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

The Achilles tendon is the strongest and largest tendon in the body. Rupture of this tendon usually occurs in the third and fourth decade and can be significantly debilitating. Repair of neglected ruptures of Achilles tendon pose a challenge to the orthopaedic surgeon due to the retraction and atrophy of the ends of the tendon. Various surgical procedures have been described which include VY plasty, fascia lata, peroneus brevis, plantaris tendon, flexor digitorum longus, flexor hallucis longus, allograft, and synthetic materials. We carried out a prospective study to compare the results of peroneus brevis transfer with flexor hallucis longus transfer in the management of neglected ruptures of Achilles tendon. Forty-seven patients who had neglected ruptures of Achilles tendon were included in this study. They were randomly divided into two groups; the first group underwent peroneus brevis transfer (24 patients) and the second group had flexor hallucis longus transfer (23 patients). Patients were assessed using the Quigley's scoring system. We conclude that Flexor hallucis longus transfer is better than peroneus brevis transfer as it is a long, durable tendon which is much stronger when compared to other tendon transfers. Flexor hallucis longus acts in the same axis as the Achilles tendon, is in the same gait phase and is in close proximity, making harvesting of the tendon easy