SLR - April 2018 - Jonathan Lee

Reconstruction for Chronic Achilles Tendinopathy: Comparison of Flexor Hallucis Longus (FHL) Transfer Versus V-Y Advancement

Reference: Staggers JR, Kenneth S, de C Netto C, Naranje S, Prasad K, Shah A. Reconstruction for Chronic Achilles Tendinopathy: Comparison of Flexor Hallucis Longus (FHL) Transfer Versus V-Y Advancement. Int Orthop. 2018 Feb 16

Reviewed By: Jonathan Lee, DPM
Residency Program: Grant Medical Center, Columbus, OH

Podiatric Relevance: Achilles tendon repair typically depends on the extent of the damage or degeneration to the tendon itself and the presence of a rupture. Although several procedures have been described in literature, there is no consensus on the most effective technique. The authors aimed to compare the outcomes of two commonly performed procedures for the primary repair of chronic insertional Achilles tendinopathy—the flexor hallucis longus (FHL) tendon transfer and the V-Y advancement.

Methods: The authors retrospectively evaluated 49 ankles that underwent isolated FHL transfers or V-Y advancements after failing conservative treatment for at least six months. Patients with a history of Achilles tendon rupture or revision surgery were excluded from this study. Outcome measures included patient satisfaction, subjective plantarflexion strength comparing preoperative and postoperative ability to climb a flight of stairs, subjective plantarflexion strength compared to the unaffected limb, Visual Ankle Scale, willingness to recommend the procedure and the Victorian Institute of Sports Assessment for Achilles (VISA-A) tendon scores.

Results: A total of 49 ankles were separated into two groups—21 ankles in the FHL transfer group compared to 28 ankles in the V-Y advancement group. In the FHL group, with an average follow-up of 50.6 months, 78 percent reported equal or greater strength in the operative limb compared to preoperative strength, 83 percent reported equal or greater strength compared to the contralateral limb, 89 percent were satisfied with the outcome and 94 percent would recommend this procedure. In the V-Y advancement group, with an average follow-up of 40.3 months, 67 percent reported equal or greater strength in the operative limb compared to preoperative strength, 61 percent reported equal or greater strength than the contralateral limb, 74 percent were satisfied with the outcome and 84 percent would recommend this procedure. The authors found that both procedures had favorable outcomes without statistically significant differences between the complication rate, VAS and VISA-A scores, subjective strength and satisfaction and willingness to recommend the procedure to others.

Discussion: The authors aimed to compare the FHL tendon transfer to the V-Y advancement for the treatment of chronic insertional Achilles tendinopathy and simultaneously highlight advantages of each procedure. Although the FHL tendon transfer had superior outcome scores, it was not statistically significant when compared to those of the V-Y advancement. Thus, based on the findings of this study, the V-Y advancement proved to be a viable option in treating the aforementioned pathology. Understanding the limitations and advantages of each technique will allow the surgeon the freedom to perform patient-specific procedures for the best possible outcome. 

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