 test with significance set at a value of P < .05 followed by post hoc analysis. The arthroscopic approach maintained the lowest rate of postoperative complications, followed by the single- and double-incision techniques. A significant difference in the number of postoperative complications was found between all incisional approaches. The pairwise comparisons, however, could not identify which incisional approaches significantly differed between each other. A reduction in postoperative complications places arthroscopy and the single-incision techniques as the preferred approaches for flexor hallucis longus tendon transfer following an Achilles tendon rupture. Although current literature shows arthroscopy to be superior to single- and double-incision methods, this review demonstrates the need for a greater number of published cases using arthroscopy to establish significance regarding postoperative complications.

Endoscopic Flexor Hallucis Longus Transfer for Achilles Noninsertional Tendinopathy: Description of Surgical Technique and Functional Outcomes

Background. The transfer of the flexor hallucis longus (FHL) tendon is an established treatment for replacing a dysfunctional Achilles tendon. Objectives. (1) Describe a new technique for endoscopic FHL transfer for noninsertional Achilles tendinopathy and (2) describe the functional outcomes and complications after endoscopic and open FHL transfer. Materials and Method. Retrospective study of patients who underwent open or endoscopic FHL transfer between 2014 and 2016. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot scale was used preoperatively and postoperatively to measure the functional results. Results. We included 18 endoscopic FHL transfers and 24 open FHL transfers. The mean age of endoscopic and open procedures was 47.5 years (range 25-77 years) and 61.2 years (range 43-72 years), respectively. An improvement on the average AOFAS of 52.8% (31.9 points) was observed in the endoscopy group during the follow-up from the baseline. The mean improvement in AOFAS score for the open group was 41.4% (24.5 points). Four and 7 cases reported complications in the endoscopy and open FHL transfer groups, respectively. Conclusion. While both procedures were effective in treating noninsertional Achilles tendinopathy, the described arthroscopic treatment led to a greater improvement in the AOFAS score and is slightly less prone to lasting complications.Level of Evidence: Level IV: Case series.

Modified Tension-Slide Technique for Endoscopy-Assisted Flexor Hallucis Longus Tendon Transfer

The rupture of the Achilles tendon (AT) usually occurs in high-caliber athletes, but low-demand patients are also are risk, mainly if they are under corticoids or quinolones. The diagnosis of the AT rupture is usually neglected, and this could result in a worse prognosis for the patient if not treated in an appropriate time. For these patients or for those with high surgical risk, an option of minimally invasive surgery remains attractive. Classical techniques consist of direct repair or augmentation with the tendon of the flexor hallucis longus as well as nonanatomical tendon transfers which can generate issues with the donor site. We present a pioneering technique that is analogous to that used for the surgical treatment of distal rupture of the biceps tendon, which consist of a transfer technique of flexor hallucis longus by extracortical fixation interference screw associated to a direct tendon reinsertion performed through a bone tunnel on the superior and posterior aspect of the calcaneus using an extracortical drilling system and an interference screw within the calcaneal tunnel. The arthroscopic approach may be technically challenging, and a high-level of arthroscopic skills are required to complete the procedure but after a learning curve it represents a feasible a safe technique.Levels of Evidence:Therapeutic, Level IX: Evidence from opinion of authorities and/or reports of expert committee.

Comparison of Gastrocnemius Turn Flap and Hamstring Graft for the Treatment of Kuwada Type 3 Chronic Ruptures of the Achilles Tendon: A Retrospective Study

Background:

Chronic Achilles tendon rupture is challenging to repair, and many procedures have been suggested to fill the gap that separates the distal and proximal ends of the ruptured tendon.

Purpose:

To compare clinical outcomes between the free hamstring graft (HG) and gastrocnemius turn flap (GTF) procedures in the treatment of chronic Achilles tendon rupture.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective study included 26 patients (25 males, 1 female; mean age, 36.7 years; range, 22-53 years) with Kuwada type 3 chronic rupture of the Achilles tendon. A total of 11 patients underwent GTF surgery, whereas 15 patients underwent HG surgery. Follow-up assessments were conducted at 3, 6, and 12 months postoperatively.

Results:

The complication rate was significantly higher in the GTF group compared with the HG group (27.2% vs 6.6%, respectively; χ² = 12.462; P = .001). At the 3-month follow-up, the degree of ankle dorsiflexion was significantly higher in the HG group than in the GTF group (t = 3.144; P = .004). At 6-month and 1-year follow-up, no significant differences in ankle function were seen between the 2 groups.

Conclusion:

Hamstring tendon graft is associated with better early recovery of dorsiflexion compared with GTF. The long-term clinical outcomes of these 2 procedures are similar.

Acute Achilles Tendon Rupture: Ultrasonography and Endoscopy-Assisted Percutaneous Repair

To date, there is no consensus concerning the treatment of acute Achilles tendon ruptures. Although surgical treatment decreases the risk of a recurrent rupture, it is not without complications. In particular, percutaneous sutures may cause a lesion of the sural nerve. The purpose of this Technical Note is to describe a reliable and reproducible surgical procedure for treating these lesions. The first operative phase consists of an ultrasound detection that makes it possible to identify the tendon extremities and the sural nerve, which is necessary to secure the posterolateral arthroscopic tract as well as to perform the percutaneous suture. The entry point is thus centered on the lesion and placed at a distance from any surrounding nerve risk. The second arthroscopic phase makes it possible to release the tendon lesion, control the transtendon passage of the surgical threads, and evaluate the dynamic contact of the tendon edges. At the end of the intervention, the complete disappearance from the transillumination via the rupture also makes it possible to ensure the disappearance of the tendon gap. Achilles tendon percutaneous sutures after the ultrasound detection and under arthroscopic control thus makes it possible to control the contact of the tendon edges, while at the same time decreasing the risk of a lesion of the sural nerve, with minimal scarring.

Endoscopic Flexor Hallucis Longus Transfer for Chronic Noninsertional Achilles Tendon Rupture

BACKGROUND:

Operative management of chronic Achilles tendon ruptures is challenging, and numerous techniques have been described. Risk of infection and wound breakdown have been described after open techniques, and minimally invasive methods have been proposed to avoid them. The aim of this study was to describe the clinical and radiological results obtained after endoscopic flexor hallucis longus (FHL) tendon transfer in patients with chronic Achilles tendon rupture.

METHODS:

Between 2012 and 2015, a total of 22 patients were endoscopically treated for chronic Achilles tendon rupture. Mean age was 69 years (range, 59-84 years). Mean follow-up was 30.5 months (range, 18-46 months). Preoperative magnetic resonance imaging (MRI) was obtained and tendon gap measured. An MRI was obtained at 9 to 12 months following surgery to evaluate Achilles tendon changes.

RESULTS:

Preoperative MRI examination showed a mean tendon gap of 6.3 cm (range, 3-10.7 cm). The MRI control was obtained only in 12 patients, and a normal or close to normal Achilles tendon was observed in all but 1 patient. The mean American Orthopaedic Foot & Ankle Society score increased from 55 preoperatively (range, 26-75) to 91 (range, 74-100) at final follow-up. All patients returned to their daily activities without difficulties. No patients reported complaints or symptomatic deficits of great toe flexion strength. No major complications were encountered.

CONCLUSION:

Chronic Achilles tendon ruptures were successfully treated by an all-endoscopic procedure. The endoscopically assisted FHL transfer provided excellent results while benefiting from the minimally invasive procedure advantages. However, it entailed some technical challenges and may not be suitable for less experienced surgeons.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Correlation of some predisposing intrinsic conditions with the morphological integrity of the Achilles tendon

BACKGROUND

Most studies have focused on ill-tendons with a little insight on how intrinsic factors correlate with the Achilles tendon (AT) morphology.

AIM

This study aims at establishing how blood pressure (BP), blood glucose (BG), and body mass index (BMI) correlate with the morphology of the AT with emphasis on width changes.

MATERIALS AND METHODS

Participants were volunteers who were recruited during and after an organized health fair by the Medical Students' body of All Saints University, School of Medicine, Commonwealth of Dominica. A total of 336 people, consisting of 135 males and 201 females volunteered for the study. The most dominant age group was between 60 and 65 years. A self-administered questionnaire was used to acquire necessary information, and a preliminary clinical procedure was used to check for BP, BG, and BMI. Ultrasound examination was done in B-mode using a linear array high-frequency probe with a mediolateral approach at the AT.

RESULTS

Among the participants, 42.68%, 69.75%, and 30.38% had normal BP, BG, and BMI readings, respectively. BP, BG, and BMI statistically supported the hypothesis. Individuals with extreme BP, BG, and BMI had their AT width wider when compared with individuals with normal systemic readings. Sonographic examination revealed most participants with normal tendon morphology while some identifiable changes were observed among others.

CONCLUSION

This study suggests that BP, BG, and BMI could affect the morphological integrity of the AT. It indicates that asymptomatic high blood sugar and BP could weaken the AT, leading to pain which may appear unrelated to the physician and patient.

Failed synthetic graft after acute Achilles tendon repair

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.

Using Arthroscopic Techniques for Achilles Pathology

Endoscopically assisted procedures have been established to provide the surgeon with minimally invasive techniques to address common Achilles conditions. Modifications to some of these techniques as well as improvements in instrumentation have allowed these procedures to provide similar clinical results to the traditional open surgeries while reducing wound complications and accelerating patient's recoveries. The available literature on these techniques reports consistently good outcomes with few complications, making them appealing for surgeons to adopt.

Endoscopic Flexor Halluces Longus transfer for Chronic Achilles Tendon rupture - technique description and early post-operative results

Background

Achilles tendon ruptures may lead to proximal retraction of the stump if not treated acutely, increasing the chances of poorer functional outcomes. The flexor halluces longus transfer is a well-established treatment option, usually performed as an open procedure. The aim of this paper is to report the preliminary results and describe the technique of endoscopic flexor halluces longus transfer.

Material and methods

Six patients with chronic Achilles tendon injuries or re-ruptures were treated with endoscopic FHL transfer. The Achilles Tendon Rupture Score was used to clinically evaluate the patients. Single leg heel rise ability, functional hallux weakness, complications and procedure length were also checked.

Results

On average, we took 56 minutes to perform the surgery. All patients had a major increase in the ATRS score value postoperatively. Single leg heel rise was possible for all patients without limitation. None of the patients noticed functional weakness of the hallux during daily life activity and no wound or soft tissue complications were seen.

Conclusion

Endoscopic FLH transfer is a reliable option for patients with high skin risk and soft tissue complications. Other studies are needed to compare this technique with the open procedure, gold standard by now, to ensure its safety and efficacy.

Level of evidence

4.