Similar outcomes found with or without FHL transfer for Achilles tendinopathy

Issue: October 2012

Augmenting the flexor hallucis longus tendon in addition to decompression and debridement of Achilles tendinopathy may improve ankle plantarflexion strength, without loss of strength in the hallux; however, preliminary data do not show an improvement in functional outcome.

“It is not clear with the numbers available whether [flexor hallucis longus] FHL transfer is better in terms of functional improvement,” Kenneth J. Hunt, MD, said at the American Orthopaedic Foot and Ankle Society 2012 Annual Meeting.

In a double-blinded study, Hunt and colleagues prospectively compared patients aged 50 years and older who underwent decompression and debridement alone to those who underwent decompression and debridement with FHL tendon transfer. All patients had failed conservative management of their insertional Achilles tendinopathy.

Researchers obtained outcome scores preoperatively and at 6 months and 1 year. At the time of Hunt’s presentation, 37 patients had been enrolled in the study, including 17 who underwent debridement alone and 20 who also underwent FHL tendon transfer.

“Outcome measures show that AOFAS scores increased in both groups, with no difference between the two groups at 6 months and 1 year,” Hunt said. “Visual analog scores also improved in both groups, and at 1 year, there was a trend toward more improvement in the FHL group compared with the non-FHL group, although it has not reached statistical significance with the available numbers.”

Ankle plantarflexion strength increased only among patients who underwent FHL tendon transfer, and researchers observed no difference in ankle plantarflexion strength among patients in the debridement-only group. This finding was statistically significant at 6 months and 1 year postoperatively.

Surgeons performed Haglund’s removal, debridement and Achilles insertion repair using an L incision and central tendon split.

Image: Hunt KH

“Interestingly, hallux plantarflexion strength did not change in either group, so even 6 months to a year after the procedure with FHL transfer, patients did not lose much strength in their halluxes despite loss of the FHL,” Hunt said.

Patient satisfaction overall was 86%, and researchers found no difference between the groups. Patients who underwent FHL tendon transfer experienced a higher rate of wound complications (nearly 45%). However, none of these complications required surgery or resulted in long-term problems. Hunt stressed that surgeons be mindful of the soft tissue when performing FHL tendon transfer to decrease the risk for wound complications. – by Tina DiMarcantonio

References:

Hunt KJ. Surgical treatment of insertional Achilles tendinopathy with or without flexor hallucis longus tendon transfer: A prospective, randomized, controlled trial. Presented at the American Orthopaedic Foot and Ankle Society 2012 Annual Meeting. June 21-23. San Diego.

Kenneth J. Hunt, MD, can be reached at Orthopaedic Specialists, 450 Broadway St., Pavilion A, 2nd Floor MC 6120, Redwood City, CA 94063; email: kjhunt@stanford.edu.

Disclosures: Hunt has no relevant financial disclosures.