SLR - April 2013 - Harshini Avula
Reference: Shon LC, Shores JL, Faro FD, Vora AM. Flexor Hallucis Longus Tendon Transfer in the Treatment of Achilles Tendinosis, J Bone Joint Surg Am. 2013;95:54-60.
Scientific Literature Review
Reviewed by: Harshini Avula, DPM
Residency Program: Sisters of Charity Hospital, Buffalo, NY
Podiatric Relevance:
Achilles tendinosis is a degeneration of the tendon, usually secondary to “over-use” type injuries. This condition most commonly occurs at the insertion or the midsubstance of the tendon. Conservative treatment options are physical therapy for stretching, strengthening, and other various modalities such as ultrasound and electrical stimulation. If this fails, then surgically the tendon can be debrided and augmented. This article discusses Achilles tendon debridement and augmentation with flexor hallucis tendon transfer in older, sedentary and overweight patients.
Methods:
This is a prospective study of 56 patients with 58 affected limbs from August 2003 to May 2008. The diagnosis of tendinosis was made based on MRI and radiographic evidence of degenerative thickening with or without calcifications. Patients with previous Achilles tendon surgery or those unwilling to consent to the follow-up regimen were excluded. Outcome measurements included measurement of calf circumference, ability to perform single heel rise, visual analog pain scale (VAS), the short form-36 health survey and the ankle osteoarthritis scale. Possible hallux-specific dysfunction post-surgery was also evaluated. Follow-up time was three, six, 12 and 24 months.
Results:
A total of 56 patients underwent the procedure and 10 were lost to follow-up. Therefore, 48 limbs in 46 patients were available for evaluation. Mean age was 54±10years; mean body mass index was 33.8±6.8 kg/m^2. Between baseline and 24 months, the outcome measurements included VAS (6.7±2.3 versus 0.8±2.0; p<0.001), SF-36 physical score (34.3±8.0 versus 49.0±9.3; p<0.001), ankle osteoarthritis score for pain (54.4±19.2 versus 1.9±2.7; p<0.001), dysfunction (62.6±21.4 versus 11.0±24.2; p <0.001) and performance of single heel rise (1.9±3.0 versus 7.3±2.7cm; p<0.001). At 24 months only 4 percent (two out of 46 patients) reported constant lack of balance secondary to hallux weakness.
Conclusions:
This is a prospective study showing significant improvement in symptoms of Achilles tendinosis post debridement and augmentation with flexor hallucis longus tendon transfer, without negatively impacting great toe function. The authors do not recommend that this procedure be performed in younger, lighter patients or in athletes. The limitation of the study is the low number of patients and three different surgeons performing the procedures.