[Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]

Recurrence rates for surgically treated insertional Achilles tendinopathy

INTRODUCTION

Insertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery.

MATERIALS AND METHODS

The authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed.

RESULTS

Out of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence.

CONCLUSION

IAT recurrence after primary surgery occurs in up to 14% of patients.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Treatment of Insertional Achilles Tendinosis With Polyurethane Urea-Based Matrix Augmentation

INTRODUCTION

Surgical treatment for insertional Achilles tendinosis (IAT) sometimes requires tendon repair augmentation. The purpose of this study is to evaluate the efficacy of polycaprolactone-based polyurethane urea (PUUR) matrix augmentation in the treatment of IAT.

METHODS

A retrospective review was performed in surgically treated IAT. Repairs were augmented with a PUUR matrix. Factors evaluated included date of full weightbearing, patient satisfaction, Visual Analog Scale (VAS) pain score, strength, and ankle motion. The Wilcoxon signed-rank test was used to compare baseline and final follow-up VAS scores.

RESULTS

A total of 18 cases were included in the study. The mean patient age was 54.61 ± 8.25 (40-75) years with a mean follow-up of 163.61 ± 57.81 (92-314) days. Patient satisfaction was obtained on 15 of 18 patients, with 14 patients satisfied with their outcome. Mean VAS for pain significantly decreased from 6.19 ± 1.97 (2.5-9) to 0.83 ± 1.54 (0-5) postoperatively, which was statistically significant (P < .01).

CONCLUSION

Achilles tendon augmentation with the PUUR matrix is a viable option in the treatment of IAT. Its use in this condition has minimal morbidity and can be an alternative to other forms of augmentation.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

[Surgical treatment of calcifying insertional Achilles tendinopathy via a lateral approach]

OBJECTIVE

Reduction of pain and swelling over the Achilles tendon insertion while maintaining function.

INDICATIONS

Strong, intolerable pain over the Achilles tendon insertion with chronic, calcifying insertional tendinopathy that does not respond to non-operative treatment over a minimum of 6 months.

CONTRAINDICATIONS

Chronic wounds or severe circulatory deficits at the foot or ankle, irradiating or projected pain, complex regional pain syndrome (CRPS).

SURGICAL TECHNIQUE

The intratendinous heel spur is resected via a lateral approach. The superior surface of the calcaneal tuberosity is trimmed by resection of the dorsal heel spur with the oscillating saw. A second osteotomy at the medial edge of the tuberosity extends to the insertion of the plantaris tendon. With the third osteotomy, the Haglund deformity is resected. At the resulting area with cancellous bone, the Achilles tendon is reinserted with a suture anchor.

POSTOPERATIVE MANAGEMENT

A ventral plastic splint in 20° plantar flexion is worn for a week. Full weight-bearing is allowed in a walking boot with 4 cm heel lift for 6 weeks. The heel lift is then gradually reduced for another 2 weeks. After 8 weeks only an elastic wedge of 1 cm is worn. Physical therapy (isometric exercises) starts in the boot and is intensified after removal of the boot.

RESULTS

Seven of 12 patients treated with that technique for calcifying insertional Achilles tendinopathy (58%) stated being pain free according to the Likert scale, while the remaining 5 patients (42%) reported a "substantial improvement". The VISA‑A score averaged 84 of 100 points. Postoperative complications have not been observed.

Satisfactory Functional Outcome and Significant Correlation with the Length of Haglund's Deformity after Endoscopic Calcaneoplasty: A Minimum 4-Year Follow-Up Study

Background

Haglund's syndrome is a posterosuperior calcaneal prominence with posterior heel pain causing functional disability to the patient. Operative treatment is indicated after failure of conservative measures and includes resection of the bony hump along with retrocalcaneal bursectomy. This study aimed to evaluate the functional outcome and degree of patient satisfaction after endoscopic resection of Haglund's deformity with assessment of correlation with the length of bony exostosis.

Methods

Seventeen patients (21 feet) with a mean age of 44.7 ± 5.1 years were included in this study. Six females and 11 males underwent endoscopic calcaneoplasty. Clinical outcome evaluation included the assessment of the visual analog scale (VAS) and the American Orthopedic Foot and Ankle Society score (AOFAS). The preoperative and postoperative lengths of bony exostosis were measured radiologically. The paired t test and the Wilcoxon signed-rank test compared the preoperative and final postoperative means. P < 0.05 was considered statistically significant.

Results

The mean follow-up period was 56.4 ± 5.1 months. Statistically significant improvements in the preoperative mean of AOFAS (from 55.7 ± 9.3 to 94.3 ± 7.1) and VAS (from 8.1 ± 1.4 to 0.7 ± 1.04) at the final follow-up were noted (P < 0.0001). There was a statistically significant correlation between clinical scores (AOFAS and VAS) and the final postoperative length of the bone above parallel pitch lines (PPLs). The patients were satisfied and returned to their previous activities without reporting major morbidities except one patient who had mild pain with exertion.

Conclusion

Endoscopic calcaneoplasty is a safe, less invasive surgical procedure for the management of Haglund's syndrome after failure of conservative treatment. It provided a satisfactory clinical result without serious complications at a minimum 4-year follow-up.

Do pre-operative radiologic assessment predict postoperative outcomes in patients with insertional Achilles tendinopathy?: a retrospective database study

INTRODUCTION

Diagnosis and treatment of insertional tendinopathy of the Achilles tendon (IAT) remains a challenge. The aim of this study was to assess the influence of pre-operative radiological pathologies on the patient-reported outcomes following open debridement of all pathologies for IAT.

MATERIALS AND METHODS

In this IRB-approved retrospective correlation and comparative study, patients with pre-operative imaging were identified from the authors' retrospective IAT database comprising of 118 patients. All were treated by a standardized surgical treatment strategy utilizing a midline, transachillary approach and debridement of all pathologies. A total of fifteen radiologic parameters were measured on radiographs (RX) and MRI. The patient-reported outcomes were assessed using the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G) and the general health questionnaire SF-12 at a minimum follow-up of 12 months. The data are presented as mean ± SD (95% CI).

RESULTS

88 patients (74.6%) with an average age of 50 ± 12 (47-52) years were included. Radiographs were available in 68 patients and MRI in 53. The mean follow-up was 3.8 ± 1.9 (3.4-4.3) years. The overall VISA-A-G was 81 ± 22 (77-86), the SF-12 PCS 54 ± 7 (52-55), and the SF-12 MCS 52 ± 9 (50-54) points. None of the assessed radiological parameters had a significant influence on the patient-reported outcome following surgical treatment for IAT.

CONCLUSION

In this retrospective correlation study, no significant association was found between preoperative radiographic and MRI radiologic parameters for IAT and postoperative patient-reported outcomes (VISA-A-G and SF-12).

Endoscopic speed bridge: A new treatment for insertional Achilles tendinopathy

Surgical treatment may be indicated after failure of medical management of insertional Achilles tendinopathy, and may consist in simple calcaneoplasty, increasingly performed endoscopically, or in open detachment-reattachment. Isolated calcaneoplasty sometimes shows poor results in case of multiple overlooked lesions (bone, tendon, pre- or retro-tendinous bursitis). Detachment-reattachment may be indicated in case of tendon lesion, but incurred scar and infection related risk in up to 30% of cases in certain reports. In this context, we describe a new original technique using an endoscopic Achilles speed bridge, which we call the "snake technique" for the S-shaped order of performance of the 6 necessary approaches.

Endoscopic treatment of insertional Achilles tendinopathy: A cadaver feasibility study

INTRODUCTION

One treatment option in insertional Achilles tendinopathy is open reconstruction of the insertion, resecting the enthesophyte and posterosuperior calcaneal prominence and reinserting the tendon using anchors. Although classically performed as an open procedure, the necessary subcutaneous release and dissection can entail problems of healing in at-risk patients.

HYPOTHESIS

It is possible to perform Achilles disinsertion-reinsertion with posterosuperior calcaneal prominence resection endoscopically, without iatrogenic risk, enabling complete resection of the enthesophyte and posterosuperior calcaneal prominence and satisfactory reinsertion.

MATERIAL AND METHODS

An operative technique was developed, consisting in Achilles disinsertion-reinsertion with resection of the posterosuperior calcaneal prominence and enthesophyte endoscopically via 5 portals. A feasibility study was conducted in an anatomy laboratory on 10 foot specimens, assessing iatrogenic impact. Bone resection quality was assessed under endoscopic and fluoroscopic control. Reinsertion quality was assessed endoscopically and on dissection of the specimens.

RESULTS

In the 10 procedures, there were no failures. Resection of the calcifications and the calcaneal prominence was complete in all cases. Reinsertion was satisfactory in all cases. There were no iatrogenic neural lesions.

DISCUSSION/CONCLUSION

It was possible to perform endoscopic Achilles disinsertion-reinsertion with resection of the posterosuperior calcaneal prominence and enthesophyte. The procedure did not seem to increase iatrogenic risk, and enabled complete bone resection and satisfactory reinsertion. This endoscopic technique now needs to be validated clinically, with comparison versus open surgery.

LEVEL OF EVIDENCE

IV; cadaver study.

Endoscopic SpeedBridge Procedure for the Treatment for Insertional Achilles Tendinopathy: The Snake Technique

Surgical treatment of insertional Achilles tendinopathy is indicated in case of failure of conservative therapy. A choice is then made within a large spectrum of procedures from minimally invasive techniques such as endoscopic calcaneoplasty to more invasive procedures, such as dorsal closing wedge calcaneal osteotomy. Isolated calcaneoplasties can lead to poor results in cases of pre-existing Achilles tendon lesions; in these cases the tendon disinsertion is justified. In this context, we describe an endoscopic treatment of insertional Achilles tendinopathy.

Flexor hallucis longus hypertrophy secondary to Achilles tendon tendinopathy: an MRI-based case-control study

PURPOSE

The purpose of this study was to outline an indirect sign of advanced Achilles tendinopathy on magnetic resonance imaging (MRI), based on the hypothesis that these patients would present with secondary hypertrophy of the flexor hallucis longus muscle (FHL).

METHODS

MRI scans of Achilles tendon were analyzed retrospectively in two cohorts. The study group consisted of consecutive patients presenting with clinical signs of Achilles tendinopathy and no previous surgeries, while the control group were patients that had an MRI due to other reasons and no signs of tendinopathy. Two parameters from two muscle bellies were measured and compared on axial MRI scans 4-5 cm above the ankle joint line at the level of greatest thickness: area and diameter of the triceps surae (TS) and of the FHL muscle. Ratios (FHL/TS) were calculated for area (Ar) and diameter (Dm) measurements. Interobserver agreement was analyzed. A receiver operating characteristic (ROC) curve was created for both ratios to assess potential cutoff points to differentiate between the groups.

RESULTS

A total of 60 patients for each study group were included. Both ratios Ar(FHL/TS) and Dm(FHL/TS) showed significant higher values in the tendinopathy group (p < 0.001). There were strong to very strong intraclass correlation coefficients (ICC = 0.75-0.93). A diameter ratio Dm (FHL/TS) of 2.0 or higher had a sensitivity of 49% and specificity of 90% for concomitant Achilles tendinopathy.

CONCLUSION

In our patient cohort, FHL hypertrophy was observed in patients with Achilles tendinopathy as a possible compensatory mechanism. Measuring a diameter ratio Dm(FHL/TS) of 2.0 or higher on an axial MRI, may be indicative as an indirect sign of functional deterioration of the Achilles tendon.

Complications Associated With Midline Incision for Insertional Achilles Tendinopathy

BACKGROUND

The midline-incision trans-achillary approach (MITA) is frequently used for addressing all pathologies of insertional Achilles tendinopathy (IAT). The aim of this study was to assess the complication rate and possible influencing factors following a MITA for IAT treatment.

METHODS

Presented is a retrospective cohort study with current follow-up. Patients treated surgically by a MITA, addressing all pathologies of IAT, between January 2010 and October 2016 at a single reference center with at least 12 months of follow-up were included. General demographics (age, sex, and body mass index), medical history, surgical details (individual and sum of pathologies addressed), and duration of in-hospital stay were assessed. Patient satisfaction, shoe conflict, current employment status, time to return to sports, and type of sports were recorded using a custom questionnaire. Standard statistics, chi-square, and t tests were performed using SPSS. A total of 118 patients (follow-up, 63.4%) with a mean age (± SD) of 50 ± 12 years and a mean final follow-up time (± SD) of 4.2 ± 2.1 were included.

RESULTS

Fourteen percent of patients had a minor complication, the majority (75%) of which were surgical site infections. Forty-one percent were limited in their shoe selection, and 32% reported a shoe conflict. Seventy-eight percent were very satisfied, and 89% would recommend the surgery. Neither the individual surgical procedures, their sum, nor any other parameter showed a significant influence on the complication rate. The only factor negatively affecting patient satisfaction was a shoe conflict (P < .001).

CONCLUSION

The MITA for IAT treatment showed a moderate minor complication rate with good midterm patient satisfaction. However, the approach might predispose patients to shoe conflict, which negatively influences their satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Transtendinous approach calcaneoplasty versus endoscopic calcaneoplasty for Haglund's disease

PURPOSE

In this study, we performed a comparison between open calcaneoplasty through transtendinous approach and endoscopic calcaneoplasty for Haglund's disease.

METHODS

A retrospective review was performed of patients who had undergone either a calcaneoplasty with transtendinous approach or endoscopic for Haglund's disease from three centres. Inclusion criteria were patients with Haglund's disease confirmed radiographically, neutral alignment of the hindfoot and at least one year of follow-up. Patients were excluded in case of ipsilateral ankle osteoarthritis or other neighbouring joints, previous foot surgery, hindfoot malalignment and marked calcific insertional Achilles tendinosis. A chart review was performed to collect demographic data, including age, sex and body mass index (BMI). Functional outcome analysis included the Foot Function Index, AOFAS score and VAS for pain pre-operatively and post-operatively at the last follow-up. This patient-reported outcome scores were used in the native language of each patient (Italian).

RESULTS

Clinical and functional outcomes were collected from 54 patients (28 heels treated by open technique and 26 heels treated by endoscopic technique). In the open group, the AOFAS score improved from a pre-operative value of 65.67 ± 10.09 points to a value of 91.78 ± 9.67 points at the last follow-up (P < 0.05). In the endoscopic group, the AOFAS score improved from a pre-operative value of 66.69 ± 7.19 points to a value of 93.69 points ± 10.04 at the last follow-up (P < 0.05). The VAS and the FFI (Disability and Pain) scores were also improved significantly in both groups at the final follow-up evaluation (P < 0.001). Comparing the final follow-up post-operative clinical scores between the two groups, there was no difference in the AOFAS, VAS or the FFI scores between the two groups. No major complications were recorded, except for one Achilles tendon tear after open calcaneoplasty. The satisfaction rate was similar for both techniques.

CONCLUSIONS

Both techniques provided good clinical outcomes with a low rate of complications.

Minimally Invasive and Endoscopic Treatment of Haglund Syndrome

Haglund syndrome is a triad of posterosuperior calcaneal prominence (Haglund deformity), retrocalcaneal bursitis, and insertional Achilles tendinopathy. The sources of pain include the posterior calcaneal wall cartilage, retrocalcaneal and subcutaneous adventitial bursa, and the Achilles tendon. Resection of the posterosuperior calcaneal tubercle, bursectomy, excision of the Achilles tendon pathology, reattachment of the Achilles tendon, gastrocnemius aponeurotic recession, and flexor hallucis longus transfer have been proposed as surgical treatment options. All of them can be performed endoscopically or under minimally invasive approaches.