Abstract. Introduction. FHL transfer for management of chronic Achilles' tendon ruptures is done both open and endoscopically. But there are no published studies comparing open and endoscopic results. Our study aims to compare them and determine the suitability of these methods. Materials and methods. Fourteen patients were treated endoscopically while 26 with an open technique. Of the 26, fourteen had an open Achilles tendon repair and FHL transfer while 12 has only open FHL transfer. All the endoscopic patients had only an FHL transfer. We compared demographics, complications of the procedure, recovery times, return to work and strength after 1 year. We noted ATRS at 6 months and 1 year for all three groups. We also conducted an MRI scan of three patients each of the three groups to determine the state of Achilles tendon and FHL tendon after 1 year of surgery. Results. There were similar complication rates for both the only FHL groups but the open FHL + Achilles' repair had more complications both for wound complications and saphenous neuropraxia. The recovery time, return to work and ATRS at 6 months was better for the endoscopic group as compared to both open groups. The strength and ATRS at 1 year were similar for all three groups. Conclusion. Endoscopic FHL transfer is safe and provides earlier return to work and better 6 months patient satisfaction then the open method. It also has less post op complications than open FHL + Achilles tendon repair, while maintains the same strength after 1 year

Introduction: A.K. Henry described the region of the cross-connection between FHL tendon and FDL tendon in the mid-foot. It had been termed “master knot”. Up to now its description was not done exactly.

Aim: In this study we were investigating the exact structure of the tendons connection and possibilities of the tendons transfer in the region of foot; especially for repairing extended or neglected Achilles ruptures.

Methods: Both feet in 30 cadavers (17 men, 13 women) had been prepared. The distance from proximal part of the knot to the distal insertion of FHL and the distance from the end of FHL origin to the proximal part of the knot had been measured. This values had been compared with the foot length.

Results: In the investigated group of cadavers had not been found any direct junction between FHL and FDL tendons proximally from the branching FDL for fingers. There is an interconnection from the FHL tendon to distal part of FDL for 2nd eventually for 3rd finger (distally from FDL branching). We did not find any connection described in anatomical study of E. O’Sullivan (Clinical Anatomy18: 121 – 125, 2005).

The average distance from the point of interconnection on the FHL to its insertion was 13,8 cm (9,8 cm–19,4 cm), from the end of muscle origin 17,9 cm (15,7 cm–19,6 cm).

The approximate distances after the conversion to the foot length were 0,70 times foot length and 0,55 times foot length.

Conclusions: There is no direct junction between FHL and FDL tendons proximally from the branching FDL for fingers. The suture of the tendons distally from the cut of transferred tendon and proximally from FDL branching is necessary to keep the correct flexion of all fingers.

Introduction. Flexor Hallucis Longus (FHL) tendon transfer is a well-recognised salvage operation for irreparable tendon Achilles (TA) ruptures and intractable Achilles tenonopathy. Several case series describes the technique and results of arthroscopic FHL tendon transfers. We present a comparative case series of open and arthroscopic FHL tendon transfers from Southmead Hospital, Bristol, UK. Methods. For the arthroscopic FHL transfers in most cases the patients were positioned semi prone with a tourniquet. A 2 or 3 posterior portal technique was used and the tendon was secured using an RCI screw. The rehabilitation was similar in both groups with 2 weeks in an equinus backslab followed by gradual dorsiflexion in a boot over the following 6 weeks. Anticoagulation with oral aspirin for 6 weeks was used. A retrospective case note review was performed. Results. There were 12 arthroscopic (8 males, 4 female) and 16 open procedures (9 male, 7 female). Both had a mean age of 56. 1 arthroscopic FHL was lost to follow up. There were no concomitant procedures in the arthroscopic group. In the open group the TA was repaired in 7 cases (3 of these involved z-shortening). There was 1 plantaris interposition, 1 V-Y advancement and 1 gastrocnemius advancement. Degenerate tendon was excised in 1 severe re-rupture of a calcified tendinopathic achilles. There was no difference in tourniquet time between the groups (arthroscopic 69mins vs open 64 mins, p=0.64). There were no complications in the arthroscopic group. In the open group there was 1 superficial wound infection, 1 nerve injury & 1 delayed DVT at 3 months. Conclusion. Arthroscopic FHL transfer is a safe and effective surgical option when no other achilles procedures are required. The soft tissue insult is minimal, making it a good option for patients with poor soft tissues or neurovascular compromise

Introduction. The delayed presentation of Achilles tendon rupture is common, and is a difficult problem to manage. A number of surgical techniques have been described to treat this problem. We describe the use of Flexor Hallucis Longus (FHL) transfer to augment the surgical reconstruction of the delayed presentation of achilles tendon rupture. Materials and Methods. Fourteen patients with chronic tendo-Achilles rupture, presenting between April 2008 and December 2010, underwent surgical reconstruction and FHL transfer. Surgery was performed employing standard operative techniques, with shortening of the Achilles tendon and FHL transfer into the calcaneum with a Biotenodesis screw (Arthrex). VISA-A scores were performed preoperatively and six months postoperatively. Complication data was collected by review of the electronic patient record and direct patient questioning. Results. One patient died of an unrelated cause shortly before outcome scoring, and another patient was excluded because casting in the preoperative period prevented accurate scoring, although he achieved a good post-treatment score. Analysis was therefore carried out on twelve patients. Eleven of the twelve patients had significant improvement in their VISA-A score, with a mean improvement in score of 30 (p < 0.05). There were no significant complications in any of the patients. Conclusion. Our results show that FHL transfer in the management of chronic Achilles tendon rupture is a good, safe and reliable technique. There is excellent improvement in the mean VISA-A score, with no significant complications. Our results support the use of FHL tendon transfer for patients with chronic tendo-Achilles rupture

Tendoscopy in the treatment of peroneal tendon disorders is becoming an increasingly safe, reliable, and reproducible technique. Peroneal tendoscopy can be used as both an isolated procedure and as an adjacent procedure with other surgical techniques. The aim of our study was to review all peroneal tendoscopy that was undertaken at the AOC, by the senior authors (IGW, SH), and to determine the safety and efficacy of this surgical technique. Methods. From 2000 to 2017 a manual and electronic database search was undertaken of all procedures by the senior authors. Peroneal tendoscopy cases were identified and then prospectively analysed. Results. 51 patients (23 male, 28 female) were identified from 2004–2017 using a manual and electronic database search. The mean age at time of surgery was 41.5 years (range 16–83) with a mean follow-up time post operatively of 11.8 months (range 9–64 months). The main indications for surgery were lateral and/or postero-lateral ankle pain and lateral ankle swelling. The majority of cases showed unstable peroneal tendon tears that were debrided safely using tendoscopy. Of the 51 patients, 23 required an adjacent foot and ankle operation at the same time, 5 open and 17 arthroscopic (12 ankle, 5 subtalar). Open procedures included 2 first ray osteotomies, 2 open debridements of accessory tissue, one PL to PB transfer. One patient also had an endoscopic FHL transfer. Complication rates to date have been low: 2 superficial wound infections (4%) and one repeat tendoscopy for ongoing pain. A small proportion of patients with ongoing pain were treated with USS guided steroid injections with good results. Conclusion. Our series of peroneal tendoscopy has a low complication rate with high patient satisfaction at discharge. Results of tendoscopic treatment are similar to open techniques, however its advantages make tendoscopic procedures an excellent method to treat peroneal tendon disorders

Introduction: Achilles tendon (AT) rupture is a common sports injury. However, about 10% to 25% of the complete AT ruptures are not diagnosed. The management of neglected or chronic AT ruptures is usually different from that of acute rupture as the tendon ends were retracted and atrophied with short fibrous distal stumps. In the current series, we reported the mid- to long-term outcome of 10 patients with neglected or chronic AT rupture managed by a modified Flexor Hallucis Longus (FHL) transfer. Materials and Methods: Between April 2002 and December 2003, 10 patients (6 males, 4 females) were operated on for a neglected or chronic AT rupture with a FHL transfer. The age at surgery averaged 44.1 years (range, 27–70). Five patients presented with a neglected AT rupture, 3 with a chronic AT rupture associated with Achilles tendinosis and 2 with an AT re-rupture. The AT defect after fibrosis debridement averaged 7.4 cm (range, 2.5–10). Beside FHL transfer, we performed a transfer augmentation with the 2 remaining Achilles fibrosis flaps. If no residual fibrosis after debridement was found, a Bosworth augmentation was performed to strengthen the transfer. Functional assessment was performed using Kitaoka score. Postoperative complications were analyzed. Delay of work and sports recovery was noticed. Isokinetic evaluation was performed using Con-Trex. ®. dynamometer. Statistical analysis was performed using Student’s t-test and Wilcoxon test (level of significance, p < 0.05). Results: The mean follow-up was 61 months (range, 40–73). Functional outcome was excellent with a significant improvement of the average Kitaoka score at latest follow-up (98/100 (range, 90–100)). Average delay of work and sports recovery was 5 months (range, 2–12) and 10 months (range, 6–18) respectively. All patients returned to a sports activity within minor limitations. No re-rupture has been described. No major complication was observed particularly on wound healing. All patients presented with a loss of active range of motion of the hallux interphallangeal joint without subsequent hyperextension. However, no patient presented with functional weakness of the hallux during athletic or daily life activities. Isokinetic testing at 30 deg/sec and 120 deg/sec revealed a significant average decrease of 28±11% and 36±4.1% respectively, in the plantar flexion peak torque of the involved ankle compared with the non-involved ankle. Discussion: Although strength deficit persisted at latest follow-up, functional improvement was significant. Morbidity due to FHL harvesting was clinically in significant at latest follow-up. For patients with neglected or chronic Achilles tendon rupture with a rupture gap of at least 5 centimeters, surgical repair using FHL transfer with fibrous AT stumps reinforcement achieved excellent outcome at our latest follow-up

Background: Neglected ruptures of the tendoachilles pose a difficult surgical problem. Intervening scar tissue has to be excised which cannot be repaired by end-to-end anastamosis. Several techniques for reconstruction of chronic ruptures have been described. The flexor hallucis longus (FHL) tendon transfer is considered advantageous over other tendon transfers. One disadvantage of FHL is it has limited excursion. There are no data to determine the optimal positioning of the FHL tendon to the calcaneum. Materials and Methods: Two computer programmes (MSC.visualNastran Desktop 2002™ and Solid Edge® V19 were used to generate a human ankle joint model. This model is able to reproduce dorsi- and plantarflexion. Different attachment points of FHL tendon transfer to the calcaneum were investigated. Results: The lowest muscle force to produce plantarflexion (single stance heel rise) was 1355N. Plantarflexion increased for a more anterior attachment point. The maximal plantarflexion was 33.4° for anterior attachment and 24.4° for posterior attachment. There was no significant difference in these figures when the attachment point was moved to either a medial or lateral position. Clinical relevance: Optimal FHL tendon transfer positioning is a compromise between achieving plantarflexion for normal physiological function versus the force generating capacity and limited excursion of FHL. A more posterior attachment point is advantageous in terms of power. The range of motion is 10° less than when attachment is more anterior, the arc of motion (24.4°) is still physiological. We recommend that FHL is transferred to the calcaneum in a posterior position

Although it is generally accepted that surgical treatment is the treatment of choice in chronic TA ruptures, therapeutic options are difficult. Traditional options include grafts (natural, allografts and synthetic grafts) and end to end repair. Natural grafts described include fascia lata and plantaris tendon. Synthetic materials such as Dacrongrafts, Marlex mesh and carbon fibers have been used. There are significant complications from graft and end to end repair. These include wound necrosis, delayed union, infection, foreign body reaction and devastating tissue loss. Also functional results are suboptimal after delayed reconstruction. Tendon transfer is another method that has been described for the treatment of these injuries. The tendons used were the flexor hallucis lomgus, flexor digitorum longus and the peronei . The FHL tendon transfer is considered advantageous to other tendon transfers because it is stronger, its axis of force is close to that of the TA and harvesting the tendon is easy and unlikely to cause any complications. We report excellent results following four operations in three patients treated with flexor hallucis longus tendon transfer for chronic Achilles tendon ruptures. All patients were on long term steroid treatment and an end to end repair would have been associated with a high complication rate. We believe that FHL transfer to replace the TA is a low morbidity alternative which gives good to excellent results in individuals with low to moderate demand

Introduction. Patients with neglected rupture of the Achilles tendon typically present with weakness and reduced function rather than pain. Shortening of the musculotendinous unit and atrophy of the muscle belly in chronic rupture potentially leads to poorer recovery following tendon transfer. Few papers have looked at the outcomes of FHL reconstruction specifically in neglected TA rupture. Of those that have none report functional outcomes following a transtendinous repair. Methods. Twenty patients with irreparable unilateral tendoachilles ruptures treated with transtendinous FHL reconstruction between 2003 and 2011 were reviewed. Achilles Tendon Rupture Score (ATRS), AOFAS hindfoot score, Tegner score and SF12 were recorded. Standard isokinetic assessment of ankle plantarflexion was performed with a Cybex dynamometer. Great toe flexion strength was tested clinically. Results. The mean age at surgery was 53 years (22–83 years). Mean time from rupture to surgery was 7 months (1–36 months). Follow up ranged from 29–120 months (mean 73 months). Sixteen patients were completely satisfied and four moderately satisfied. The mean ATRS was 80 (range 25–100) and AOFAS 94 (range 82–100). Postoperative Tegner score showed a reduction by one level from pre-injury (mean 5.1 pre injury to 4.3 post surgery). No cases of re-rupture were encountered. Six patients had wound issues. The mean maximal strength of ankle plantar flexion on the operated leg 95Nm (41–163) was less than the non-operated leg 123 Nm (50–190Nm). The average difference in strength was 24%. The operated hallux had only 40% of strength in flexion of the contralateral toe. There were no floating toes. Conclusion. Transtendinous FHL transfer for late presenting Achilles tendon ruptures provides reliable long term function and reasonable ankle plantar flexion strength. Long FHL harvest has little morbidity and lack of a distal tenodesis did not result in any notable functional loss or alignment issues to the great toe

Introduction. Chronic ruptures of the Achilles tendon pose a significant management challenge to the clinician. Numerous methods of surgical reconstruction have been described and are generally associated with a higher complication rate than with immediate repair. We report our results with a single 5cm incision technique to reconstruct chronic Achilles tendon ruptures with transfer of FHL. This simple technique also enables easy tensioning of the graft/reconstruction to match the uninjured leg and early mobilisation. Materials & Methods. All patients undergoing late Achilles tendon reconstruction (over 4 months from rupture) during the period September 2006 to January 2010 were included in the study. All patients were treated using a single incision technique and posterior ankle FHL harvest with bio absorbable interference screw fixation in the calcaneum. Weight bearing was allowed from 2 weeks post operatively with a dynamic rehabilitation regime identical to that which we use following repair of acute ruptures. A retrospective review of the records was performed and a further telephone review undertaken. Results. 15 ‘late’ Achilles tendon reconstructions were undertaken in the study period. Their mean age was 55 years (38-80). Mean time from rupture was 16 months (5-96). Significant co-morbities included diabetes, chronic renal failure, multiple schlerosis and Parkinson's disease. The mean duration of follow-up was 20 months (7–38). There were no post-operative complications. AOFAS score improved significantly in all patients and all reported good or excellent improvement in strength and return to pre-injury function (including sport in 2 cases). Conclusion. This less invasive single incision technique of FHL transfer reconstruction of chronic Achilles tendon ruptures as previously published from our unit seems to be a safe and reliable undertaking in patients with symptomatic chronic Achilles ruptures and is our preferred technique for all chronic ruptures especially in the presence of significant co-morbities

Introduction Nineteen consecutive patients underwent flexor hallucis longus (FHL) tendon transfer and medial displacement calcaneal osteotomy for the treatment of Stage 2 posterior tibial tendon dysfunction. Methods The FHL tendon was utilized for transfer because it approximates the strength of the posterior tibiais muscle and is stronger than the peroneus brevis muscle. Seventeen patients returned for follow-up examination (average 18 months). Results The AOFAS hindfoot score improved from 62/100 to 84/100. The subjective portion of the AOFAS hindfoot score improved from 31/60 to 49/60. Weight bearing pre-operative and post-operative radiographs revealed no statistically significant improvement for the medial longitudinal arch in measurements of lateral talo-first metatarsal angle, calcaneal pitch, vertical distance from the floor to the medial cuneiform or talo-navicular coverage angle. Three feet had a normal medial longitudinal arch and six feet had a longitudinal arch similar to the opposite side following the procedure. Patient satisfaction was high: 10 patients satisfied without reservations, six patients satisfied with minor reservations and one dissatisfied. No patient complained of donor defecit from the harvested FHL tendon. Conculsions Despite the inability of the procedure to improve the height of the medial longitudinal arch, FHL transfer combined with medial diplacement calcaneal osteotomy yielded good to excellent clinical results and a high patient satisfaction rate. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits