Flexor Hallucis Longus Tendon Transfer Research Articles

Does FHL Tendon Transfer Alter the Outcome of Haglund Deformity Treatment by Using Debridement and Ostectomy in Patients Older Than 50 Years? A Single-Blinded Randomized Controlled Trial.

Chronic Achilles tendinopathy following Haglund disease is a common ankle condition that is difficult to manage. In this study, we will compare the clinical outcomes of debridement and ostectomy with and without FHL tendon transfer in treating Haglund deformity. Forty eligible patients aged >50 years who did not respond to conservative treatment were randomly divided into 2 groups for surgical approach: using flexor hallucis longus (FHL) tendon transfer (FHL group) or "standard procedure" (control group). The main surgical treatment included debridement and ostectomy. AOFAS and VISA-A scores were obtained from all patients pre- and postoperatively. Twenty patients were assigned to each of the 2 groups and were observed for at least 1 year. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scores and the Victorian Institute of Sports Assessment self-administered Achilles (VISA-A) questionnaires scores improved more in the FHL group; however, the average difference in the change in scores did not reach the levels previously reported for minimal clinically important differences. Surgical complications and hallux function were not significantly different between the 2 groups. We found that FHL tendon transfer may improve the clinical outcome scores of Achilles tendon treatment in patients aged >50 years using debridement and ostectomy. However, tendon transfer increases the time of surgery and creates additional skin incisions, which may cause more short-term wound complications, and the significance of the differences in outcome improvement may not be clinically meaningful. Level II, grade A recommendation.

Salvage Reconstruction of a 12-cm Tendon Defect Following Chronic Achilles Rerupture-15-Year Follow-Up: A Case Report.

A 39-year-old man with a chronic Achilles rupture status post (1) failed primary repair and (2) secondary xenograft repair with graft rejection, resulting in a 12-cm Achilles tendon defect, which was reconstructed utilizing an Achilles bone block allograft and flexor hallucis longus (FHL) tendon transfer. At 15-year follow-up, the patient reported good functionality and satisfaction with the repair, with positive patient-reported outcome measures. Physical examination revealed excellent strength and range of motion. Magnetic resonance imaging confirmed the integrity and incorporation of the Achilles/FHL graft composite. This case study provides valuable insight into successful long-term management of complex chronic Achilles ruptures with large defects.

Chronic Achilles Tendon Avulsion Repair: Central Third Fascia Slide Technique with Flexor Hallucis Longus Transfer.

Chronic Achilles Tendon Avulsion Repair: Central Third Fascia Slide Technique with Flexor Hallucis Longus Transfer.

Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series.

To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy. A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score. Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the six-month follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011). FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.

Acute Achilles Tendon Ruptures Treated With Endoscopic Flexor Hallucis Longus Transfer

The Achilles tendon represents the most commonly ruptured tendon of the human body. Numerous studies have evaluated, throughout the years, management options regarding acute Achilles tendon rupture. Minimally invasive techniques have recently gained more popularity. Endoscopic flexor hallucis longus tendon transfer has been mainly described as a treatment method for neglected Achilles tendon ruptures. However, it has recently been described as an applicable treatment option for acute Achilles tendon ruptures as well. Nevertheless, this procedure is technically quite demanding and should be performed by experienced surgeons. This technical note thoroughly describes the endoscopic flexor hallucis longus transfer technique for acute Achilles tendon ruptures, focusing on the most important technical aspects, thus attempting to simplify and render this procedure more widely accepted.

Long-term outcome of flexor hallucis longus tendon transfer for chronic Achilles tendon rupture with large defect: A retrospective series.

There are multiple surgical options for treatment of chronic Achilles tendon (AT) rupture according to the classifications and length of defect. However, no gold standard method has been confirmed, and there is no clear evidence to support the superiority of 1 procedure over others. This study aimed to evaluate the long-term clinical outcome of flexor hallucis longus tendon (FHL) transfer for chronic AT rupture with large defect. Clinical data of patients treated with FHL transfer due to chronic AT rupture between January 2009 and October 2019 were reviewed retrospectively. All cases were presented with AT rupture for more than 4 weeks after injury. The gap between ruptured ends was > 5 cm after debridement in all patients. The harvest of FHL was performed through a single incision in accordance with AT rupture debridement in all cases. Clinical outcomes were assessed with AOFAS ankle-hindfoot scale, Achilles tendon total rupture score and AOFAS hallux metatarsophalangeal-interphalangeal scale. Twenty-eight patients were followed successfully for 62.6 ± 22.2 months. According to the complete datasets obtained from 28 patients, none of the tendons re-ruptured. The AOFAS ankle-hindfoot scale and Achilles tendon total rupture score at last follow-up visit was 90.4 ± 5.7 and 89.8 ± 5.3 respectively, which revealed statistically significant improvement from the preoperative score of 61.1 ± 6.7 and 53.8 ± 8.3. The AOFAS hallux metatarsophalangeal-interphalangeal scale at last follow-up visit was 87.5 ± 6.1. The FHL transfer through a single incision for chronic AT rupture with large defect is a safe and simple method with low risk of morbidity and complications.

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 evidenceIV.

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.

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

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. 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. 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. 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 V, expert opinion.

Reconstruction of Chronic Insertional Achilles Tendon Rupture Treated by Surgical Repair using Interference Screw and Augmentation with Flexor Hallucis Longus Tendon Transfer

Reconstruction of Chronic Insertional Achilles Tendon Rupture Treated by Surgical Repair using Interference Screw and Augmentation with Flexor Hallucis Longus Tendon Transfer

Calf muscle evaluation during rehabilitation after flexor hallucis longus tendon transfer in neglected achilles tendon rupture: A case report

Introduction: Neglected achilles tendon rupture is generally defined as a rupture with a delay of more than 4 weeks prior to diagnosis or treatment. Difficulties in management make it one of the challenging problems in orthopedic practice. They have a greater tendency to develop complications and slightly poorer functional outcomes than patients with an acute rupture. Method: This case report features a case of 30 years old female with 3 months of neglected achilles tendon rupture after landing in the wrong position while playing badminton. The patient complains of continuous pain and inability to move her ankle downward, making walking difficult. On physical examination and CT imaging, we found achiles tendon rupture with significant gap and calf muscle atrophy. The patient was then managed operatively by debridement and tendon repair with flexor halucis longus tendon transfer. Result: Follow up 3 months post-operative, found a difference in calf muscle circumference in both legs. At the same time, there is still an improvement in active ROM ankle plantarflexion and positive single heel raise test on the affected side. The functional outcome measured by ATRS obtained 80 points, and AOFAS ankle-hindfoot scales with a value of 91 points. Discussion: With several advantages, FHL tendon transfer is the currently used technique for neglected cases of achiles tendon rupture. Despite long immobilization will induce other complications. Good operative techniques and accelerated rehabilitation are still recommended to gain good functional outcomes for the patient.

Neglected tendoachilles tear treated with flexor hallucis longus tendon transfer

Background: Neglected tendoachilles tear is one of the common condition that surgeons encounter and also difficult to manage. In Indian setting the most common reason for tendoachilles tear is lavatory pan injury, followed by road traffic accident. Various methods of treating neglected tendoachilles tear are described in literature but no single method is stated as ideal.Aim: The purpose of this study is to evaluate the technique, difficulties and functional outcome of neglected tendoachilles tear treated with flexor hallucis longus tendon transfer.Materials and Methods: 10 Patients with neglected tendoachilles tear (>4 weeks) are treated with flexor hallucis longus tendon transfer are included in this study. Pre-operative evaluation done both clinically and radio logically. All patients are followed up for a maximum period of 9 months and evaluated at 2 weeks,1,3,6, and 9 months. During follow-up all patients are evaluated using American Orthopaedic Association Foot and Ankle Score.Results: All patients with neglected tendoachilles tear treated with flexor hallucis longus tendon transfer showed an average AOFAS score of 88 and was able to do single heel raise test. All patients have difficulty in hallux interphalangeal joint flexion, but no patients have difficulty in doing day to day activities.Conclusion: Flexor hallucis longus tendon transfer for neglected tendoachilles showed good clinical outcome and patient’s satisfaction with insignificant and minimal complications.

Chronic Achilles Tendon Repair: Minimally Invasive Turn-Down Technique with Flexor Hallucis Longus Tendon Transfer

Category: Sports; Ankle; Trauma Introduction/Purpose: Chronic achilles tendon injuries present several technical considerations. A reported 20-25% of acute ruptures may be missed and lead to late diagnosis. A commonly faced problem with chronic ruptures is the amount of tendon retraction that occurs, leading to the inability to perform a direct end-to-end repair. Previous studies have demonstrated that central turndown lengthening with addition of flexor hallucis longus (FHL) augmentation can be performed with good results, although it has been associated with post-surgical wound complications and infection. The following description is a turndown technique with FHL tendon transfer augmentation for chronic achilles rupture that allows increased fixation with a tendon to bone construct, accomplished with a minimally invasive approach. Methods: Dissection is made down to the Achilles rupture site. Scar tissue is debrided down to two stable ends. The residual gap is then measured and 2cm is added. This distance is then used to make a proximal incision. Dissection is performed to gastrocnemius tendinous raphe. The central third of this segment is incised perpendicularly. A quadriceps tendon harvester (Arthrex, Naples, FL) is utilized to cut in an antegrade fashion down the tendon portion percutaneously, leaving a 1-1.5cm of tendon spared distally. The tendon is pulled under and through the distal incision. A percutaneous achilles repair system (PARS, Arthrex, Naples, FL) Jig is used to span proximal tendon. FHL tendon transfer is then completed in usual fashion. Suture tails from proximal tendon are then passed through the distal end. Tension is pulled through the sutures, approximating repair. The suture is loaded onto anchors and secured into the calcaneus under tension. Results: Favorable outcomes have been observed following the 2 patients that have had chronic achilles repair with utilization of this minimally invasive turn-down technique with FHL transfer. At a follow up of at least 6 months, no patient has demonstrated wound dehiscence or breakdown. There have been no reports of re-rupture. All patients have been satisfied with the procedure and their level of returned function. Conclusion: Our method of repair with combination of central turndown procedure and FHL tendon transfer provides a suitable option for improved functional outcomes in the treatment of chronic achilles ruptures while providing a minimally invasive approach and avoiding the need for allograft tissue. By using the quadricep tendon harvester in a subcutaneous fashion, incision length can be reduced by nearly 50%. This technique can be performed with existing technologies and is readily reproducible. Using the tendon to bone fixation along with intra-tendinous shuttling, allows for excellent fixation strength, a knotless construct, and almost complete intra-substance suture placement.

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

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. 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. 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. 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 III, retrospective controlled trial.

Management of Insertional Achilles Tendinopathy.

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.

Return to Sports Activities After Flexor Hallucis Longus Transfer for Neglected Achilles Tendon Rupture

Transfer of the flexor hallucis longus (FHL) is known to be effective in the treatment of neglected Achilles tendon rupture (ATR). However, evidence on the return to sports activity levels and clinical outcomes is not sufficient. The aim of this study was assessing clinical outcomes and level of sports activity after FHL tendon transfer for treatment of neglected ATR. Twenty-eight patients who underwent FHL transfer for neglected ATR were analyzed retrospectively. Sports activity status was assessed using the Tegner Activity Scale (TAS). Clinical outcomes were evaluated using the Achilles tendon total rupture score and the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale. By the post hoc power analyses, the power level of more than 80% was identified. The preinjury median TAS score was 4 point and unchanged at the last follow-up. The mean Achilles tendon Total Rupture Scores and American Orthopedic Foot and Ankle Society Ankle-Hindfoot Scale scores at the last follow-up were 81 and 93, respectively. While the median TAS was unchanged, 9/28 patients suffered from lower activity level after the procedure. In conclusion, midterm results of FHL transfer for neglected ATR were shown to be favorable. The median TAS score was maintained. Nonetheless, 32% of patients returned to sports activities with a TAS score 1 point lower than that at preinjury and with less favorable clinical outcomes.

Revision Achilles Tendon Repair Using Posterior Tibial Tendon Allograft and Flexor Hallucis Longus Transfer

Achilles tendon ruptures are common injuries seen by orthopaedic surgeons. A myriad of surgical options have been used in the management of Achilles tendon ruptures, but currently no gold standard exists. Re-rupture of Achilles tendon injuries occurs 1.7% to 5.6% of the time, and there has been no direct relationship demonstrated between complications and repair techniques used. The aim of this technique is to provide a method of fixation for the patient with an Achilles tendon re-rupture that provides a stable repair construct and mitigates the potential sequela of re-rupture. We describe the treatment of an Achilles tendon re-rupture with the use of a flexor hallucis longus tendon transfer and posterior tibial tendon allograft for repair of an 8.5 cm tendon gap.

Single Biotenodesis Screw vs Biotenodesis Screw with Cortical Button Tension Slide Technique for Flexor Hallucis Longus Transfer: A Biomechanical Analysis

Category:Ankle; Hindfoot; Sports; OtherIntroduction/Purpose:Restoration of functional plantarflexion of the ankle joint following chronic Achilles injury is achieved through transfer of the flexor hallucis longus (FHL) tendon. Fixation of the FHL tendon transfer with a cortical button tension slide technique is an advancement that has not been measured against traditional methods. The purpose of this study is to evaluate the biomechanical differences between a single biotenodesis screw versus biotenodesis screw with cortical button tension slide technique for the fixation of FHL transfer. The authors hypothesize a biomechanical advantage for the tension slide technique compared to the biotenodesis screw alone for fixation of the flexor hallucis longus in chronic Achilles pathology.Methods:12 pairs (n=24) of fresh-frozen cadaveric tibia-to-toe samples (6 male, 6 female) were utilized to assess the biomechanics of FHL tendon transfer fixation. All specimens underwent bone density analysis. Each pair of cadaveric samples were randomized to receive either the biotenodesis screw or the tension slide technique. FHL tendon transfer was performed via standard technique using a 6.25x15mm biotenodesis screw with the foot in 20 degrees plantarflexion. A 2.6x12mm cortical button was inserted and FHL tendon was introduced with a tension-slide technique. Biomechanical loading was applied between 20N and 60N at a rate of 1Hz for 100 cycles. Post-cyclic load to failure occurred at 1.25mm/sec. Cyclic displacement, structural stiffness, and ultimate load were derived from resultant load-displacement curves. Student t-tests were used to evaluate significant effects between both FHL tendon transfer techniques. Linear regression analysis was performed to assess interactions between bone density and strength of FHL tendon transfer.Results:Average tendon diameter of the 24 FHL samples was 5.44+-0.46 mm. Average bone density for all 24 calcaneus samples was determined to be 1.06+-0.08 g/cm2. Loading data was normalized with respect to bone density and tendon diameter to account for inherent anatomical differences between cadaveric specimens. The addition of a cortical button for FHL transfer to the calcaneus did not significantly affect cyclic displacement (0.78+-0.52mm vs 0.87+-0.80mm) or structural stiffness (162.11+- 43.34N/mm vs. 167.57+-49.19N/mm). Addition of the cortical button to the FHL tendon transfer construct resulted in a 34% significant increase in ultimate load (343.72+-68.93 N) compared to biotenodesis screw alone (255.62+-77.17 N) (p=0.0002). Linear regression analyses did not reveal any significant interactions between bone density and FHL tendon transfer technique.Conclusion:Enhanced strength can be achieved for Achilles pathology repaired with FHL tendon transfer utilizing a biotenodesis screw and cortical button tension slide technique demonstrated by a statistically significant 34% increase in ultimate load, subsequent to cyclic loading. Cortical buttons in the setting of FHL tendon transfer to the calcaneus offers an additional level of support in the case of extreme tendon transfer failure.

Non-Operative Management of Chronic Achilles Tendon Ruptures: Short Term Outcomes

Category:Hindfoot; Sports; TraumaIntroduction/Purpose:The incidence of Achilles tendon rupture in the United States is approximately 2.6 per 100,000 person years, with a significant increase in incidence over recent years reported. Should the acute rupture not be diagnosed promptly, as is the case in up to 20% of patients, the injury may be termed chronic. A number of operative treatment strategies for chronic Achilles ruptures have been described, including v-y tendinous flap, flexor hallucis longus tendon transfer, peroneus brevis graft and free gracilis transfer. Despite the extensive investigation of non-operative treatment in acute ruptures, there is a lack of similar research into chronic injuries. This article aims to address this gap in the literature, reporting treatment results of patients treated conservatively after being deemed unfit for operative intervention.Methods:A retrospective review of all patients receiving non-operative treatment for chronic Achilles ruptures, in the senior author's clinic between December 2014 and May 2019 was performed. A chronic injury was defined as occurring when there was a delay of at least 28 days between initial injury and start of treatment. Patients with a minimum final follow up of less than 6 months were excluded. All patients were managed according to the previously described Leicester Achilles Management Protocol (LAMP), an eight-week functional dynamic regime with use of a VACOped boot (OPED, Valley, Germany). Formal physiotherapy treatment was also provided following completion of the LAMP. Hospital records were searched for relevant data including patient age and sex, side of injury, time between injury and start of treatment and post-treatment Achilles tendon total rupture score (ATRS).Results:A total of 17 consecutive patients with a minimum follow up of 6 months were managed non-operatively during the stated time period. The cohort included eight males and nine females with a mean age of 63.4 14.3 years. The right side was injured in five cases, with the left side affected in 12. The mean time from initial injury to start of treatment was 43.9 days (range 30 - 102 days). The mean ATRS at 6 months post treatment was 53+-17.8. A total of 10 patients were also available for follow up at 12 months. The mean ATRS in these patients at 12 months was 73 +-15.2.Conclusion:The mean 12-month ATRS of 73 achieved is lower than figures of 89-92.5 reported in previous studies describing operative treatment. However, our results indicate that good outcomes may be achieved using a non-operative protocol in patients who decline or are unfit for surgery. Recent research reports that the mean age of Achilles rupture has increased by 0.721 years every five years, since 1953. It could therefore be likely that an increasing number of patients suffering chronic Achilles ruptures may be unfit for surgical treatment. It is important that further research into the non-operative treatment of these patients is conducted.

Comparative study of flexor hallucis longus tendon length through single incision or accessory plantar medial incision: a cadaver study

Background: Flexor hallucis longus (FHL) tendon transfer to the calcaneus is used in treatment of Achilles pathology. Tendon harvest is through a posterior or medial incision. This study quantified the tendon length obtained through each technique. Methods: Seven pair-matched cadaver legs were used. One leg was randomly selected for posterior harvest, and the contralateral leg was selected for medial harvest. A dorsal to plantar calcaneus tunnel was prepared. Two tendon measurements were obtained: the total and the functional tendon length. Results: Using a posterior incision, the total and functional tendon lengths were 4.2 cm and 4.0 cm, respectively. Using the medial incision, the total and functional tendon lengths were 8.2 cm and 7.2 cm, respectively. Conclusions: The single incision provided length to anchor the FHL into the calcaneus suggesting this technique is adequate for fixation with an interference screw. For other indications, the medial incision provides additional 4.0 cm (P=0.003) total length or 2.9 cm (P=0.0016) functional length. Level of Evidence: Level V.