Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

520. Insertional Achilles Tendinopathy

Mark E. Easley and Matthew J. DeOrio

DEFINITION

images Insertional Achilles tendinopathy is posterior heel pain at the insertion of the Achilles tendon.

images The clinical diagnosis is acute and chronic pathology of the Achilles tendon insertion and its surrounding tissues.

ANATOMY

images The Achilles tendon, the condensation of the gastrocnemius and soleus tendons, inserts on the posterior calcaneal tuberosity.

images The insertion is not only posterior but also on the medial and lateral aspects of the calcaneus.

images A dorsal-posterior calcaneal prominence is most obvious on a lateral radiograph. The Achilles tendon inserts distal to this, directly posterior on the calcaneus.

images Between the distal Achilles tendon and the dorsal-posterior calcaneal prominence, immediately proximal to the Achilles insertion, is the retrocalcaneal bursa.

images A pre-Achilles bursa is superficial to the distal Achilles tendon.

PATHOGENESIS

images While not fully understood, repetitive microtrauma to the Achilles tendon insertion is thought to be the cause.

images Most likely some initial injury occurs, followed by multiple minor reinjuries that lead to chronic symptoms.

images In the acute phase, the process may have some inflammatory characteristics; however, the chronic process is degenerative, with a relative paucity of inflammatory tissue.

images Without histologic confirmation, the diagnosis of Achilles tendinitis or tendinosis cannot be made; therefore, the pathologic process at the Achilles tendon insertion is viewed as “tendinopathy” without tissue confirmation.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The patient may recall an inciting event but typically reports chronic acitivity-related aching or even sharp pain at the posterior heel.

images In addition, the patient notes a progressively enlarging prominence on the posterior heel.

images This ache is usually accompanied by exquisite tenderness directly posteriorly on the calcaneus, at the Achilles tendon insertion, with manual pressure, on contact from the shoe’s heel counter, or when the posterior heel is rested on a hard surface.

images Putting the Achilles tendon on stretch aggravates the symptoms, such as when the patient walks uphill.

images Physical examination reveals the following:

images A prominence is evident on the posterior heel, at the Achilles tendon insertion (FIG 1).

images Tenderness is felt directly on the posterior calcaneal prominence.

images No tenderness is found in the Achilles tendon proximal to its insertion on the calcaneus.

images Thompson’s test is negative.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images A lateral weight-bearing radiograph of the foot often demonstrates irregularities and calcifications at the Achilles tendon insertion on the posterior calcaneus (FIG 2A).

images While unnecessary to make the diagnosis, magnetic resonance imaging (MRI) defines the extent of tendon involvement at the insertion and the presence of retrocalcaneal and perhaps even pre-Achilles bursitis (FIG 2B).

DIFFERENTIAL DIAGNOSIS

images Pre-Achilles bursitis

images Retrocalcaneal bursitis

images Calcaneal stress fracture

images Haglund’s deformity (prominent dorsal-posterior calcaneal tuberosity impinging on the Achilles tendon)

images Calcaneal stress fracture

images Posterior ankle impingement

images Plantar fasciitis

images Noninsertional Achilles tendinopathy

NONOPERATIVE MANAGEMENT

images Activity modification (avoidance of activities that place the Achilles tendon on stretch)

images Nonsteroidal anti-inflammatory agents

images Heel lift or a shoe with a heel to unload the Achilles tendon

images Open-backed shoe or a shoe with a soft heel counter

images

FIG 1  Example of posterior calcaneal prominence characteristic of insertional Achilles tendinopathy.

images

FIG 2  A. Lateral foot radiograph demonstrating the posterior calcaneal prominence and calcification within the Achilles tendon insertion. B. T2weighted sagittal MRI of patient with insertional Achilles tendinopathy. Signal change in the distal tendon and retrocalcaneal bursitis can be seen.

images Physical therapy

images Focus on eccentric strengthening exercises

images In our experience the common practice of aggressive Achilles stretching must be avoided as it will aggravate the symptoms.

images Modalities: ultrasound, iontophoresis

images Extracorporal shockwave therapy may have some benefit but is largely unproven.

images Corticosteroid injection may lead to Achilles rupture and is contraindicated unless the process is isolated to retrocalcaneal bursitis, in which case a judicious injection of only the retrocalcaneal bursa can be performed.

SURGICAL MANAGEMENT

images The primary surgical indication is nonoperative management.

images Up to 50% of insertional Achilles tendinopathy can be successfully managed without surgery, even when there is a large posterior calcaneal prominence.

images Insertional Achilles teninopathy with central calcific tendinosis may be less amenable to nonoperative management.

Preoperative Planning

images Preoperative medical clearance

images Even in healthy patients, the thin skin on the posterior heel is at risk. Carefully inspect skin to be sure that the patient is a reasonable candidate for a posterior approach to the Achilles tendon insertion.

images With extensive Achilles tendon degeneration (confirmed with preoperative MRI), an augmentation of the insertion may be warranted. Therefore, preoperative planning should include the anticipation that the flexor hallucis longus (FHL) tendon may need to be harvested and transferred to the posterior calcaneus. The FHL tendon lies immediately deep to the deep compartment fascia that is anterior to the Achilles tendon and can readily be harvested through the same approach.

images As a rough estimate, we perform an FHL augmentation in less than 10% of cases but routinely have our preferred anchoring system available should the transfer be warranted.

images We educate all of our patients undergoing surgical management for insertional Achilles tendinopathy that, based on our intraoperative findings, an FHL tendon transfer may be necessary.

images The recovery following surgical management for insertional Achilles tendinopathy is prolonged and may take a full year before the patient returns to full activity. We educate our patients that the recovery is not rapid.

Positioning

images The patient is placed prone on the operating table.

images We routinely inflate the thigh tourniquet with the patient supine on the stretcher, then flip the patient to the prone position on the operating room table. This facilitates proper tourniquet position and avoids stressing the patient’s lumbar spine, which may be stressed when placing the tourniquet with the patient in the prone position.

images The chest and pelvis are well padded.

images The brachial plexi and ulnar nerves at the elbows are protected and relaxed.

images The genitalia are protected.

TECHNIQUES

APPROACH AND REFLECTION OF THE ACHILLES TENDON INSERTION

images  A central approach is undertaken, directly over Achilles tendon and posterior calcaneus (TECH FIG 1A).

images  The scalpel is moved through skin and into central portion of distal Achilles tendon. Deep incision is continued distally, directly to bone.

images The goal is to avoid unnecessary delamination of the soft tissues and to elevate full-thickness flaps.

images  We then elevate medial and lateral slips of Achilles tendon from the calcaneus (TECH FIG 1B,C).

images More than half of the Achilles tendon insertion can be elevated without compromising the integrity of the insertion. One study suggests that up to 75% can be released.

images We elevate the Achilles tendon until all the diseased portion of tendon can be excised.

images  Another study suggests that the entire insertion of the Achilles tendon should be routinely elevated and excised to ensure that all diseased tissue is removed. Reattachment is facilitated by a proximal Achilles tendon lengthening that also serves to unload the Achilles tendon.

images  We do not routinely elevate the entire Achilles tendon, but should one or both of the Achilles tendon slips become detached, we have uniformly been able to reattach the tendon to the calcaneus with a successful outcome.

images

TECH FIG 1  A. Central posterior approach. The foot is hanging from the end of the bed. After a full-thickness incision is made through the diseased portion of the tendon, lateral (B) and medial (C) tendon slips are developed.

DÈBRIDEMENT OF THE DISEASED PORTION OF ACHILLES TENDON

images  The diseased portion of tendon is gradually pared from the Achilles insertion, until only healthy fibers remain (TECH FIG 2AC).

images Healthy Achilles fibers have an organized, longitudinal pattern.

images Degenerated Achilles tendon substance is unorganzied and may be likened to crab meat (TECH FIG 2D,E).

images  Calcific tendinosis may be present, and all calcifications within the residual Achilles tendon must be excised (TECH FIG 2F).

images

TECH FIG 2  Débriding the diseased portion of the tendon. A. Medial tendon slip débridements. B,C. Lateral tendon slip débridement. (continued)

images

TECH FIG 2  (continuedD, E. Collection of the excised diseased portion of tendon. F. Calcific tendinosis. It is important to débride the calcifications within the residual tendon.

CALCANEAL EXOSTECTOMY

images  Retractors are used to protect the medial and lateral Achilles tendon slips.

images  We routinely use a microsagittal saw to perform the exostectomy.

images  We first define the exit point on the dorsal calcaneus in order to avoid the tendency to take unnecessary calcaneal bone (TECH FIG 3A).

images If necessary, a single fluoroscopy spot image may be used to define the trajectory of the saw blade.

images As a general rule, it is steeper (more vertical) than anticipated (TECH FIG 3B).

images  The bony prominence is mobilized with a chisel and removed with a rongeur (TECH FIG 3C,D).

images  Commonly, the exostectomy must be “touched up” to remove all of the prominence (TECH FIG 3E).

images  With the Achilles tendon slips still protected, the medial and lateral chamfers are removed (TECH FIG 3F,G).

images This helps narrow the heel and reduce the bulk of the residual calcaneus, medial, and lateral prominences that may lead to persistent pressure and impingement experienced by the patient.

images While these chamfers are near the medial and lateral insertion points of the Achilles tendon, typically they can be excised without compromising the residual tendon attachment.

images

TECH FIG 3  Calcaneal exostectomy. A. Planning the trajectory for the saw blade. B. A microsagittal saw is used to perform the exostectomy. C. A chisel is used to mobilize the excised fragment. (continued)

images

TECH FIG 3  (continuedD. A rongeur is used to remove the resected bone. E. Touch-up to ensure an appropriate amount of bone was removed and an adequate “healing” cancellous surface is exposed. Chamfer preparation to decompress the lateral (F) and medial (G) dimensions of the prominent calcaneus.

REATTACHMENT OF RESIDUAL HEALTHY ACHILLES TENDON

Primary Sutures

images  With only healthy Achilles tendon fibers remaining and the calcaneus decompressed posteriorly, medially, and laterally, the Achilles tendon should be reattached to the calcaneus.

images  While one study suggested that up to 75% of the tendon attachment can be released without compromising the integrity of the insertion, we routinely reattach the elevated portion of tendon to the exposed cancellous calcaneal surface.

images  In our opinion, reattachment not only strengthens the repair but also facilitates direct tendon healing to the calcaneus.

images  We routinely use two or three suture anchors:

images  One anchor for each tendon slip

images  Occasionally, an additional anchor to augment the reattachment of both tendon slips

images  The anchors are positioned relatively symmetrically on the exposed cancellous surface, in a position that will allow for each respective tendon slip to be reapproximated to the calcaneus in a balanced fashion (TECH FIG 4A,B).

images  The anchors must be strong enough to lift the foot from the bed (TECH FIG 4CE). If they should fail, we would prefer for them to fail now so we can rectify the problem.

images

TECH FIG 4  A. Anchor being started into bone. B. Anchor secured to bone. (continued)

images

TECH FIG 4  (continuedC. Testing the stability of the anchor by lifting the limb off the table. The medial suture anchor (D) is placed symmetrically relative to the lateral anchor and secured to bone (E).

Balancing and Securing the Sutures

images  The anchor sutures are then passed in through their respective tendon slip, also in a balanced manner to ensure that the tendon slips have near equal tension once the sutures are secured (TECH FIG 5AC).

images  We routinely check the anticipated tension by pushing the tendon slip to bone while tensioning the sutures after they have been passed through the tendon.

images  If the tension does not appear to be equal in the two slips, we readjust the position of the sutures.

images  The sutures must not only be tensioned appropriately in the longitudinal plane but must also be balanced well in the medial-to-lateral plane, so that the two tendon slips may also be reapproximated side to side and reconfigure the physiologic Achilles attachment.

images  The sutures are then secured (TECH FIG 5D,E). Have the assistant hold the ankle in plantarflexion so that the tendon slips fully contact the calcaneus.

images

TECH FIG 5  A. the suture is passed through the tendon. B. Confirming the optimal balance of the tendon slip on the anchor. C. Passing the sutures through the second tendon slip. (continued)

images

TECH FIG 5  (continuedD. Lateral tendon slip fully approximated to bone. Note that the ankle is held in plantarflexion to facilitate tendon approximation. E. Medial tendon slip being attached.

Additional Sutures

images  We have a low threshold to place a third suture anchor to further stabilize both Achilles slips distally on the calcaneus (TECH FIG 6AC).

images  Finally, the most distal Achilles fibers are reapproximated to the fascial tissue immediately distal to the calcaneus (TECH FIG 6D,E).

images Avoid trapping fat in this portion of the repair as it may lead to fat necrosis.

images  The two Achilles slips are then reapproximated to one another with an absorbable suture (TECH FIG 6F).

images  Gently test dorsiflexion. The ankle should typically still reach neutral without compromising the repair. If it does not, however, it is not a problem.

images Patients rarely if ever develop equinus contracture.

images Once the Achilles tendon insertion is again healthy and asymptomatic, it has been our experience that the gastrocnemius and soleus muscles accommodate.

images

TECH FIG 6  A. A third anchor is being placed centrally and distal to the other anchors. B. Securing these sutures to both tendon slips. C. Tightening these sutures to bring distal tendon slips to bone. D–F.Reapproximating the tendon slips to the distal fascia. D. Passing suture. E. Fully closing the gap between the distal tendon and the fascia. (continued)

images

TECH FIG 6  (continuedF. Reapproximating two tendon slips proximal to the reattachment.

CLOSURE

images  Close the paratenon (TECH FIG 7A).

images  Reapproximate the subcutaneous tissues (TECH FIG 7B).

images  Perform a tensionless closure. We routinely use staples in the proximal wound but favor suture in the distal wound, where the skin does not evert as readily (TECH FIG 7C).

images  Sterile dressings, abundant padding, and a posterior splint with the ankle in its resting tension complete the closure.

images

TECH FIG 7  Closure. A. Paratenon. B. Subcutaneous tissue. C. Skin (sutures are used distally to ensure that skin margins did not invert).

FLEXOR HALLUCIS TENDON AUGMENTATION

images  Only rare patients present with a combination of insertional and noninsertional Achilles tendinopathy.

images  Extensive dèbridement of diseased tendon is required (TECH FIG 8A,B).

images  After fasciotomy of the deep compartment, the FHL tendon is identified, the tibial nerve is protected, and the FHL is harvested from its medial fibrosseous tunnel with the ankle and hallux interphalangeal joint in maximum plantarflexion (TECH FIG 8C).

images  With this local (short) harvest of the FHL, in contrast to a long harvest from the plantar foot via a separate incision, the tendon length is ample for augmentation of the Achilles reattachment (TECH FIG 8D).

images  The FHL tendon is anchored via an interference screw in the central calcaneus, within the exposed cancellous surface created after exostectomy (TECH FIG 8E).

images A suture goes through the plantar calcaneus to allow optimal tensioning of the FHL tendon (TECH FIG 8F).

images  Suture anchors for reattachment of the the Achilles slips are balanced on either side of the FHL anchor point (TECH FIG 8G).

images

TECH FIG 8  A,B. Extensive débridement that left relatively thin residual Achilles slips. C–F. FHL tendon transfer. C. Short harvest of FHL tendon through same incision. D. Adequate length of FHL using the short harvest (harvest from posterior ankle and foot). E. Determining the optimal position to anchor the FHL (ideally, as posterior as possible to maximize mechanical advantage). F. Interference screw fixation of FHL (note the suture through plantar foot to appropriately tension the FHL). G. Suture anchors are placed symmetrically for reattachment of Achilles slips, without interfering with the FHL anchor point.

images

POSTOPERATIVE CARE

images Weeks 0 to 2: Posterior splint with the ankle in resting tension of plantarflexion

images At 2 weeks: Return to clinic for suture removal and casting

images Weeks 2 to 5: Short leg, plantarflexed (5 to 10 degrees) weight-bearing cast, with weight bearing permitted but use of an assistive device encouraged

images At 5 weeks: Return to clinic for cast removal and transfer to a cam boot

images Weeks 5 to 8: Cam walker boot with a 5to 10-degree heel lift; initiate a physical therapy program, with a gradual progression to careful resistance exercises

images Weeks 8 to 12: Progression to a regular shoe with a heel lift or an open-back shoe with a slight heel; physical therapy with a progressive eccentric strengthening exercises

images Between 3 and 6 months: return to full activities; home program for physical therapy

images It may take a full year before patients “can forget about this Achilles tendon.”

images Maintain independent basic physical therapy exercises for a lifetime.

OUTCOMES

images Most patients undergoing surgical management of insertional Achilles tendinopathy have good to excellent results, albeit without returning to full activity for 6 to 12 months.

images However, most studies note that there are patients that do not return to full activity and while they are improved, they are not pain-free.

images Johnson et al5 reported a mean improvement in the AOFAS ankle outcomes score from 53 to 89 points for 22 patients at 34 months’ average follow-up.

images McGarvey et al9 noted an 82% satisfaction rate in 22 patients at mean follow-up of 33 months. Thirteen of 22 patients were pain-free and and an equal number could return to full acitivities.

COMPLICATIONS

images Wound dehiscence

images Infection

images Avulsion of Achilles tendon from anchors on calcaneus

images Persitent pain despite apparent successful procedure

images Suture reaction or irriation

REFERENCES

1.     Calder JD, Saxby TS. Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int 2003;24:119–121.

2.     Den Hartog BD. Insertional Achilles tendinosis: pathogenesis and treatment. Foot Ankle Clin 2009;14:639–650.

3.     DeOrio MJ, Easley ME. Surgical strategies: insertional Achilles tendinopathy. Foot Ankle Int 2008;29:542–550.

4.     Furia JP. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles tendinopathy. Am J Sports Med 2006; 34:733–740.

5.     Johnson KW, Zalavras C, Thordarson DB. Surgical management of insertional calcific Achilles tendinosis with a central tendon splitting approach. Foot Ankle Int 2006;27:245–250.

6.     Knobloch K, Kraemer R, Lichtenberg A, et al. Achilles tendon and paratendon microcirculation in midportion and insertional tendinopathy in athletes. Am J Sports Med 2006;34:92–97

7.     Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund’s deformity: a biomechanical study. Foot Ankle Int 1999;20:433–437.

8.     Maffulli N, Testa V, Capasso G, Sullo A. Calcific insertional Achilles tendinopathy: reattachment with bone anchors. Am J Sports Med 2004;32:174–182.

9.     McGarvey WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19–25.

10. Nicholson CW, Berlet GC, Lee TH. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int 2007;28:472–477.

11. Rompe JD, Furia J, Maffulli N. Eccentric loading compared with shock wave treatment for chronic insertional Achilles tendinopathy: a randomized, controlled trial. J Bone Joint Surg Am 2008;90A: 52–61.

12. Wagner E, Gould J, Bilen E, et al. Change in plantarflexion strength after complete detachment and reconstruction of the Achilles tendon. Foot Ankle Int 2004;25:800–804.

13. Wagner E, Gould JS, Kneidel M, et al. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int 2006;27:677–684.



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