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Isolated Flexor Hallucis Longus Tendon Transfer for Chronic Achilles Tendon Rupture: Systematic Review and

Yasmine J Khair¹, Hugh Milchem¹, Maamoun Adra²

¹School of Medicine, University of Nicosia, 2417 Nicosia, Cyprus.

Healthcare (Basel, Switzerland)

|November 13, 2025

Summary

Flexor Hallucis Longus (FHL) tendon transfer significantly improves outcomes for chronic Achilles tendon ruptures (CATRs). This surgical option enhances functionality and patient satisfaction, offering a viable treatment choice.

Keywords:

Achilles repair autograft calcaneal rupture repair tendon injuries tendon transfer

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Area of Science:

Orthopedic Surgery
Sports Medicine
Musculoskeletal Research

Background:

Chronic Achilles tendon ruptures (CATRs) present a significant clinical challenge due to a lack of established treatment guidelines.
The Flexor Hallucis Longus (FHL) tendon transfer is explored as a potential surgical solution for CATRs.

Purpose of the Study:

To evaluate the efficacy of Flexor Hallucis Longus (FHL) tendon transfer in treating chronic Achilles tendon ruptures (CATRs).
To analyze functional and subjective outcomes, as well as complication rates associated with FHL tendon transfer for CATRs.

Main Methods:

A comprehensive literature search was conducted across major databases (Ovid MEDLINE, EMBASE, Cochrane) up to July 31, 2025.
Included studies focused on patients of all ages with CATRs, no prior ankle surgery, treated with FHL tendon transfer.
Data from 16 studies involving 323 patients were meta-analyzed.

Main Results:

Significant improvements were observed in functional scores: American Orthopaedic Foot & Ankle Society-Ankle Hindfoot (AOFAS-AH) scores increased from 56.85 to 91.46, and Achilles Tendon Rupture Score (ATRS) improved from 31.04 to 90.73 at ≥12 months post-operation.
The minimum clinically important difference (MCID) for ATRS was achieved by 12 months post-surgery.
Overall complication rates were low at 7.5%, including superficial infections (4.2%), activity limitations (4%), and disturbed wound healing (3.8%).

Conclusions:

Flexor Hallucis Longus (FHL) tendon transfer is an effective surgical treatment for chronic Achilles tendon ruptures (CATRs).
This procedure demonstrates significant improvements in patient functionality and subjective outcomes.
FHL tendon transfer is a supported and viable option among available treatment modalities for CATRs.