 FOOT AND ANKLE

The functional and dynamometer-tested

results of transtendinous flexor hallucis
longus transfer for neglected ruptures of the
Achilles tendon at six years’ follow-up
C. J. Lever, Aims
H. A. Bosman, Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment
A. H. N. Robinson of the neglected tendo Achillis (TA) rupture.

From Addenbrooke’s Patients and Methods

Hospital, Cambridge
University Hospitals
NHS Trust, Cambridge,
United Kingdom
We report a retrospective review of 20/32 patients who had undergone transtendinous FHL
transfer between 2003 and 2011 for chronic TA rupture. Their mean age at the time of
surgery was 53 years (22 to 83). The mean time from rupture to surgery was seven months
(1 to 36). The mean postoperative follow-up was 73 months (29 to 120). Six patients
experienced postoperative wound complications.

Results
The mean postoperative Achilles tendon Total Rupture Score (ATRS) was 83 (40 to 100) and
the mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 94.3 (82 to 100).
Tegner scoring showed a mean reduction of one level from the pre-injury level of activity.
There was a mean reduction of 24% (4 to 54) in dynamometer-measured strength of ankle
plantarflexion, in comparison with the non-operated side. The hallux had a mean of only
40% (2 to 90) strength of plantarflexion in comparison with the contralateral side.

 C. J. Lever, MBChB,
FRCS(Tr&Orth), Foot & Ankle
Fellow
Wirral University Teaching
Hospital, Wirral, UK.
Conclusion
We conclude that transtendinous FHL transfer for neglected TA ruptures, with a long harvest
to allow reattachment of the triceps surae, provides reliable long-term function and good
ankle plantarflexion strength. Despite the loss of strength in hallux plantar flexion, there is
little comorbidity from the FHL harvest.
Cite this article: Bone Joint J 2018;100-B:584–9.

 H. A. Bosman, MBBS, BSc,
MSc (SEM), FRCS(Tr&Orth),
Consultant Orthopaedic
Surgeon
Broomfield Hospital,
Chelmsford, UK.
 A. H. N. Robinson, MBBS,
BSc, FRCS(Tr&Orth),
Consultant Orthopaedic
Surgeon
Department of Trauma and
Orthopaedics, Addenbrooke’s
Hospital, Cambridge University
Hospitals NHS Trust,
Cambridge, UK.
Correspondence should be sent
to A. H. N. Robinson; email:
fred.robinson@addenbrookes.
nhs.uk
©2018 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.100B5.
BJJ-2017-1053.R1 $2.00
Bone Joint J
2018;100-B5:584–9.
Flexor hallucis longus (FHL) tendon transfer can
be undertaken to repair an otherwise irreparable
defect in the tendo Achillis (TA) resulting from
extensive tendinopathy or a neglected rupture. As
a quarter of these ruptures are not diagnosed
acutely,1 treatment of the late presenting or
neglected TA rupture is important.
In general, FHL tendon transfer is considered a
successful procedure.2-6 The evidence supporting
it is, however, mixed, with studies not
differentiating whether the transfer is for a rupture
or tendinopathy.6-8 This is important, as neglected
rupture leads to shortening of the
musculotendinous unit and atrophy of the muscle
belly, potentially leading to a poorer functional
outcome. This is not the case if the surgery is
undertaken for tendinopathy. There are also subtle
variations in the operative technique, which are
not always acknowledged. Patients with neglected
TA rupture typically present with weakness and
loss of function; this contrasts with chronic
Achilles tendinopathy, where the patient presents
with limitation of activity by pain.
Few papers report the outcome of FHL
reconstruction specifically for neglected TA
rupture.2-5,7,9 Of those that do, none report both the
functional outcome and quantitative strength-
testing following a transtendinous repair. The
transtendinous FHL transfer offers the advantage
of recreating the correct muscular insertion, unlike
transosseous reconstructions, and also negates the
requirement for interference screws or anchors.
There have been some suggestions that a
transtendinous reconstruction may become
weaker over time due to stretching of the repair,
although this has never been demonstrated
clinically.7
In this series, a long tendon graft was used to
allow the FHL tendon to be brought proximally in
order to reattach and re-establish function in the

584 THE BONE & JOINT JOURNAL

 THE FUNCTIONAL AND DYNAMOMETER-TESTED RESULTS OF TRANSTENDINOUS FLEXOR HALLUCIS LONGUS TRANSFER
Fig. 1
Transtendinous flexor hallucis longus reconstruction
of the neglected tendo Achillis rupture – surgical
technique.
triceps surae, which is known to be up to 93% stronger than
FHL.10
We present the largest case series with the longest follow-up
to date of transtendinous FHL transfer performed for
irreparable, neglected TA ruptures. Patients have been assessed
both with isokinetic dynamometer testing and validated
functional outcome scores.
Patients and Methods
All cases of FHL reconstructions performed between 2003 and
2011 at Addenbrooke’s Hospital, Cambridge for neglected
rupture were included. The patients were identified from theatre
records and surgical logbooks. In all cases, the two tendon ends
could not be apposed at the time of surgery. The patients all
presented at least four weeks following injury and all had
unilateral injuries. The diagnosis was confirmed by clinical
examination and ultrasound or MRI scan. Preoperatively, all
patients demonstrated inability to single heel raise on the
affected side. Each had Medical Research Council grade 5
power of the FHL on the ipsilateral leg and a normal range of
passive ankle movements without contracture.11 All eligible
patients were contacted by letter, sent functional outcome
scoring questionnaires to complete, and invited to attend for
clinical review and isokinetic strength-testing. A total of 32
patients were eligible, of whom 20 agreed to participate. Three
patients had moved abroad, one had died of unrelated causes,
and one further patient did not have time for clinical review but
reported good function with no issues during a telephone
consultation. Seven patients could not be contacted. The cohort
comprised 16 male and four female patients. Eight patients had
right-sided repairs. The mean age at time of surgery was 53
years (32 to 83). The mean age at follow-up was 60 years (39 to
87). The mean time from rupture to surgery was seven months
(1 to 36).
VOL. 100-B, No. 5, MAY 2018
585
Surgery. All procedures were undertaken in a clean laminar air
flow theatre. Patients were positioned prone with a thigh
tourniquet. Intravenous flucloxacillin (1 g) was administered
prior to inflation of the tourniquet. Skin preparation was
performed with chlorhexidine. A posteromedial incision was
used, the paratenon was opened, and the two ends of the TA
were identified. If a neotendon had formed, it was excised back
to true tendon, characterized by visible fasicles. The proximal
stump of the TA was mobilized and advanced as distally as
possible. In all patients in this series, the TA gap was such that
the tendon ends could not be apposed, even with the foot in full
plantar flexion. No tendon-lengthening or turndown procedures
were performed. FHL was identified through the bed of the TA
at the level of the ankle joint. A second incision was made over
the plantar aspect of the midfoot and FHL was harvested distal
to the knot of Henry. Tenodesis of FHL to flexor digitorum
longus (FDL) was not performed. The harvested stump of FHL
was brought back into the proximal wound where it was passed
transversely through the distal stump of the TA, tensioned with
the ankle in 5° of plantarflexion, and sutured. The remaining
FHL was reflected superiorly and woven into the proximal
stump of the TA (Fig. 1). Wound closure was performed in
layers with intradermal 3-0 Monocryl (Ethicon, Inc., Johnson &
Johnson, Somerville, New Jersey) followed by interrupted 2-0
Vicryl Rapide (Ethicon, Inc.) to skin.
Postoperatively, the patients were placed in a ventral plaster
of Paris slab in 5° of plantarflexion. They were kept non-
weight-bearing for two weeks. Following this a weight-bearing
cast or boot was applied in which patients were allowed to bear
weight for six weeks. At this stage, the immobilization was
removed and physiotherapy commenced. Subcutaneous
dalteparin was administered at prophylactic dosage (according
to weight) for two weeks whilst in the non-weight-bearing
phase.
Outcome assessment. Clinical review and testing of power
was performed independently by two surgeons (HB and CL).
The Achilles Tendon Rupture Score (ATRS),12 American
Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score,13
Tegner activity level score,14 and 12-item Short Form Health
Survey (SF-12)15 were recorded. The ATRS is a patient-
reported instrument with high reliability, validity, and
sensitivity for measuring outcome after treatment in patients
with a total TA rupture.12 Patients were also asked to rate their
satisfaction with the surgery on a five-point scale as completely
satisfied, moderately satisfied, neutral, moderately unsatisfied,
or completely unsatisfied.
Standard isokinetic assessment was performed with a Cybex
dynamometer (Cybex International, Inc., Medway,
Massachusetts). Patients were seated with the knee flexed over
a support. Shoes were worn. The centre of rotation for the foot
plate was positioned over the lateral malleolus. Testing was
performed on both ankles with the non-operated side tested first.
As is standard for the machine-testing programme, two pilot
cycles of ten repetitions were performed on each limb prior to
the final testing set. The peak torque of ankle plantarflexion
(Nm) at a velocity of 60°/second was recorded.
586 C. J. LEVER, H. A. BOSMAN, A. H. N. ROBINSON
Fig. 2
Photograph showing measurement of flexor hallucis longus strength.
Table I. American Orthopaedic Foot and Ankle Society (AOFAS)
scores, by subsection
Subsection Mean (range)
Pain (0 to 40) 37.4 (30 to 40)
Function (0 to 50) 47.2 (32 to 50)
Alignment (0 to 10) 9.7 (5 to 10)
Total (0 to 100) 94.3 (82 to 100)
To test the strength of great toe flexion, the patient was seated
with both feet on the floor. A card attached to a weight gauge
was placed under the distal phalanx of the great toe and patients
were asked to resist pull-out of the card (Fig. 2). The maximum
load resisted was recorded, with the non-operated side tested
first.
At clinical review, postoperative complications and ATRS,
AOFAS, and SF-12 scores were recorded. Patients were also
asked to score their current post-injury Tegner activity level and
to retrospectively score their pre-injury level.
Statistical analysis. Statistical analysis with descriptive
statistics (mean and standard deviation) were calculated through
Microsoft Excel (Microsoft, Redmond, Washington). Graphical
illustrations of data were generated through the same
programme.
Results
The mean follow-up was 73 months (29 to 120) after surgery.
Complications. No cases of rerupture were encountered. Six
(30%) patients had postoperative wound problems. There were
three cases of superficial infections requiring treatment with
oral antibiotics. One patient had a minor wound dehiscence,
requiring admission for intravenous antibiotics. A further
patient had a wound that was slow to heal. The final patient had
scar adhesions. No patient required further operative treatment.
Three of the patients were smokers all of whom had wound
healing issues.
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Table II. Ankle plantarflexion peak torque (Nm) at angular velocity 60°/
sec and great toe interphalangeal joint resistance to pull-out (kg)
Operated Non-operated
Mean ankle plantar flexion, Nm (SD) 95 (38.4) 123 (37.8)
Mean hallux IPJ flexion, kg (SD) 3.4 (2.3) 9.1 (2.9)
IPJ, interphalangeal joint
Scoring. A total of 16 patients were completely satisfied and
four patients were moderately satisfied with the outcome of
their surgery. One of the moderately satisfied patients competes
in 60-mile cycling road races. All patients reported that they
would have the surgery again in similar circumstances.
The mean postoperative ATRS, where score of 100 denotes
no limitations, was 83 (40 to 100) and the mean postoperative
AOFAS was 94.3 (82 to 100) (Table I).
Postoperatively, the Tegner score showed a mean reduction
of one level (from mean level five to four, range from +2 levels
to -7 levels) from the pre-injury activity level. A Tegner score of
five is defined as undertaking heavy labouring work (e.g.
construction) and sport (e.g. competitive cycling or jogging on
uneven ground twice weekly). A score of four represents
moderately heavy labour (e.g. truck-driving). The SF-12 scores
showed a mean 47.8 (23.4 to 59.3) for the physical component
score and 54.3 (37.7 to 65.1) for the mental component score.
Strength testing. A total of 17 patients underwent
dynamometer testing of the strength of ankle plantarflexion
(Table II). The mean maximum strength of the operated leg was
95 Nm (41 to 163), by contrast with 123 Nm (50 to 190) in the
uninjured leg. The mean difference in strength was a 24% (4%
to 54%) reduction in ankle plantarflexion strength in
comparison with the non-operated leg. Of the three patients who
did not have data, one patient underwent telephone review, data
collection failed in one due to a computer fault, and one patient
was unable to undergo dynamometer testing due to bilateral
total hip arthroplasty.
On testing the strength of the great toe, the operated hallux
was markedly weaker with only 40% of the strength of the
contralateral great toe. Despite this, no patient had a floating toe
and in general the patients did not report any problems from the
great toe. The exception was one male who reported the
subjective finding that if he jumped from a height onto his toes,
he felt instability.
Scatter plot graphing showed a positive association between
strength and time from repair (Fig. 3). Age at the time of surgery
had a negative association with strength at follow-up (Fig. 4).
Discussion
We report 20 patients who had suffered a neglected TA rupture
and were treated with a transfer of the FHL tendon through the
distal TA stump. We consider their outcome scores acceptable,
especially in the context of a mean age of 60 years (39 to 87) at
follow-up. In the light of their postoperative improvement, all
patients were completely or moderately satisfied and would
have the surgery again if required.
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 THE FUNCTIONAL AND DYNAMOMETER-TESTED RESULTS OF TRANSTENDINOUS FLEXOR HALLUCIS LONGUS TRANSFER 587

100
actual Tegner level is not specified, just the number of levels of
improvement.6
90 2
R = 0.129
Rahm et al7 compared 18 transosseous (13 ruptures, mean 35
80
months follow-up, range 13 to 50) FHL transfers with 22
% strength compared with

70
transtendinous (eight ruptures, mean 73 months follow-up,
non-operated leg

60 range 53 to 89) and reported no significant difference between

50 the two techniques. Isokinetic testing at a speed of 30°/second
40 showed a mean deficit of 25% in the transtendinous group and
30
23% in the transosseous group. There was a 22 % wound
infection rate.
20
When isokinetic testing has been performed following FHL
10
transfer for chronic TA tendinopathy, mean deficits of between
0
20 40 60 80 100 120 140
22% and 28% have been reported.16,17 Wilcox et al18 reported a
Months since surgery smaller mean deficit of 7% in 20 patients following
Fig. 3 transosseous transfer mainly for tendinosis. However, they
tested at a higher speed of 120°/second which may account for
A graph showing the percentage strength of the operated versus non-
operated leg for each against time since surgery. A regression line has the lower deficit seen. Testing at lower speeds, between 30°/
been fitted. second and 60°/second, has been shown to be more reliable and
is not directly comparable with high-speed testing.19
It should also be borne in mind that patients with an acutely
100
diagnosed TA rupture with a ≥ 10 mm ultrasound-measured gap
90
treated nonoperatively had a mean peak torque deficit of 23%.20
80
The peak torque deficit in our patients is, therefore, comparable
% strength compared with

70 R2 = 0.2832 with that obtained after recovery in these patients with acute
nonoperated leg

60 ruptures, who did not report a significant deficit in functional

50
40
30
20
10
0 flaps,24 free flaps (e.g. semitendinosus), gastrocnemius fascial
25 35 45 55
Age at surgery (yrs)
Fig. 4
A graph plotting the strength of the operated versus non-operated
leg for each patient by patient age at time of surgery. A regression
line has been fitted.
To the authors’ knowledge, there is no comparable study with
such a long follow-up that has looked solely at transtendinous
repairs in these patients. Previous studies had heterogeneous
indications for the FHL transfer, as well as variations in the
operative technique, methods of isokinetic testing, and outcome
scoring.2-7,9,16-18 A similar cohort of 11 patients followed up at
79 (48 to 81) months who underwent transosseous transfer for
neglected rupture, reported by Wegryzn et al,4 showed a mean
28% reduction in strength at 30°/second compared with the
uninjured limb.
In 13 patients who underwent a transtendinous repair for
either rupture or chronic tendinosis (two complete ruptures, five
partial ruptures, six tendinopathy alone), the mean
plantarflexion deficit was 35% at 60°/second in the operated
limbs and their Tegner scores improved by three levels
postoperatively, at mean follow-up of 46 months (24 to 63). The
scores.
Various operative techniques exist for reconstruction of
neglected TA ruptures. As well as FHL transfer, other tendon
transfers, such as FDL and peroneus brevis, have been
described.21-23 Some techniques involve V-Y advancement
65
75 85 95
flaps, or even allograft reconstruction. It is difficult to directly
compare our results with these other techniques due to the
heterogeneity of these studies. Very few of the papers include
any isokinetic data.21-23
Despite the ATRS score being the only score specifically
designed to measure outcomes in TA rupture, it has not been
used in the majority of studies reporting the outcomes of
neglected rupture.25 The most widely reported score is the
AOFAS score, the use of which in this group of patients is
questionable. Nevertheless, most studies in this population,
regardless of the technique employed, report AOFAS scores of
over 85 following operative intervention.4,5,9,21,26,27 In our
cohort, the mean AOFAS score was 94.
Few papers reporting alternative methods of TA
reconstruction after delayed diagnosis have quantitatively
measured plantarflexion strength. Sebastian et al22 looked at
minimally invasive peroneus brevis transfer in a group of
17 patients, with similar injuries but a lower mean age of 39
years. The patients had a mean ATRS of 91 at two years’ follow-
up with isokinetic testing showing a deficit of 15% in
plantarflexion. Strength-testing was not performed with a
standard dynamometer, but with the authors’ proprietary force
plate system. There was also a deficit of 15% in strength of
eversion, which was not considered clinically significant,
despite a concern that reduced strength of eversion may lead to

VOL. 100-B, No. 5, MAY 2018

588 C. J. LEVER, H. A. BOSMAN, A. H. N. ROBINSON
ankle instability.28 Takao et al21 reported on ten patients who
underwent a gastrocnemius turn-down flap for rupture and
showed a 23% deficit in plantarflexion strength. Elias et al23
advocated combining a V-Yplasty with FHL transfer in large
defects. The addition of the V-Yplasty may, however, be
unnecessary in the context of isokinetic deficits of 23% at 60°/
second, similar to our results when using FHL transfer alone.
The main complications we encountered were wound-
healing problems, which are well documented issues with
surgery around the TA.29-31 A 20% rate of superficial wound
infections is high, albeit in a small cohort. In part, we attribute
this to the increased risk among smokers, who remained eligible
for this procedure. In our study, all the smokers had wound
problems, which reinforces the importance of smoking
cessation prior to surgery. We also noted that by performing a
transtendinous reconstruction and weaving the FHL back into
the proximal Achilles, our reconstruction is bulkier than a
transosseous repair and requires careful wound closure. Mann et
al32 used an FDL reconstruction technique for chronic TA
ruptures with a cross-weave technique and reported wound
issues in two of seven patients postoperatively. A systematic
review of all reconstructive procedures for neglected TA rupture
showed a 7.6% infection rate with an incidence of 4.7% for
wound problems.33 These are lower than our results, but there
was some variability between studies in the reporting of
complications, with some papers recording deep infection rates
rather than superficial. Our results reflect all wound infections,
which in our series were all superficial, and none of which
required operative intervention. This contrasts with the work of
Hahn et al6 which reported wound issues in three of 13 patients
(23%), with two of those requiring soft-tissue procedures for
skin necrosis.
As reported by Rahm et al,7 we have found that the hallux is
weaker postoperatively. Nevertheless, this was not a clinical
issue for most patients. Although other studies have reported
floating halluces with hyperextension and alignment
problems,6,7,34 we have not seen such results. Rahm et al7
reported that great toe alignment problems were seen in patients
who had undergone an FHL to FDL tenodesis. We do not
routinely perform or advocate a repair of the harvested FHL
with tenodesis to the FDL in the foot.
It has been suggested that a disadvantage of a transtendinous,
rather than transosseous, reconstruction is the potential risk of
soft-tissue attenuation, with transtendinous reconstructions
stretching over time.7 Our study showed a slight increase in
strength over time, suggesting this concern may not hold true. It
is interesting that the return to strength appears to be slow. We
did not routinely obtain MR imaging postoperatively and so
cannot determine whether this is because of the gradual reversal
of fatty atrophy within the triceps surae or a hypertrophy of FHL
over time.
The main limitations of our study are the potential sampling
bias, a result of being unable to follow-up all patients with a full
clinical review, and the lack of preoperative scoring. The
strength is that this represents the largest cohort and the longest
follow-up in the literature with functional and isokinetic
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outcomes for transtendinous FHL reconstruction in neglected
TA rupture.
In conclusion, a long harvest of FHL tendon with transfer
through the distal TA stump and its reconnection to the triceps
surae proximally gives good long-term functional outcomes
with good strength of plantarflexion. There is little comorbidity
from the tendon harvest, and lack of a distal FHL to FDL
tenodesis does not give rise to any significant functional loss or
alignment issues of the great toe.
Take home message:
- Transtendinous flexor hallucis longus transfer is a reliable
surgical treatment for neglected ruptures of the tendo Achillis.
- Good functional outcome scores and ankle plantar flexion strength on
dynamometer testing are achievable.
- Lack of tenodesis of the distal flexor hallucis longus stump to flexor dig-
itorum longus did not result in any significant morbidity.
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Author contributions:
C. J. Lever: Collecting and analyzing the data, Clinical reviews, Dynamome-
ter testing, Writing and editing the manuscript.
H. A. Bosman: Designing the study, Collecting the data, Clinical reviews,
Dynamometer testing.
A. H. N. Robinson: Performing the surgical procedures, Supervising the
study, Writing and editing the manuscript.
Funding statement:
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
This article was primary edited by P. Page and first proof edited by G. Scott.