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Systematic Review and Meta-Analysis Comparing Open FHL Tendon Transfer, Hamstring Transfer, and Turndown Flaps to
Bedri Karaismailoglu1,2,3, Samir Ghandour1, Joris Hendriks1,4
1Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Foot & Ankle International
|April 25, 2025
Summary
Surgical repair of chronic Achilles tendon ruptures (CATRs) involves complex techniques. While functional outcomes are similar, turndown flaps have higher wound complication rates than flexor hallucis longus or hamstring tendon transfers.
Area of Science:
- Orthopaedic Surgery
- Musculoskeletal Research
- Regenerative Medicine
Background:
- Chronic Achilles tendon ruptures (CATRs) pose treatment challenges due to delayed diagnosis and complex salvage procedures.
- Existing reconstructive surgical options for CATRs have varied advantages and disadvantages, with limited comparative data.
- This meta-analysis addresses the need for a comprehensive comparison of commonly used salvage techniques for CATRs.
Purpose of the Study:
- To compare clinical outcomes of three primary salvage techniques for CATRs: flexor hallucis longus (FHL) transfer, hamstring tendon transfer, and gastric-soleal turndown flap.
- To evaluate functional improvements and complication rates associated with each surgical approach.
- To provide evidence-based insights for surgical decision-making in CATR management.
Main Methods:
- Systematic review adhering to PRISMA guidelines, including studies registered on PROSPERO.
- Searches across multiple databases for studies on surgical treatment of CATRs using FHL transfer, hamstring tendon transfer, or turndown flaps.
- Data extraction, quality assessment, and meta-analysis of clinical scores and complication data.
Main Results:
- Twenty-five studies involving 1910 identified studies met inclusion criteria.
- Mean American Orthopaedic Foot & Ankle Society (AOFAS) scores showed comparable improvements across groups (turndown flap: 38.9, FHL transfer: 31.8, hamstring transfer: 26.0).
- Complication rates significantly differed, with turndown flaps having the highest overall and wound complication rates (12.5%) compared to FHL transfer (5.7%) and hamstring transfer (3.5%).
Conclusions:
- Surgical technique choice significantly impacts complication rates in CATR management, despite similar functional outcomes.
- Turndown flaps, while effective for restoring musculotendinous continuity, are associated with increased risks of wound complications.
- Evidence-based decision-making for CATR surgical management requires careful consideration of technique-specific complication profiles.
