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. 2025 Mar 31;10(1):24730114251325862.
doi: 10.1177/24730114251325862. eCollection 2025 Jan.

Endoscopic Flexor Hallucis Longus Transfer With Interference Screw and Additional Tension Slide Cortical Button for Chronic Achilles Tendon Rupture

Ayla Claire Newton  1 , Samuel Franklin  1 , Thomas Lorchan Lewis  1 , Sanjana Mehrotra  2 , Siddhartha Murhekar  1 , Vikramman Vignaraja  1 , Robbie Ray  1
Affiliations

Endoscopic Flexor Hallucis Longus Transfer With Interference Screw and Additional Tension Slide Cortical Button for Chronic Achilles Tendon Rupture

Ayla Claire Newton et al. Foot Ankle Orthop. .

Abstract

Background: Endoscopic flexor hallucis longus (FHL) tendon transfer can be used in the management of acute or chronic Achilles tendon rupture (ATR), including in elite sportspeople. A recent cadaveric study demonstrated that an increased ultimate load could be applied using an FHL tendon transfer with interference screw and cortical button applied using a tension slide technique compared with interference screw alone. The aim of this study was to explore patient-reported functional outcomes following this modification to this operation.

Methods: We reviewed the imaging, history, patient-related outcome measures (PROMs), and complications of 17 patients who underwent endoscopic FHL tendon transfer for chronic ATR using the modified FHL reconstruction technique. The primary outcome was the Manchester-Oxford Foot Questionnaire (MOxFQ), EuroQol-5 Dimensions (EQ-5D), and visual analog score for pain (VAS-Pain) with a mean follow up of 1.5 years.

Results: Seventeen patients (11 male, 6 female) underwent endoscopic FHL tendon transfer for chronic ATR between September 2020 and May 2023. Mean (SD) age at the time of surgery was 58.3 (16.1) years, and mean (SD) BMI was 27.6 (4.8). A specific event in the history associated with the rupture was present in 13 of 17 patients (76.5%); the median (IQR) time between injury and surgery was 33 weeks (21-42). Sixteen surgeries were primary procedures for chronic ATR, and 1 surgery was a revision procedure after a failed open acute ATR repair. MOxFQ, EQ-5D, and VAS-pain scores all showed a statistically significant improvement postoperatively (minimum 10 months) when compared to preoperative scores. There was 1 symptomatic complication of tibial neuritis (5.9%).

Conclusion: Endoscopic FHL tendon transfer for chronic ATR augmented using a cortical button as well as an interference screw seems to be a safe and effective procedure, with patients reporting a statistically significant improvement in health-related quality of life, pain, and specific foot and ankle outcome function.Level of Evidence: Level IV, case series.

Keywords: Achilles rupture; Achilles tendon; ankle arthroscopy; ankle endoscopy; flexor hallucis longus; sports ankle surgery; tendon transfer.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Robbie Ray, MBChB, ChM(T&O), FRCSed(Tr&Orth), FEBOT, reported disclosures related to manuscript of previously receiving funding from Arthrex beyond the scope of this study and general disclosures being on the surgeon advisory board for Enovis; consults for Enovis/Novastep and Medartis; and has teaching commitments for Enovis, Novastep, Marquardt UK, Medartis, and Arthrex. Disclosure forms for all authors are available online.

Figures

Figure 1.
Figure 1.
Sagittal magnetic resonance imaging scan demonstrating high signal in the Achilles tendon.
Figure 2.
Figure 2.
Saw bone photographs demonstrating the technique of endoscopic flexor hallucis longus tendon transfer using a cortical button and interference screw. (A) The flexor hallucis longus tendon has been whipstitched and a 2.4 spade-tipped wire is drilled bicortically through the calcaneus. (B) Overdrilling with a cannulated flexible reamer matching the size of the tendon to a depth of 25 mm. (C) Whipstitched tendon threaded into cortical button and introduced into calcaneus. (D) Button detached and flipped on plantar aspect of calcaneus. (E) The tension slide technique has been used to fully dock the tendon and the interference screw is being inserted. (F) The final construct with cortical button and interference screw.
Figure 3.
Figure 3.
Postoperative radiograph of the flexor hallucis longus tendon transfer with interference screw and cortical button construct.
Figure 4.
Figure 4.
Flowchart demonstrating patient participation and follow-up rates in study.
Figure 5.
Figure 5.
Graph demonstrating statistically significant improvement in pre- and postoperative outcomes in all MOXFQ domains following endoscopic flexor hallucis longus tendon transfer for chronic Achilles tendon rupture.
Figure 6.
Figure 6.
Postoperative radiographic case where the interference screw backed out but the cortical button remained in place, holding the repair. The patient was asymptomatic.
See this image and copyright information in PMC

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