The Efficacy of Simple Debridement Compared to Augmentation with Flexor Hallicus Longus Transfer for Surgical Treatment of Moderate to Severe Insertional Achilles Tendinopathy
Authors: Mizher Rami , Kim Jaeyoung , Rajan Lavan , Cychosz Chris , Srikumar Syian , Ellis Scott J. 
Published: February 2023

Category: Hindfoot; Sports Introduction/ Purpose: Insertional Achilles tendinopathy is a common condition with several treatment modalities encompassing conservative and operative strategies. Surgical treatment often includes debridement and reattachment of the tendon usually with ostectomy of impinging calcaneal bone spurs. Augmentation with a flexor hallicus longus (FHL) tendon transfer is performed to help provide extra strength to the degenerated tendon in more severe cases. Few studies have compared these procedures, and it is currently unclear whether simple debridement is effective for patients with advanced Achilles degeneration. Therefore, the aim of this study is to investigate the efficacy of simple debridement compared to augmentation with FHL transfer for the surgical treatment of moderate to severe insertional Achilles tendinopathy. Methods: This retrospective cohort study included 57 patients who underwent surgical treatment of moderate to severe insertional Achilles tendinopathy as graded on magnetic resonance imaging (MRI) using a classification system described previously. Moderate tendinopathy was defined as tendon thickening greater than 8 mm with less than 50% degeneration while severe was defined by the same degree of thickening but greater than 50% degeneration. Thirty-one patients underwent Achilles tendon debridement and reattachment with or without calcaneal ostectomy and were classified into the “simple debridement” group (mean age: 57.6 years). Twenty-six patients had the same procedures with the addition of a FHL transfer and were classified into the “FHL transfer” group (mean age: 57.9 years). Preoperative, minimum 1-year postoperative, and preoperative to postoperative change in six domains of PROMIS scores were compared within and between groups. Clinical outcomes such as complications, recurrence, and reoperations were also compared. Results: There were no significant differences in demographics between groups. Preoperatively as well as postoperatively, there were no significant differences in PROMIS scores in any domain between groups (Table 1). Both groups demonstrated significant preoperative to postoperative improvements in PROMIS Physical Function, Pain Interference, Pain Intensity, and Global Physical Health (all P< .001). Only the FHL transfer group had significant improvements in Global Mental Health (P = 0.02). Conclusion: Our study found no significant differences in functional and pain-related outcomes between simple debridement and augmentation with FHL transfer for the treatment of moderate to severe insertional Achilles tendinopathy. These results suggest that simple debridement may also be effective in more advanced Achilles tendinopathy and may spare patients the need for FHL augmentation. However, our study is limited by its retrospective design and relatively small sample size. Thus, additional research including prospective long-term follow-up in more advanced tendinopathic stages is required to understand the true differences between the procedures.