Comparative Meta-Analysis of Clinical Outcomes in Chronic Achilles Ruptures: Isolated FHL Transfer, Hamstring Transfer, and Turndown Flaps
Authors: Karaismailoglu Bedri , Ghandour Samir , Hendriks Joris R.H. , Eftekhari Mani , Eltouny Ehab , Waryasz Gregory R. , Guss Daniel , Kwon John Y. , Ashkani-Esfahani Soheil , Bejarano-Pineda Lorena , DiGiovanni Christopher W. 
Published: December 2024

Category: Sports; Trauma Introduction/Purpose: Chronic Achilles tendon ruptures (CATR) adefined as those with a diagnosis or treatment exceeding four weeks present with retracted tendon ends and adhesions, complicating treatment and prognosis. Several surgical techniques including flexor hallucis longus (FHL) transfer, turndown flaps, V-Y advancement, and hamstring tendon transfer, have been described as treatment options, each with advantages, drawbacks, and potential complications. Despite the extensive use of patient-reported outcome measurements (PROMs) such as AOFAS, ATRS, and VISA-A, there is a lack of literature concerning comparative analyses of surgical options for CATRs. This study aims to describe the clinical and functional outcomes with each technique, and to providevaluable insights for evidence-based decision-making in the management of this pathology. Methods: This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered on the International prospective register of systematic reviews (PROSPERO, registration No. CRD42023444150). The inclusion criteria encompassed studies reporting clinical outcomes of CATR patients treated with isolated FHL transfer, hamstring tendon transfer, or turndown flaps. Clinical studies reporting at least one of the following outcomes were included: American Orthopedic Foot and Ankle Society (AOFAS) score or complications (wound complications, nerve injury, postoperative deep vein thrombosis, re-rupture, etc.). To be included, the studies had to provide sufficient data for extraction and pooling, including mean value, standard deviation (SD), and the number of subjects. Exclusion criteria comprised studies not published in English, less than 12 months of follow-up, and those with fewer than ten patients. Results: Eleven studies (295 patients) were included for isolated FHL transfer, 9 studies (168 patients) for hamstring transfer, and 6 studies (246 patients) for turndown flaps. All groups demonstrated a comparable improvement in AOFAS scores. The overall weighted complication rates were 4.1% in the Hamstring group, 6.1% in the isolated FHL group, and 12.6% in the turndown flap group. The complication rate in the Hamstring transfer group was significantly lower as compared to the turndown flaps group. The turndown flap group exhibited a significantly higher incidence of wound complications (12.5%, 95% C.I.: 8.4–16.5) compared to the isolated FHL (5.7%, 95% C.I.: 3.2–8.3) and hamstring groups (3.5%, 95% C.I.: 0.9–6.2). Conclusion: While all three techniques yielded comparable improvements in AOFAS scores for CATR management, turndown flaps were associated with a higher incidence of wound complications compared to the other two techniques. Enhanced study designs, incorporating direct comparisons of these different techniques within the same study setting, are essential. This approach will contribute to a clearer path towards identifying the optimal intervention and refining the standard of care for CATR patients.