Published: 2018-02-23

Chronic insertional achilles tendon ruptures treated by suture anchor repair and augmentation with flexor hallucis longus tendon transfer

Athar Ahemad M. A., Naser Mohd Abdul, Mushir Ali Syed


Background: Different surgical procedures have been used for treatment of chronic ruptures of the Achilles tendon with varying results. This study assesses the functional outcomes and complications of chronic insertional tears of Achilles tendon.

Methods: 10 patients with chronic ruptures of the Achilles tendon were followed for a mean period of 10.3 months. Only ruptures at or near (within 1 cm) insertion were included. They were treated by direct repair of tendon to calcaneum by suture anchor. Flexor hallucis longus (FHL) tendon transfer fixed to calcaneal tunnel with an interference screw was used to augment the repair.

Results: Outcome was assessed by AOFAS Ankle-Hindfoot (AHS) score. The mean preoperative score of 41.2 improved to 85.4 at final follow-up out of a total 100 points. We achieved excellent results in 80% and good outcome in 20% cases. No re-ruptures were noted.

Conclusions: In insertional chronic ruptures of Achilles tendon, FHL transfer to calcaneum with interference screw fixation and repair of Achilles tendon with suture anchor is a reliable technique with good outcome and is recommended.


Achilles tendon, Flexor hallucis longus, Tendon transfer, Suture anchor

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Maffulli N. Rupture of the Achilles tendon. J Bone Joint Surg Am. 1999;81:1019-36.

Maffulli N, Ajis A, Longo UG, Denaro V. Chronic rupture of tendo Achilles. Foot Ankle Clin North Am. 2007;12:583-96.

Abraham E, Pankovich AM. Neglected rupture of the Achilles tendon: treatment by V-Y tendinous flap. J Bone Joint Surg Am. 1975;57:253-5.

Hansen ST. Trauma to the heel cord. In: Jahss MH, ed. Disorders of the foot and ankle, 2nd edn. W.B. Saunders, Philadelphia, 1991: 2357.

DeCarbo WT, Hyer CF. Interference screw fixation for flexor hallucis longus tendon transfer for chronic achillestendonopathy. J Foot Ankle Surg. 2008;47(1):69-72.

Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle, hindfoot, midfoot, hallux and lesser toes. Foot Ankle. 1994;15:349-53.

Den Hartog BD. Surgical Strategies: delayed diagnosis or neglected Achilles tendon ruptures. Foot Ankle Int. 2008;29:456-63.

Wegrzyn J, Luciani JF, Phillipot R, Brunet-Guedj E, Moyen B, Besse JL. Chronic Achilles Tendon rupture reconstruction using a modified flexor hallucis longus transfer. Int Orthop. 2010;34:1187-92.

Yeoman T, Brown MJC, Pillai A. Early postoperative results of neglected tendo-Achilles rupture reconstruction using short flexor hallucis longus tendon transfer: A prospective review. The Foot. 2012;22:219-23.

Mulier T, Pienaar H, Dereymaeker G, Reynders P, Broos P. The management of chronic Achilles tendon ruptures: gastrocnemius turn down flap with or without flexor hallucis longus transfer. Foot Ankle Surg. 2003;9(3):151-6.

Luis P, Zhang P, Chan K, Qin L. Biology and augmentation of tendon- bone insertion repair. J Orthop Surg Res. 2010;21(5):59.

El-Tantawy A, Azzam W. FHL tendon transfer in the reconstruction of extensive insertional Achilles tendinopathy in elderly: an improved technique. Eur J Orthop Surg Traumatol. 2015;25;583-90.

van der Linden-van der Zwang HMJ, Nelissen RGHH, Sintenie JB. Results of surgical vs non-surgical treatment of Achilles tendon rupture. Int Orthop. 2004;28:370-3.

Silver RL, dela Garza J, Rang M. The myth of muscle balance. A study of relative strengths and excursions of normal muscles about the foot and ankle. J Bone Joint Surg Br. 1985;67:432-7.

Hahn F, Maiwald C, Horstmann T, Vienne P. Changes in plantar pressure distribution after Achilles tendon augmentation with flexor hallucis longus transfer. Clin Biomech. 2008;23(1):109-16.