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Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost\u2010effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost\u2010effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost\u2010effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness\u2010to\u2010pay threshold of $100,000 per quality\u2010adjusted life\u2010year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one\u2010way sensitivity analysis was conducted by sequentially varying each model parameter within a given range.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>For the reference case, incremental cost\u2010effectiveness ratios exceeded the willingness\u2010to\u2010pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness\u2010to\u2010pay threshold of $100,000, open surgery was cost\u2010effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Surgical treatments have a moderate likelihood of being cost\u2010effective at a willingness\u2010to\u2010pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health\u2010related quality of life may be better suited for improved cost\u2010effectiveness.<\/jats:p><\/jats:sec><jats:sec><jats:title>Level of evidence<\/jats:title><jats:p>Level III.<\/jats:p><\/jats:sec>","DOI":"10.1007\/s00167-022-07146-5","type":"journal-article","created":{"date-parts":[[2022,9,23]],"date-time":"2022-09-23T05:02:58Z","timestamp":1663909378000},"page":"2001-2014","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost\u2010effectiveness profile in the treatment of acute Achilles tendon ruptures"],"prefix":"10.1002","volume":"31","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9234-7041","authenticated-orcid":false,"given":"Pedro","family":"Diniz","sequence":"first","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedic Surgery Hospital de Sant\u2019Ana Rua de Benguela 501, 2775\u2010028, Parede Lisbon Portugal"},{"name":"<!--<label>2<\/label>--> Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences Instituto Superior T\u00e9cnico, Universidade de Lisboa Lisbon Portugal"},{"name":"<!--<label>3<\/label>--> Associate Laboratory i4HB Institute for Health and Bioeconomy, Instituto Superior T\u00e9cnico, Universidade de Lisboa Lisbon Portugal"},{"name":"<!--<label>4<\/label>--> Fisiogaspar Lisbon Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andr\u00e9 Soares","family":"Ferreira","sequence":"additional","affiliation":[{"name":"<!--<label>1<\/label>--> Department of Orthopaedic Surgery Hospital de Sant\u2019Ana Rua de Benguela 501, 2775\u2010028, Parede Lisbon Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L\u00edgia","family":"Figueiredo","sequence":"additional","affiliation":[{"name":"<!--<label>5<\/label>--> Clinical Department Club Atletico Boca Juniors, CAJB Centro Artroscopico Buenos Aires Argentina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jorge Pablo","family":"Batista","sequence":"additional","affiliation":[{"name":"<!--<label>6<\/label>--> Head of Orthopedic Department Dr Nasef OrthoClinic, Private Practice Cairo Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nasef","family":"Abdelatif","sequence":"additional","affiliation":[{"name":"<!--<label>7<\/label>--> Orthopaedic Department Centro Hospitalar P\u00f3voa de Varzim Vila Do Conde Portugal"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"H\u00e9lder","family":"Pereira","sequence":"additional","affiliation":[{"name":"<!--<label>8<\/label>--> Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence Murcia\/Madrid Spain"},{"name":"<!--<label>9<\/label>--> PT Government Associate Laboratory University of Minho ICVS\/3B\u2019s Braga\/Guimar\u00e3es Portugal"},{"name":"<!--<label>10<\/label>--> Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Academic Center for Evidence Based Sports Medicine (ACES) Amsterdam University Medical Centers, Amsterdam Collaboration for Health and Safety in Sports (ACHSS) Amsterdam The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gino M. 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