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

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.

Endoscopic flexor hallucis longus tendon transfer with horizontal calcaneal fixation and suturing onto itself

Endoscopic flexor hallucis longus (FHL) tendon transfer to replace the calcaneal tendon is being increasingly performed. The main advantage is minimisation of approach-related morbidity. Fixation of the FHL tendon is usually achieved with a tenodesis screw placed in a vertical calcaneal tunnel. Here, we describe an endoscopic technique with FHL fixation by tenodesis in a horizontal calcaneal tunnel combined with suturing of the tendon onto itself. LEVEL OF EVIDENCE: IV.

Endoscopically Assisted Percutaneous Harvesting of the Flexor Hallucis Tendon in Zone 2: An Anatomical Study

BACKGROUND

Flexor hallucis longus (FHL) transfer is a well-established method for treating chronic Achilles tendon ruptures and tendinopathy. Harvesting of the FHL tendon in zone 2 results in greater length but is also associated with an increased risk of injury to the medial plantar nerve and requires an additional plantar incision. Because of the anatomic proximity of the FHL tendon to the tibial neurovascular bundle in zone 2, the purpose of this study was to investigate the risk of vascular or nerve injury with arthroscopic assisted percutaneous tenotomy in zone 2 of the FHL tendon.

METHODS

Endoscopically assisted percutaneous FHL transfer was performed on 10 right lower extremities from 10 cadaveric human specimens. The FHL tendon lengths and the relationship between FHL tendon and the tibial neurovascular bundle at zone 2 was analyzed.

RESULTS

We observed a complete transection of the medial plantar nerve in 1 case (10%). The mean length of the FHL tendon was 54.7 ± 9.5 mm and the mean distance from the distal stump of the FHL tendon to local neurovascular structures was 1.3 ± 0.7 mm.

CONCLUSION

There is a risk of neurovascular injury after endoscopic FHL tenotomy in zone 2. The tenotomy site is within 2 mm of the local neurovascular structures in the majority of cases. The additional length gained from this technique is unlikely to be required for the majority of FHL tendon transfer procedures. If additional length is needed, we would recommend the use of intraoperative ultrasonography or a mini-open approach to minimize injury risk.

LEVEL OF EVIDENCE

Level V, expert opinion.

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.

Outcomes of Percutaneous Achilles Repair Compared With Endoscopic Flexor Hallucis Longus Tendon Transfer to Treat Achilles Tendon Ruptures

BACKGROUND

Both percutaneous and endoscopically assisted methods are reported to produce good results in the surgical management of acute Achilles tendon ruptures. The aim of this retrospective study was to compare between a percutaneous method and a recently described isolated endoscopically assisted flexor hallucis longus (FHL) transfer method as surgical means of management in patients with acute Achilles tendon ruptures.

METHODS

One hundred seventeen patients were included in the current study and divided into 2 groups: 59 patients who underwent percutaneous Achilles repair (PAR Group) and 58 patients who underwent isolated endoscopic FHL transfer (FHL Group) were compared. Patients were clinically evaluated using American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon Total Rupture Score (ATRS), and Achilles tendon resting angle (ATRA) measures. In addition, ankle plantarflexion power, FHL dynamometry, Tegner activity levels, and return to previous levels of activity were also documented for all patients.

RESULTS

Nine months after surgery, patients in the FHL transfer group were more likely to be able to return to normal activities (91% vs 73%, P < .01). Thirty months after surgical treatment, we found no difference in ATRS, AOFAS, ATRA, ankle plantarflexion strength, or Tegner activity scores between study groups. Overall complications were reported in 6 patients in the FHL group (10.3%) and in 8 patients in the PAR group (13.6%). No major neurovascular or skin complications were encountered.

CONCLUSION

The current study demonstrated satisfactory and comparable results and complications when comparing isolated endoscopic FHL tendon transfer or percutaneous Achilles tendon repairs in the surgical management of acute Achilles tendon ruptures.

LEVEL OF EVIDENCE

Level III, retrospective controlled trial.

Arthroscopic Flexor Halluces Longus Transfer and Percutaneous Achilles Tendon Repair for Distal Traumatic Ruptures

The Achilles tendon is the largest and strongest tendon in the human body. It is the tendon that most often suffers injury and accounts for 20% of all tendon ruptures. These types of ruptures often occur 2 to 6 cm proximal to the stumps in an area of reduced vascularity. One such injury, the distal acute Achilles tendon rupture, is quite uncommon. For distal repairs, there have been studies that used a pullout technique, a button technique, and the use of local tendons for open-fashion augmentation. Although percutaneous repair and endoscopic flexor hallucis longus (FHL) tendon transfer techniques have been described for both acute midportion and chronic Achilles tendon rupture repair, there are no studies that describe the use of percutaneous sutures and biological augmentation with FHL transfer as a treatment option for acute distal injuries. The purpose of this Technical Note is to describe a novel approach to repair. It combines arthroscopic FHL tendon transfer with a percutaneous Achilles tendon repair technique for traumatic distal ruptures.

Management of chronic Achilles ruptures: a scoping review

PURPOSE

This scoping review aims to systematically map and summarise the available evidence on the management of chronic Achilles ruptures, whilst identifying prognostic factors and areas of future research.

METHODS

A scoping review was performed according to the frameworks of Arksey and O'Malley, Levac and Peters. A computer-based search was performed in PubMed, Embase, EmCare, CINAHL, ISI Web of Science and Scopus, for articles reporting treatment of chronic Achilles ruptures. Two reviewers independently performed title/abstract and full text screening according to pre-defined selection criteria.

RESULTS

A total of 747 unique articles were identified, of which 73 (9.8%) met all inclusion criteria. A variety of methods are described, with flexor hallucis longus tendon transfer being the most common. The most commonly reported outcome is the American Orthopaedic Foot and Ankle Society (AOFAS) score, although 16 other measures were reported in the literatures. All studies comparing pre- and post-operative outcomes reported significant post-treatment improvement. Complications were reported in 50 studies, with an overall pooled complication rate of 168/1065 (15.8%).

CONCLUSION

Although beneficial results were reported following a variety of techniques, comparison between these is challenging due to the low-level study designs used and confounding factors such as treatment delay and tendon gap size. Further research comparing the efficacy of different techniques is required in order to facilitate the development of an evidence-based treatment protocol. Such work would allow clinicians to better understand the suitability of the large variety of reported techniques and select the optimal strategy for each individual patient.

Endoscopically Assisted, Minimally Invasive Reconstruction for Chronic Achilles Tendon Rupture With a Double-Bundle Flexor Hallucis Longus

Background:

High morbidity has been reported regarding Achilles tendon (AT) injuries, and the upward trend has accelerated since the mid-1990s. A chronic Achilles tendon rupture usually results from a neglected or misdiagnosed acute rupture, and about one-fifth of acute AT ruptures are missed and lead to chronic AT rupture. Although many techniques have been described, there is no gold standard in the treatment of chronic AT ruptures.

Hypothesis:

Endoscopically assisted, minimally invasive reconstruction for chronic AT rupture using a double-bundle flexor hallucis longus (FHL) tendon would result in improvement of the overall function, with a low rate of wound complications.

Study Design:

Case series; Level of evidence, 4.

Methods:

Between May 2015 and November 2016, a total of 19 consecutive patients were enrolled and treated using endoscopically assisted, minimally invasive reconstruction for chronic AT rupture using a double-bundle FHL. The operative assessment comprised the Achilles Tendon Total Rupture Score, the American Orthopaedic Foot & Ankle Society score, the Victorian Institute of Sports Assessment–Achilles score, and a postoperative questionnaire. All postoperative complications were recorded.

Results:

The mean follow-up time for all patients was 31 months (range, 20-42 months). According to the postoperative questionnaire, the result of surgery was excellent in 8 (42%) of 19 patients, good in 10 (53%), and fair in 1 (5%). All clinical outcome scores (mean ± SD) improved significantly after surgery: Achilles Tendon Total Rupture Score, 23.3 ± 10.3 vs 98.3 ± 9.2 (postoperatively vs preoperatively); American Orthopaedic Foot & Ankle Society, 52.1 ± 12.4 vs 97.5 ± 18.9; and Victorian Institute of Sports Assessment–Achilles, 23.4 ± 11.2 vs 95.7 ± 17.1 (P < .05). No complications with regard to wound healing or infection were noted. Twelve relatively young patients returned to preinjury activity levels, such as playing basketball or badminton, and the older patients were able to meet their daily needs, such as walking up stairs and jogging.

Conclusion:

Chronic AT ruptures were successfully treated via minimally invasive reconstruction using a double-bundle FHL, which provided excellent functional improvement. It is best suited for patients with complex requirements who are at high risk for wound complications.

Achilles Tendon Lesions - Part 2: Ruptures

The increasing incidence of calcaneal tendon ruptures has substantially impacted orthopedic care and costs related to its treatment and prevention. Primarily motivated by the increasing of life expectancy, the growing use of tenotoxic drugs and erratic access to physical activity, this injury accounts for considerable morbidity regardless of its outcome. In recent years, the evolution of surgical and rehabilitation techniques gave orthopedists better conditions to decide the most appropriate conduct in acute tendon rupture. Although still frequent due to their high neglect rate, Achilles chronic ruptures currently find simpler and more biological surgical options, being supported by a new specialty-focused paradigm.

Strength Measurement After Achilles Tendon Repair

The goal of treatment after Achilles tendon rupture (ATR) is to restore appropriate tension to the tendon, so that normal baseline strength and functional soft-tissue length can be achieved. The assessment of plantarflexion strength has shown widespread variability. The purpose of this study is to document variations in strength assessment after the treatment of ATR in the literature. A comprehensive literature review was performed. In total, 2758 articles were found on Achilles tendon rupture and Achilles tendon strength measurement. The full text of articles including strength as a functional outcome measurement in the abstract were assessed. All objective strength measurements performed were reviewed and recorded for comparison. One-hundred articles were included in our study. In 78 articles, a dynamometer was used to measure strength, whereas in 22 articles, an endurance test (n=14) or formal gait assessment (n=8) was applied. When a dynamometer was used, there was wide variability in the various methods used including the incorporation of both isokinetic (n = 65) and isometric (n = 29) exercises utilizing varying degrees of knee flexion and patient testing position. Furthermore, the number of measurements at certain angular velocities varied. This study illustrates that no general consensus exists regarding an optimal method for measuring strength after ATR. The variability creates difficulty and challenges medical professionals' ability to formulate consistent conclusions when determining functional performance outcomes. A more uniform way of measuring strength after ATR may allow for better comparisons between studies in the literature, potentially leading to a better understanding of strength. Levels of Evidence: Therapeutic, Level II.

Endoscopic Management of Chronic Achilles Tendon Rupture

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.