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Bone Joint J. 2018 Sep;100-B(9):1175-1181. doi: 10.1302/0301-620X.100B9.BJJ-2018-0100.R2.

Biomechanical evaluation of two methods of fixation of a flexor hallucis longus tendon graft.

Author information

Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria.
Department of Trauma Surgery, Trauma Center Meidling - AUVA, Vienna, Austria.
Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.
Department of Radiology, Hanusch Hospital, Vienna, Austria.



The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing.

Materials and Methods:

Tendon grafts were undertaken in 24 paired lower-leg specimens and randomly assigned in two groups using fixation with a transosseus suture (suture group) or a tenodesis screw (screw group). The biomechanical behaviour was evaluated using cyclical and ultimate loading tests. The Student's t-test was performed to assess statistically significant differences in bone mineral density (BMD), displacement, the slope of the load-displacement curves, and load to failure.


The screw group showed less displacement (loosening) during cyclical loading, which was significant during 300, 500, 600, 700, 800, 900, and 1000 cycles (p < 0.05: other cycles: 0.079 < p < 0.402). Compared with the suture group, the screw group had higher mean ultimate load values (133.6 N, sd 73.5 vs 110.1 N, sd 46.2; p = 0.416).


Fixation of the FHL tendon with a tenodesis screw enables a less invasive procedure to be undertaken and shows similar biomechanical behaviour and primary strength compared with fixation using a transosseus suture. Cite this article: Bone Joint J 2018;100-B:1175-81.


Achilles tendinopathy; Achilles tendon; Bio-tenodesis screw; Flexor hallucis longus tendon transfer; Interference screw; Tendon transfer

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