title: Surgical Treatment of Insertional Achilles Tendinopathy With or Without Flexor Hallucis Longus Tendon Transfer: A Prospective, Randomized Study.
abstract: BACKGROUND
  Chronic insertional Achilles tendinopathy is a common pathology that can be difficult to manage. Some experts have advocated augmentation with the flexor hallucis longus (FHL) tendon in patients over age 50 and those with more severe tendon disease. We hypothesized that FHL augmentation would be associated with superior clinical outcome scores and greater ankle plantar flexion strength compared with Achilles debridement alone.
  
  
  METHODS
  Consecutive patients older than 50 years who had failed nonoperative treatment for chronic insertional Achilles tendinopathy were randomly assigned to Achilles decompression and debridement alone (control group) or Achilles decompression and debridement augmented with FHL transfer (FHL group). Outcome measures included American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot score, visual analog scale (VAS) for pain, ankle and hallux plantar flexion strength, and a patient satisfaction survey. A total of 39 enrolled patients had a minimum 1-year follow-up, 18 in the control group and 21 in the FHL transfer group. The average patient age was 60.5 years.
  
  
  RESULTS
  AOFAS and VAS scores improved in both groups at 6 months and 1 year with no difference between groups. There was greater ankle plantar flexion strength in the FHL group at 6 months and at 1 year compared with the control group (P < .05). There was no difference between the 2 groups in hallux plantar flexion strength preoperatively and at 1 year after surgery. Some 87% of patients were satisfied with the outcome of their procedure. There was no significant increase in wound complications in the FHL group (P < .05).
  
  
  CONCLUSIONS
  We found no differences in pain, functional outcome (as measured by the AOFAS ankle/hindfoot scale), and patient satisfaction when comparing patients treated with Achilles debridement alone versus FHL augmentation for chronic Achilles tendinopathy. Ankle plantar flexion strength appeared to be improved with FHL transfer, with no loss of hallux plantar flexion strength. Although FHL transfer was a safe adjunct to tendon debridement and partial ostectomy for insertional Achilles tendinopathy in older patients with little compromise in function, it may not be necessary for primary cases.
  
  
  METHODS
  Level 1, prospective randomized trial.
authors.affiliation: Department of Orthopaedic Surgery, Stanford University, Redwood City, CA, USA.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Hunt
authors.affiliation: OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.
authors.forename: Bruce E
authors.initials: BE
authors.lastname: Cohen
authors.affiliation: OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.
authors.forename: W Hodges
authors.initials: WH
authors.lastname: Davis
authors.affiliation: OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Anderson
authors.affiliation: OrthoCarolina Foot and Ankle Institute, Charlotte, NC, USA carrolljones3@gmail.com.
authors.forename: Carroll P
authors.initials: CP
authors.lastname: Jones
mesh_terms: D000125:Achilles Tendon / Q000601:surgery*; D000368:Aged; D003646:Debridement; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D017060:Patient Satisfaction; D011446:Prospective Studies; D052256:Tendinopathy; D013709:Tendon Transfer; D064232:Visual Analog Scale
keywords: outcome studies; tendon disorders