SLR - January 2022 - Sara Yancovitz

Patient Reported Outcomes and Satisfaction Following Single Incision Flexor Hallucis Longus (Fhl) Augmentation for Chronic Achilles Tendon Pathologies

Reference: Yassin M, Gupta V, Martins A, Mahadevan D, Bhatia M. Patient Reported Outcomes and Satisfaction Following Single Incision Flexor Hallucis Longus (Fhl) Augmentation for Chronic Achilles Tendon Pathologies. J Clin Orthop Trauma. 2021 Oct 19;23:101650. doi: 10.1016/j.jcot.2021.101650. PMID: 34824973.

Level of Evidence: IV

Scientific Literature Review

Reviewed By: Sara Yancovitz, DPM
Residency Program: OhioHealth Grant Medical Center – Columbus, OH

Podiatric Relevance: There are various surgical techniques to augment the Achilles tendon in patients with chronic Achilles tendon pathologies. The single incision flexor hallucis longus (FHL) transfer has become more popular due to its ease of harvest and low donor site morbidity. The objective of this study is to assess patient reported outcomes and satisfaction following this surgical technique to treat chronic Achilles tendon pathologies.

Methods: This retrospective case series included consecutive patients undergoing single incision FHL augmentation for chronic Achilles tendon pathology. The surgeries were performed between 2010 and 2020 at three centers by two foot and ankle surgeons who used identical surgical technique. A questionnaire was used to measure patient reported outcomes using EQ-5D, EQ-VAS, Achilles Tendon Rupture Scores (ATRS) and satisfaction scores.

Results: A total of 30 patients were included in the study with a mean age of 61 years old and a mean follow-up of 57 months. Sixteen patients underwent the procedure for a delayed presentation/neglected Achilles tendon rupture, eight failed non-operative treatment of Achilles tendon rupture, and six had recalcitrant non- insertional Achilles tendinopathy. The mean EQ-5D index value was 0.750 and mean EQ-VAS score of 74, which indicated that the majority of patients reported good state of health. A mean deficit of 16 ATRS points was found between the operated and unaffected limb, which indicated continued functional deficit despite the surgical intervention. Overall satisfaction rate for the operation was over 86 percent in all patients. No postoperative deep venous thrombosis/pulmonary embolism, wound problem, infection, nor nerve injury was noted. The most common complication was weakness of the great toe and was seen in six patients.

Conclusions: FHL augmentation using a single incision technique is a feasible option for treating patients with delayed presentation/neglected Achilles tendon rupture, failed non-operative treatment of Achilles tendon rupture, and recalcitrant non-insertional Achilles tendinopathy as it results in high level of patient satisfaction. The satisfaction rate remains high despite a residual minor functional deficit in the affected limb. In addition, weakness of the great toe was noted which was clinically insignificant in most patients. It is reasonable to incorporate these findings during surgical consultation to set patient expectations pre- operatively. Providing insight on a predictable post-operative course may further improve patient perceived satisfaction rates.

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