FHL Augmentation for Insertional Achilles Tendinopathy: A Prospective, Randomized Study Disclosures I have no potential conflicts with regard to this presentation Kenneth J. Hunt, MD 1 Carroll P. Jones, MD 2 Bruce E. Cohen, MD 2 W. Hodges Davis, MD 2 Robert B. Anderson, MD 2 Achilles tendinopathy is a common problem Lifetime prevalence of 52% in runners Chronic insertional Achilles tendinopathy can be difficult to manage Maffulli et al, Clin Sports Med. 2003 1
Chronic insertional Achilles tendinopathy can be difficult to manage Decompression, debridement and repair Effective pain reduction, functional improvement 74%-95% satisfaction and full return to activities Chronic insertional Achilles tendinopathy can be difficult to manage Decompression, debridement and repair Effective pain reduction, functional improvement 74%-95% satisfaction and full return to activities are less reliable in patients over 50 yrs Higher pain scores Slower to full WB Much longer time to functional recovery McGarvey et al., 2002 FAI FHL transfer for chronic Achilles disorders Den Hartog 2003 Level IV 29 patients Debridement and FHL transfer Significant improvement in AOFAS scores 8.2 months to full recovery Age > 50 showed better improvement Wapner et al., 1993 FAI Den Hartog et al, 2003 FAI 2
Den Hartog 2003 Level IV 29 patients Debridement and FHL transfer Significant improvement in AOFAS scores 8.2 months to full recovery Age > 50 showed better improvement To date- no level 1 studies comparing FHL to no FHL in patients >50 Purpose The purpose of this study is to prospectively compare Achilles debridement alone to debridement with FHL transfer in pts > 50 We hypothesize that FHL augmentation will be associated with superior outcome scores and greater ankle plantarflexion strength Den Hartog et al, 2003 FAI IRB approved study Prospective, randomized, blinded design Patients age > 50 years Randomized to receive Achilles decompression/debridement alone Achilles decompression/debridement with FHL transfer AOFAS Ankle/Hindfoot score Visual analog pain scale (VAS) Ankle and hallux plantarflexion strength Measured with Cybex 6000 Dynamometer Patient satisfaction survey 3
Surgical Approach Surgeon Preference Surgical Technique Single incision Haglunds resection and debridement of Achilles In FHL augmentation group: Harvest of FHL tendon at sustentaculum Standardized rehabilitation program Surgical Technique Fixation of FHL with tenodesis screw Repair or reattachment of Achilles insertion Repair of FHL to Achilles 39 patients with minimum 1 yr follow-up 18 Debridement alone 21 FHL transfer No difference in demographic data Patient Demographics FHL No FHL Age 60.8 + 6.9 60.1 + 7 Weight 215.1 + 35 201.8 + 31 BMI 35.9 + 6 31.7 + 4.8 Pre-op AOFAS score 61 + 9 56 + 13 Smoker (%) 9.5% 0.0% Diabetes Mellitus (%) 14.3% 11.1% 4
AOFAS Ankle/Hindfoot score Visual analog pain scale (VAS) AOFAS scores VAS in Morning VAS with Activities Ankle plantarflexion strength in operative leg Hallux plantarflexion strength in operative leg * * * p<0.05 Ankle plantarflexion strength Hallux plantarflexion strength 5
Patient satisfaction survey at 1 year Minor wound complications % % Satisfaction? Surgery Again? Summary Conclusions Clinical outcome scores Patient satisfaction Ankle PF strength Wound complications Hallux PF strength FHL Transfer Debridement alone No Difference No Difference Better More (all minor) No Difference FHL tendon augmentation Provides improved ankle plantarflexion strength without loss of hallux PF strength No significant advantages in pain relief and function Higher minor wound complication rate 6
Conclusions FHL tendon augmentation my be useful Insertional Achilles tendinopathy age >50 Non-insertional Achilles tendinopathy Chronic Achilles ruptures S/p resection due to tumor or infection Conclusions Great care must be taken with soft tissues If in doubt- leave sutures an extra week Studies with more robust functional outcome scores may be helpful Ultimate goal is to optimize the treatment algorithm Thank You 7