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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

Abstract

Background

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.

Results

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.

Conclusions

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.

Keywords

Insertional tendinopathy Achilles tendon defects FHL transfer Turn-down flap 

Notes

Conflict of interest

None.

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)

References

  1. 1.
    Kader D, Saxena A, Movin T, Maffulli N (2002) Achilles tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 36:239–249CrossRefPubMedCentralPubMedGoogle Scholar
  2. 2.
    DeOrio MJ, Easley ME (2008) Surgical strategies: insertional Achilles tendinopathy. Foot Ankle Int 29:542–550CrossRefPubMedGoogle Scholar
  3. 3.
    Krahe MA, Berlet GC (2009) Achilles tendon ruptures, re rupture with revision surgery, tendinosis, and insertional disease. Foot Ankle Clin 14:247–275CrossRefPubMedGoogle Scholar
  4. 4.
    Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M (2000) Long-term prognosis of patients with Achilles tendinopathy. Am J Sports Med 28:634–642PubMedGoogle Scholar
  5. 5.
    Nicholson CW, Berlet GC, Lee TH (2007) Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int 28(4):472–477CrossRefPubMedGoogle Scholar
  6. 6.
    Yodlowski ML, Sheller AD Jr, Minos L (2002) Surgical treatment of Achilles tendonitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity. Am J Sport Med 30:318–321Google Scholar
  7. 7.
    Wapner KL, Pavlock GS, Hecht PJ, Naselli F, Walther R (1993) Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle 14:443–449CrossRefPubMedGoogle Scholar
  8. 8.
    Den Hartog BD (2003) Flexor hallucis longus transfer for chronic Achilles tendonosis. Foot Ankle Int 24:233–237Google Scholar
  9. 9.
    Wong MWN, Ng VWS (2005) Modified flexor hallucis longus transfer for Achilles insertional rupture in elderly patients. Clin Orthop Relat Res 431:201–206CrossRefPubMedGoogle Scholar
  10. 10.
    Mahajan RH, Dalal RB (2009) Flexor hallucis longus tendon transfer for reconstruction of chronically ruptured Achilles tendons. J Orthop Surg (Hong Kong) 17(2):194–198Google Scholar
  11. 11.
    Wegrzyn J, Luciani JF, Philippot R, Brunet-Guedj E, Moyen B, Besse JL (2010) Chronic Achilles tendon rupture reconstruction using a modified flexor hallucis longus transfer. Int Orthop 34:1187–1192CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Thompson TC, Doherty J (1962) Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test. J Trauma 2:126–129CrossRefPubMedGoogle Scholar
  13. 13.
    Maffulli N (1996) Clinical tests in sports medicine: more on Achilles tendon. Br J Sports Med 30:250CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle 15:349–353CrossRefPubMedGoogle Scholar
  15. 15.
    Wilcox DK, Bohay DR, Anderson JG (2000) Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 21:1004–1010PubMedGoogle Scholar
  16. 16.
    McGarvey WC, Palumbo RC, Baxter DE, Leibman BD (2002) Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int 23:19–25PubMedGoogle Scholar
  17. 17.
    Martin RL, Manning CM, Carcia CR, Conti SF (2005) An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot Ankle Int 26:691–697PubMedGoogle Scholar
  18. 18.
    Suttinark P, Suebpongsiri P (2009) Clinical outcomes of flexor hallucis longus transfer for the treatment of Achilles tendinosis rupture. J Med Assoc Thai 92(6):S226–S231PubMedGoogle Scholar
  19. 19.
    Philippot R, Wegrzyn J, Grosclaude S, Besse JL (2010) Repair of insertional Achilles tendinosis with a bone-quadriceps tendon graft. Foot Ankle Int 31(9):802–806CrossRefPubMedGoogle Scholar
  20. 20.
    Lui P, Zhang P, Chan K, Qin L (2010) Biology and augmentation of tendon-bone insertion repair. J Orthop Surg Res 21–5:59CrossRefGoogle Scholar
  21. 21.
    Coull R, Flavin R, Stephens MM (2003) Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity. Foot Ankle Int 24:931–934PubMedGoogle Scholar
  22. 22.
    Lindholm A (1959) A new method of operation in subcutaneous rupture of the Achilles tendon. Acta Chir Scand 117:261–270PubMedGoogle Scholar
  23. 23.
    Tay D, Lin HA, Tan BSA, Chong KW, Rikhraj IS (2010) Chronic Achilles tendon rupture treated with two turndown flap and flexor hallucis longus augmentation two-year clinical outcome. Ann Acad Med Singap 39:58–60PubMedGoogle Scholar
  24. 24.
    Arastu MH, Partridge R, Crocombe A, Solan M (2011) Determination of optimal screw positioning in flexor hallucis longus tendon transfer for chronic tendoachilles rupture. Foot Ankle Surg 17:74–78CrossRefPubMedGoogle Scholar
  25. 25.
    Kangas J, Pajala A, Ohtonen P, Leppilahti J (2007) Achilles tendon elongation after rupture repair: a randomized comparison of 2 postoperative regimens. Am J Sports Med 35:59–64CrossRefPubMedGoogle Scholar
  26. 26.
    Kangas J, Pajala A, Siira P, Hδmδlδinen M, Leppilahti J (2003) Early functional treatment versus early immobilization in tension of the musculotendinous unit after Achilles rupture repair: a prospective, randomized, clinical study. J Trauma 54:1171–1180CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France 2014

Authors and Affiliations

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

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