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

521. Surgical Management of Calcific Insertional Achilles Tendinopathy Using a Lateral Approach

Anthony Watson

DEFINITION

images Calcific Achilles tendinopathy is the most common cause of posterior heel pain.

images Intratendinous degeneration results in ectopic calcification and ossification at the Achilles tendon insertion to the calcaneus.

ANATOMY

images The Achilles tendon inserts over the inferior half of the posterior calcaneal tuberosity (FIG 1).

images The insertion expands over the tuberosity to become the calcaneal periosteum.

images The inferior half of the posterior calcaneal tuberosity has a rough surface with an extensive Sharpey fiber network.

images The superior half of the posterior calcaneal tuberosity has a smooth, almost articular surface.

images The retrocalcaneal bursa occupies the interval between the Achilles tendon and the superior half of the posterior calcaneal tuberosity. The bursa also extends superiorly over the posterosuperior process of the calcaneus.

images The ossification–calcification typically develops at the insertion, extends proximally into the tendon, and may comprise several segments within the more proximal tendon.

PATHOGENESIS

images The pathogenesis is not well understood.

images Two patient groups are typically affected: athletically active individuals in their 30s and 40s and overweight women in their 50s and 60s.

images Biochemical and histologic findings include:

images Degenerative changes2

images An anaerobic environment1

images Longitudinal tears of the Achilles tendon2,5

images Chondral metaplasia and endochondral ossification without insertional fibers from the tendon3,5

NATURAL HISTORY

images Symptoms compromise the patient's ability to wear shoes with a heel counter and participate in activity ranging from walking to intense athletic activity.

images Symptoms may improve in at least 50% of cases with activity modification, physical therapy, or shoe modifications.6

images Disabling symptoms that do not improve with nonoperative treatment may benefit from surgery.

images Achilles tendon rupture in the presence of insertional calcification is extremely rare, even without any form of treatment.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The typical patient complaint is posterior heel pain aggravated by activity or shoe wear.

images Symptoms develop insidiously over time.

images Inflammatory enthesopathies such as psoriasis, Reiter syndrome, and inflammatory bowel disease may be present.

images Tenderness localized to the Achilles insertion on palpation (the examiner should press directly posteriorly on the heel where the Achilles tendon inserts) confirms the diagnosis.

images Tenderness may also be present in the Achilles tendon itself or over the retrocalcaneal bursa. The examiner should lightly squeeze the tendon between the index finger and thumb; squeezing hard on the tendon can result in a falsepositive result. A thickened or painful tendon will require MRI to determine whether tendon transfer reconstruction is necessary.

images Peritendinous swelling is rare, but increased caliber of the Achilles tendon may be present.

images Weakness is rare, but Achilles tendon contracture is common.

images Achilles tightness should be addressed with stretching before considering nonoperative treatment a failure.

images Pain with resisted plantarflexion suggests more extensive tendinosis.

images

FIG 1 • Anatomy of insertional calcification of the Achilles tendon. Note expansion of Achilles tendon fibers over posterior calcaneal tuberosity and intratendinous location of calcification.

images

FIG 2 • Lateral radiograph of heel with insertional calcification of the Achilles tendon.

images Pain with maximum passive plantarflexion suggests inflammation of the paratenon.

images Palpation of the retrocalcaneal bursa will differentiate retrocalcaneal bursitis from insertional tendinosis because a tender retrocalcaneal bursa may benefit from bursectomy.

images Pain with toe walking supports the diagnosis. Inability to do either suggests the need for rehabilitation before considering surgery.

images The surgeon must accurately assess the neurovascular status of the foot and the presence and appearance of any previous incisional scars.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Lateral radiograph of heel (FIG 2)

images The examiner should identify insertional ossification, characterize the size of the posterosuperior process of the calcaneus, and identify intratendinous calcification more proximally.

images Parallel pitch lines and the Fowler angle provide no diagnostic, therapeutic, or prognostic information.

images MRI is indicated when the tendon is thickened, tender, or calcified to determine whether greater than 50% of the crosssectional area of the tendon is involved (FIG 3).

DIFFERENTIAL DIAGNOSIS

images Retrocalcaneal bursitis

images Calcaneal stress fracture

images Plantar fasciitis

images Calcaneal periostitis

images Achilles tendinosis without insertional calcification

NONOPERATIVE MANAGEMENT

images Nonoperative management is helpful in at least 50% of cases.

images Initial treatment is with a removable walker boot with removable wedges.

images Two or three wedges are used for 2 weeks, and then a wedge is removed every 2 weeks.

images Use of the boot is continued for 2 weeks after removal of the last wedge.

images Weight bearing as tolerated is permitted in the boot.

images Physical therapy is started upon completion of removable walker boot immobilization and should include eccentric closed-chain strengthening exercises.6

images Corticosteroid injection is contraindicated.

SURGICAL MANAGEMENT

images Surgical treatment is indicated for disabling symptoms that do not improve with thorough nonoperative treatment.

images Patients should be counseled that recovery can be a lengthy and sometimes frustrating process, as it is often 12 to 18 months before maximum improvement occurs, especially in nonathletic patients.4,7

images Recurrent prominence occurs in 50% of cases but is rarely symptomatic.7

Preoperative Planning

images It may be helpful to have patients undergo crutch training preoperatively.

images A flexor hallucis longus tendon transfer reconstruction of the Achilles tendon will be necessary if an MRI demonstrates that greater than 50% of the cross-sectional area of the Achilles tendon is involved with degenerative tendinosis.

Positioning

images The lateral or prone position is necessary. The heel is more accessible in older or heavier patients when positioned prone. Anesthesia concerns may require lateral positioning.

Approach

images Lateral, medial, posterior, and combined approaches have all been described. The lateral approach will be described here.

images Advantages of the lateral approach are:

images Direct exposure of the insertional calcification

images Less compromise of the Achilles insertion expansion than other approaches because the strongest insertion is medial

images The scar is less likely to be irritated by shoes, as with the posterior approach.

images

FIG 3 • Axial T1-weighted MRI showing intratendinous degeneration comprising greater than 50% of the cross-sectional area of the Achilles tendon (white arrow).

TECHNIQUES

RETROCALCANEAL DECOMPRESSION BY LATERAL APPROACH

images After administration of anesthesia, position the patient lateral decubitus or prone.

images Apply a thigh tourniquet.

images Prepare and drape the leg, exsanguinate the leg, and inflate the tourniquet.

images Make a longitudinal incision along the lateral heel anterior to the anterior margin of the Achilles tendon. The incision should extend distally to nearly the plantar surface and proximally superior to the retrocalcaneal bursa (TECH FIG 1).

images Carefully perform sharp dissection to create full-thickness flaps, taking care to identify and protect any branches of the sural nerve.

images

TECH FIG 1 • Location of incision.

images Make a longitudinal periosteal incision and extend it proximally through the retrocalcaneal bursa, and excise the retrocalcaneal bursa.

images Elevate the periosteum anteriorly, then elevate it posteriorly.

images Continue sharp elevation of the calcaneal periosteum and Achilles tendon insertion expansion medially along the posterior calcaneal tuberosity all the way to the medial aspect of the tuberosity.

images Subperiosteal exposure of the insertional ossification requires careful dissection to preserve the Achilles sleeve.

images Resect any degenerative tendinosis of the Achilles tendon. If preoperative MRI showed tendinosis affecting greater than 50% of the cross-sectional area of the Achilles tendon, a flexor hallucis longus tendon transfer, described elsewhere, will be necessary.

images Resect the posterior calcaneus along a line from inferior to the insertional ossification to anterior to the posterosuperior process of the calcaneus using a saw or osteotome (TECH FIG 2).

images Round over the sharp edges medially and laterally with a rasp or rongeur.

images Place two suture anchors in the cancellous bone left after ostectomy and repair the Achilles tendon to the calcaneus (TECH FIG 3).

images Repair the periosteum laterally.

images Close the incision.

images Apply a sterile dressing and plaster posterior mold splint with the ankle in resting plantarflexion.

images

TECH FIG 2 • Location of ostectomy to include the posterosuperior process of the calcaneus and the insertional calcification.

images

TECH FIG 3 • Location of suture anchors and repair of Achilles tendon to ostectomy surface of calcaneus.

images

POSTOPERATIVE CARE

images Non–weight-bearing is continued for 4 weeks postoperatively.

images Two weeks after surgery, the postoperative splint is changed to a removable walker boot with an Achilles wedge like that used for nonoperative care.

images The removable walker boot is continued for 6 weeks, for a total of 8 weeks of immobilization.

images Active, nonresistive ankle and hindfoot range-of-motion exercises are begun once the incision has healed.

images Physical therapy begins 8 weeks after surgery.

OUTCOMES

images Fifty to 85% of patients report good or excellent results 2 years after surgery.4,7

images The percentage of good or excellent results is higher in athletic than nonathletic patients.4

images Radiographically recurrent insertional calcification occurs in 50% of patients, but symptoms do not always recur with radiographic recurrence.7

images Some patients have recurrent symptoms without radiographic recurrence.7

images Maximum symptomatic relief may not occur until 12 to 18 months after surgery.

images A 1to 2-month period of temporary symptomatic recurrence often occurs 7 to 10 months after the surgery.7

COMPLICATIONS

images Superficial or deep infection is especially common in diabetic and overweight patients.

images Delayed wound healing is also especially common in diabetic and overweight patients.

images Paresthesias and hypoesthesias can be avoided by identifying and protecting the sural nerve and its calcaneal branch.

images Achilles avulsion

images Deep venous thrombosis

images Recurrence

REFERENCES

1.     Alfredson H, Bjur D, Thorsen K, et al. High intratendinous lactate levels in painful chronic Achilles tendinosis: an investigation using microdialysis technique. J Orthop Res 2002;20:934–938.

2.     Astrom M, Rausing A. Chronic Achilles tendinopathy: a survey of surgical and histopathologic findings. Clin Orthop Relat Res 1995; 316:151–164.

3.     Maffulli N, Reaper J, Ewen SW, et al. Chondral metaplasia in calcific insertional tendinopathy of the Achilles tendon. Clin J Sports Med 2006;16:329–334.

4.     Maffulli N, Testa V, Capasso G, et al. Surgery for chronic Achilles tendinopathy yields worse results in nonathletic patients. Clin J Sports Med 2006;16:123–128.

5.     Rufai A, Ralphs JR, Benjamin M. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res 1995; 13:585–593.

6.     Shalabi A, Kristoffersen-Wilberg M, Svensson L, et al. Eccentric training of the gastrocnemius-soleus complex in chronic Achilles tendinopathy results in decreased tendon volume and intratendinous signal as evaluated by MRI. Am J Sports Med 2004;32: 1286–1296.

7.     Watson AD, Anderson RB, Davis WH. Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int 2000; 21:638–642.



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