Flexor hallucis longus tendon transfer in the reconstruction of extensive insertional Achilles tendinopathy in elderly: an improved technique

  • Ahmad El-TantawyEmail author
  • Wael Azzam
Original Article



Insertional Achilles tendinopathy is a degenerative disease associated with disabling posterior heel pain, gait dysfunction and significant morbidity. The aim of this prospective study was to evaluate the outcomes of complete excision of the pathological tendo-achilles segment in elderly patients with extensive involvement, and reconstructing the defect using a modified technique which was proposed to allow early weight-bearing and rehabilitation.

Patients and methods

Thirteen patients (mean age 58.2 years) with extensive insertional Achilles tendinopathy (seven with spontaneous rupture and six without rupture) were operated between January 2008 and July 2012. The average tendon gap after debridement was 6.8 cm. All patients were reconstructed with flexor hallucis longus tendon transfer augmented with a modified turn-down flap. Patient’s satisfaction was evaluated using the American orthopedic foot and ankle society (AOFAS)-ankle-hindfoot scale.


The mean follow-up period was 24.5 months. The AOFAS scores improved from 57.5 ± 8.44 preoperatively to 98.3 ± 1.01 at final follow-up (p < 0.001). Complete pain relieve was achieved in ten patients, while the other three had mild occasional pain. Eleven patients had excellent results, and two had good results. There was no single case of re-rupture, and two patients acquired superficial wound infection which was resolved conservatively.


The modified technique provides a transfer with sufficient length and strength that can restore large tendo-achilles defects in elderly, and is stable enough to allow early protected weight-bearing and rehabilitation with favorable clinical result and minimal morbidity. Resection of all degenerated tendon tissue alleviates pain and improves function.


Insertional tendinopathy Achilles tendon defects FHL transfer Turn-down flap 


Conflict of interest


Supplementary material

A short-cut intra-operative video adopted (with patient’s permission) after finishing our augmented procedure. The patient was under spinal anesthesia with recovery of motor function and preservation of sensory block. The patient was instructed to do active ankle planter-flexion to show the integration of gastroc-soleus complex with FHL in planter-flexion, and to confirm the immediate stability of our construct (WMV 3724 kb)


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Copyright information

© Springer-Verlag France 2014

Authors and Affiliations

  1. 1.Orthopedic and Traumatology Department, Faculty of MedicineTanta UniversityTantaEgypt

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