Insertional Achilles Tendinopathy

Weightbearing Protocols and Outcomes in Open Surgical Management of Haglund Syndrome: A Large Retrospective Analysis

Background

Following insertional Achilles tendinopathy debridement and Haglund prominence resection for Haglund syndrome, patients undergo varying degrees of weightbearing limitation (weightbearing as tolerated [WBAT], partial weightbearing [PWB], touchdown weightbearing [TDWB], and nonweightbearing [NWB]). Given the scarcity of large-scale literature on the topic, the purpose of this study is to evaluate the impact of postoperative weightbearing protocols on outcomes after open surgical management of Haglund syndrome.

Methods

This was a retrospective cohort study of patients who underwent open surgical management for Haglund syndrome between January 2015 and December 2023 at a single academic institution by fellowship-trained foot and ankle surgeons. Patients were excluded if they underwent concurrent operative management of additional foot pathologies. Patient demographics, comorbidities, surgical techniques, and postoperative weightbearing protocols were recorded. Complications (Achilles tendon rupture, wound breakdown/infection, persistent pain, plantarflexion weakness) and revision rates were compared across weightbearing protocols. Statistical analysis was conducted using R with significance set at P <.05.

Results

Three-hundred eighty-seven patients were included (mean age 55.2 years, 66.1% female) with a mean follow-up of 10.1 (range: 0-86.3) months. The most common regimen was NWB (n = 268; 69.3%) followed by TDWB (n = 56; 14.5%), WBAT (n = 54; 14.0%), and PWB (n = 9; 2.3%). There were no significant differences in complications between the weightbearing protocols (P = .48354). Complications included persistent pain (n = 40; 10.3%), weakness (n = 6; 1.6%), wound breakdown/infection (n = 33; 8.5%), and rupture (n = 1; 0.3%)]. Revision surgery occurred in 1.8% (n = 7).

Conclusion

This large cohort study found no significant association between postoperative weightbearing protocols and outcomes following open surgical treatment for Haglund syndrome at a mean follow-up of 10.1 months. This study provides evidence that surgeons can individualize appropriate weightbearing protocols based on patient needs and preferences when treating Haglund syndrome with Achilles debridement and Haglund resection.

Level of Evidence

Level III, comparative study.

Complications Following Surgical Treatment of Haglund's Syndrome With and Without Flexor Hallucis Longus Tendon Transfer

BACKGROUND

In the surgical treatment of Haglund syndrome, combining a flexor hallucis longus (FHL) tendon transfer with Achilles tendon may improve plantarflexion strength and reduce strain on the repaired Achilles tendon. However, there is limited research comparing complication rates between surgical approaches with or without concurrent FHL tendon transfer.

METHODS

This was retrospective study of patients who underwent surgical management for Haglund syndrome between January 2015 and December 2023. Surgical management included open central-splitting Achilles tendon débridement, Haglund prominence resection, and subsequent Achilles tendon reattachment, either with or without concurrent FHL tendon transfer. Patient demographics, comorbidities, and postoperative complications were collected. Statistical analysis was conducted to compare outcomes between the two groups.

RESULTS

Among the 390 patients who underwent surgical intervention for Haglund syndrome, 52 individuals received FHL tendon transfer. The average follow-up duration was 10.1 ± 12.9 months. Overall, complications included persistent pain (10.3%), wound breakdown (8.2%), infection (1.8%), plantar flexion weakness (1.5%), and Achilles tendon rupture (0.3%). No notable difference was observed in complication rates between the two groups. However, wound breakdown was higher in the FHL tendon transfer group compared with the non-FHL group (P = 0.5). No patients who received a FHL tendon transfer experienced a postoperative Achilles tendon rupture.

CONCLUSION

In the largest study of patients who underwent surgical treatment for Haglund syndrome, with or without FHL tendon transfer, the overall complication rate was comparable. However, the FHL tendon transfer group exhibited a higher tendency for wound breakdown.

Platelet-rich plasma in chronic Achilles tendinopathy

INTRODUCTION

Achilles tendinopathy [AT] is a functional problem characterised by swelling and pain above the Achilles tendon insertion region. In individuals with AT, PRP or platelet-rich plasma can be used as an alternative modality of treatment with an aim to lessen the discomfort and enhance functional recovery. We assessed the available data supporting the effectiveness of PRP in treating chronic AT.

MATERIALS AND METHODS

We did a literature search for randomised controlled trials [RCTs] that contrasted the effectiveness of PRP with that of eccentric exercise and placebo injections as treatment for AT in databases such as the Cochrane Library, Web of Science, PubMed, and EMBASE. The Visual analogue scale [VAS] score, Victorian Institute of Sports Assessment-Achilles [VISA-A] score, and Achilles tendon thickness were used to measure the results. We used the RevMan 5.3.5 software for statistical analysis.

RESULTS

We included five RCTs in this meta-analysis. There was no significant difference in the VISA-A between the PRP and placebo groups at 12 weeks, 24 weeks and 1 year after treatment. However, at 6 weeks after treatment, PRP exhibited better efficacy than the placebo treatment. Two studies in our meta-analysis included VAS scores and tendon thickness. There was no significant difference in VAS scores at 6 weeks and 24 weeks after treatment. However, VAS scores at 12 weeks and tendon thickness were significantly different.

CONCLUSION

PRP injection is an effective treatment for chronic AT. It has a unique potential for increasing function and reducing discomfort in AT patients.

[Achilles tendon pathologies]

Achilles tendon pathologies are a frequent problem in the clinical practice. A distinction must be made between insertional and noninsertional tendinopathies. In addition to intrinsic risk factors, such as diabetes mellitus, there are also extrinsic risk factors, such as overuse and running. Sonography, X‑ray imaging and magnetic resonance imaging (MRI) are established imaging methods, depending on the question. The primary treatment includes a conservative approach. First-line treatment includes administration of nonsteroidal anti-inflammatory drugs (NSAID), physical rest and the use of assistive devices. Established conservative treatment procedures include eccentric stretching, shockwave therapy and infiltration with, e.g., platelet-rich plasma. There are numerous other conservative treatment options. After exhausting the conservative treatment options, a surgical approach can be considered. The surgical procedure depends on the clinical symptoms and findings. Established procedures are minimally invasive or endoscopic procedures or even open debridement.

Effectiveness of platelet-rich plasma in the treatment of Achilles tendon disease

BACKGROUND

The effectiveness of Platelet-Rich Plasma (PRP) in the treatment of patients with Achilles tendon rupture (ATR) and Achilles tendinopathy (AT) has been controversial.

AIM

To assess PRP injections' effectiveness in treating ATR and AT.

METHODS

A comprehensive review of relevant literature was conducted utilizing multiple databases such as Cochrane Library, PubMed, Web of Science, Chinese Science and Technology Journal, EMBASE, and China Biomedical CD-ROM. The present investigation integrated randomized controlled trials that assessed the effectiveness of platelet-rich plasma injections in managing individuals with Achilles tendon rupture and tendinopathy. The eligibility criteria for the trials encompassed publications that were published within the timeframe of January 1, 1966 to December 2022. The statistical analysis was performed utilizing the Review Manager 5.4.1, the visual analogue scale (VAS), Victorian Institute Ankle Function Scale (VISA-A), and Achilles Tendon Thickness were used to assess outcomes.

RESULTS

This meta-analysis included 13 randomized controlled trials, 8 of which were randomized controlled trials of PRP for AT and 5 of which were randomized controlled trials of PRP for ATR. PRP for AT at 6 wk [weighted mean difference (WMD) = 1.92, 95%CI: -0.54 to 4.38, I2 = 34%], at 3 mo [WMD = 0.20, 95%CI: -2.65 to 3.05, I2 = 60%], and 6 mo [WMD = 2.75, 95%CI: -2.76 to 8.26, I2 = 87%) after which there was no significant difference in VISA-A scores between the PRP and control groups. There was no significant difference in VAS scores between the PRP group and the control group after 6 wk [WMD = 6.75, 95%CI: -6.12 to 19.62, I2 = 69%] and 6 mo [WMD = 10.46, 95%CI: -2.44 to 23.37, I2 = 69%] of treatment, and at mid-treatment at 3 mo [WMD = 11.30, 95%CI: 7.33 to 15.27, I2 = 0%] after mid-treatment, the PRP group demonstrated better outcomes than the control group. Post-treatment patient satisfaction [WMD = 1.07, 95%CI: 0.84 to 1.35, I2 = 0%], Achilles tendon thickness [WMD = 0.34, 95%CI: -0.04 to 0.71, I2 = 61%] and return to sport [WMD = 1.11, 95%CI: 0.87 to 1.42, I2 = 0%] were not significantly different between the PRP and control groups. The study did not find any statistically significant distinction between the groups that received PRP treatment and those that did not, regarding the Victorian Institute of Sport Assessment - Achilles scores at 3 mo [WMD = -1.49, 95%CI: -5.24 to 2.25, I2 = 0%], 6 mo [WMD = -0.24, 95%CI: -3.80 to 3.32, I2 = 0%], and 12 mo [WMD = -2.02, 95%CI: -5.34 to 1.29, I2 = 87%] for ATR patients. Additionally, no significant difference was observed between the PRP and the control groups in improving Heel lift height respectively at 6 mo [WMD = -3.96, 95%CI: -8.61 to 0.69, I2 = 0%] and 12 mo [WMD = -1.66, 95%CI: -11.15 to 7.83, I2 = 0%] for ATR patients. There was no significant difference in calf circumference between the PRP group and the control group after 6 mo [WMD = 1.01, 95%CI: -0.78 to 2.80, I2 = 54%] and 12 mo [WMD = -0.55, 95%CI: -2.2 to 1.09, I2 = 0%] of treatment. There was no significant difference in ankle mobility between the PRP and control groups at 6 mo of treatment [WMD = -0.38, 95%CI: -2.34 to 1.58, I2 = 82%] and after 12 mo of treatment [WMD = -0.98, 95%CI: -1.41 to -0.56, I2 = 10%] there was a significant improvement in ankle mobility between the PRP and control groups. There was no significant difference in the rate of return to exercise after treatment [WMD = 1.20, 95%CI: 0.77 to 1.87, I2 = 0%] and the rate of adverse events [WMD = 0.85, 95%CI: 0.50 to 1.45, I2 = 0%] between the PRP group and the control group.

CONCLUSION

The use of PRP for AT improved the patient's immediate VAS scores but not VISA-A scores, changes in Achilles tendon thickness, patient satisfaction, or return to sport. Treatment of ATR with PRP injections alone improved long-term ankle mobility but had no significant effect on VISA-A scores, single heel lift height, calf circumference or return to sport. Additional research employing more extensive sampling sizes, more strict experimental methods, and standard methodologies may be necessary to yield more dependable and precise findings.

The Efficacy of Platelet-Rich Plasma Injection Therapy in the Treatment of Patients with Achilles Tendinopathy: A Systematic Review and Meta-Analysis

BACKGROUND

Over the past few years, many studies have been conducted to evaluate the effectiveness of platelet-rich plasma (PRP) in treating musculoskeletal conditions. However, there is controversy about its benefits for patients with Achilles tendinopathy.

OBJECTIVE

This study aimed to investigate whether platelet-rich plasma injections can improve outcomes in patients with Achilles tendinopathy.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Web of Science, China Biomedical CD-ROM, and Chinese Science and Technology Journal databases to identify randomised controlled clinical trials that compared the efficacy of PRP injection in patients with Achilles tendinopathy (AT) versus placebo, published between 1 January 1966 and 1 December 2022. Review Manager 5.4.1 software was used for the statistical analysis, and the Jadad score was used to assess the included literature. Only 8 of the 288 articles found met the inclusion criteria.

RESULTS

Our work suggests that: The PRP treatment group had a slightly higher VISA-A score than the placebo group at 6 weeks [MD = 1.92, 95% CI (-0.54, 4.38), I² = 34%], at 12 weeks [MD = 0.20, 95% CI (-2.65 3.05), I² = 60%], and 24 weeks [MD = 2.75, 95% CI (-2.76, 8.26), I² = 87%]). However, the difference was not statistically significant. The Achilles tendon thickness was higher at 12 weeks of treatment in the PRP treatment group compared to the control group [MD = 0.34, 95% CI (-0.04, 0.71), p = 0.08], but the difference was not statistically significant. The VAS-improvement results showed no significant difference at 6 and 24 weeks between the two groups, respectively (MD = 6.75, 95% CI = (-6.12, 19.62), I² = 69%, p = 0.30), and (MD = 10.46, 95% CI = (-2.44 to 23.37), I² = 69%, p = 0.11). However, at 12 weeks of treatment, the PRP injection group showed a substantial VAS improvement compared to the control group (MD = 11.30, 95% CI = (7.33 to 15.27), I² = 0%, p < 0.00001). The difference was statistically significant. The return to exercise rate results showed a higher return to exercise rate in the PRP treatment group than the placebo group [RR = 1.11, 95% CI (0.87, 1.42), p = 0.40]; the difference was not statistically significant.

CONCLUSION

There is no proof that PRP injections can enhance patient functional and clinical outcomes for Achilles tendinopathy. Augmenting the frequency of PRP injections may boost the outcomes, and additionally, more rigorous designs and standardised clinical randomised controlled trials are needed to produce more reliable and accurate results.

Does additional extracorporeal shock wave therapy improve the effect of isolated percutaneous radiofrequency coblation in patients with insertional Achilles tendinopathy? Study protocol for a randomized controlled clinical trial

BACKGROUND

No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy.

METHODS

The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis.

DISCUSSION

We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment.

TRIAL REGISTRATION

ChiCTR1800017898; pre-results. Registered on 20 August 2018.

Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications

Therapeutic exercise is widely considered a first line fundamental treatment option for managing tendinopathies. As the Achilles tendon is critical for locomotion, chronic Achilles tendinopathy can have a substantial impact on an individual's ability to work and on their participation in physical activity or sport and overall quality of life. The recalcitrant nature of Achilles tendinopathy coupled with substantial variation in clinician-prescribed therapeutic exercises may contribute to suboptimal outcomes. Further, loading the Achilles tendon with sufficiently high loads to elicit positive tendon adaptation (and therefore promote symptom alleviation) is challenging, and few works have explored tissue loading optimization for individuals with tendinopathy. The mechanism of therapeutic benefit that exercise therapy exerts on Achilles tendinopathy is also a subject of ongoing debate. Resultingly, many factors that may contribute to an optimal therapeutic exercise protocol for Achilles tendinopathy are not well described. The aim of this narrative review is to explore the principles of tendon remodeling under resistance-based exercise in both healthy and pathologic tissues, and to review the biomechanical principles of Achilles tendon loading mechanics which may impact an optimized therapeutic exercise prescription for Achilles tendinopathy.

The Statistical Fragility of Platelet-Rich Plasma as Treatment for Chronic Noninsertional Achilles Tendinopathy: A Systematic Review and Meta-analysis

Background:

Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by P <.05, are often used to guide decision making. Noted lack of reproducibility of some RCTs has brought special attention to the limitations of this approach. In this meta-analysis, we assessed the robustness of RCTs evaluating platelet-rich plasma (PRP) for the treatment of chronic noninsertional Achilles tendinopathy (AT) by using fragility indices.

Methods:

The present study was a systematic review and meta-analysis of RCTs comparing outcomes after PRP injection vs alternative treatment in patients with AT. Representative data sets were generated for each reported continuous outcome event using summary statistics. Fragility indices refer to the minimal number of patients whose status would have to change from a nonevent to an event to turn a statistically significant result into a nonsignificant result, or vice versa. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively, by manipulating each data set until reversal of significance (a=0.05) was achieved. The corresponding fragility quotient (FQ) and continuous FQ (CFQ) were calculated by dividing FI/CFI by sample size.

Results:

Of 432 studies screened, 8 studies (52 outcome events) were included in this analysis. The 12 dichotomous outcomes had a median FI of 4.5 (FQ: 0.111), and the 40 continuous outcomes had a median CFI of 5 (CFQ: 0.154). All 52 outcome events included lost-to-follow-up data, and 12 (23.1%) indicated a greater number of patients lost to follow-up than the FI or CFI.

Conclusion:

Our findings suggest that RCTs evaluating PRP for AT therapy lack statistical robustness, because changing only a small number of events may alter outcome significance.

Level of Evidence:

Level II, therapeutic study.

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.

Functional Outcomes of Insertional Achilles Tendinopathy Treatment: A Systematic Review

BACKGROUND

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional, and effective treatment of each type can vary. We sought to investigate the current evidence on different treatment methods for insertional Achilles tendinopathy with a focus on functional outcomes.

METHODS

We performed a systematic review of the available literature using the PubMed/MEDLINE and Cochrane Central Register of Controlled Trials databases. Data from included studies were categorized according to treatment method and reported with respect to functional outcomes and complications.

RESULTS

A total of 1,457 abstracts were reviewed; 54 studies with 2,177 patients met the inclusion criteria. Among the 54 studies, 6 operative techniques and 6 nonoperative treatments were evaluated.

CONCLUSIONS

Eccentric exercises and low-energy extracorporeal shockwave therapy (ESWT) have the greatest evidence for the initial management of insertional Achilles tendinopathy. ESWT has been increasingly studied in recent years, but more high-quality evidence is needed. Operative treatment with tenotomy, debridement, retrocalcaneal bursectomy, and calcaneal exostectomy is effective. Flexor hallucis longus tendon transfer may benefit cases of more severe disease. Minimally invasive procedures have a potential role in the treatment algorithm and require more rigorous study.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy: a cross-sectional study

OBJECTIVE

to examine psychological factors during rehabilitation of patients with Achilles or patellar tendinopathy as well as the association between psychological factors and tendinopathy severity, sport participation, and satisfaction with activity level and tendon function.

DESIGN

cross-sectional study.

SETTING

online survey platform.

PARTICIPANTS

119 patients (mean age: 44 years (SD 14)) diagnosed with Achilles or patellar tendinopathy.

MAIN OUTCOME MEASURES

A range of patient-reported psychological and outcome measures were recorded. Multivariate regression analyses were performed to establish the association between each psychological factor and outcome measures, adjusted for relevant confounders.

RESULTS

Psychological readiness and confidence to return to sports (I-PRRS) and pain catastrophizing (PCS) were significantly associated with tendinopathy severity (modified VISA), sport participation(OSTRC-O), and satisfaction. Kinesiophobia (TSK) and the importance to patients of returning to pre-injury activity level were significantly associated with sports participation and satisfaction.

CONCLUSION

The current study provides evidence of impairments in psychological factors during rehabilitation of patients with Achilles and patellar tendinopathy. Most investigated psychological factors were associated with tendinopathy severity, function, participation, and satisfaction. Physical therapists should recognize patients with lack of psychological readiness to return to sports and also patients with kinesiophobia or catastrophizing thoughts when experiencing pain.

Study of the clinical and functional results of open calcaneoplasty and tendinous repair for the treatment of the insertional tendinopathy of the Achilles' tendon

BACKGROUND AND OBJECTIVES

Insertional tendinopathy accounts for 23% of the pathology of the Achilles tendon. Surgery is indicated when conservative treatment of pain and functional limitation fails. Our objective is to analyse the clinical-functional results of surgical treatment with disinsertion, debridement and double row reattachment with high strength suture tape.

MATERIAL AND METHODS

We present 13 patients with insertional Achilles tendinopathy, treated between February 2015 and October 2016. In all of them we performed inverted T-tendon disinsertion, debridement and calcareoplasty followed by double row tendon re-anchorage, without knots, with high resistance suture tape. Functional results were assessed with the AOFAS scale before and after surgery, with an average follow-up of 22 months.

RESULTS

The patients, 11 males and 2 females, with an average age of 43 years, presented a preoperative AOFAS score of 34.77±10.1 that reached 90.85±7 points after the operation, with an average increase of 56.08 points (IC 95% 48.13-64.02; P<0.01). The time to return to sports activities was 19 weeks (16-22). There were no complications.

CONCLUSION

The technique we present reports excellent results as a surgical treatment of insertional Achilles tendinopathy with intralesional calcification; it allows a wide contact surface between bone and tendon and an earlier return to previous sports activity.

Mid-term results of open debridement and reattachment surgery for insertional Achilles tendinopathy: A retrospective clinical study

OBJECTIVE

The aim of this study was to determine the effects of age and body mass index (BMI) on the functional outcomes, satisfaction rates, and recovery time after open debridement and reattachment surgery in non-athletic patients with insertional Achilles tendinopathy (IAT).

METHODS

In this retrospective study, 33 non-athletic patients (34 ankles) in whom open debridement and reattachment surgery was performed for IAT from 2006 to 2016 were included. Change in pain intensity was assessed using a Visual Analogue Scale (VAS) preoperatively and at the final follow-up. Functional assessment was done by preoperative and postoperative American Orthopaedics Foot and Ankle Score (AOFAS) and final follow-up Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A). Patient satisfaction was evaluated by Roles - Maudsley score (RMS). The recovery time was defined as the time interval from the first appearance to postoperative relief of symptoms and recording. In addition, the recurrent Haglund's deformity was determined by postoperative control radiographs.

RESULTS

The mean age at the time of the operation was 51.19 years. The mean follow-up was 61.75±8.49 months. According to BMI, 5 patients were determined as morbid obese, 19 as obese, 3 as overweight, and 6 as normal. The mean VAS score significantly decreased from 8.5 preoperatively to 1.3 postoperatively (p<0.001). The mean AOFAS score significantly improved from 55.8 preoperatively to 92 postoperatively (p<0.001). Postoperative VISA-A score was 86% (range=32%-100%). According to RMS, 22 patients reported the result as excellent, 8 as good, 2 as fair, and 1 as poor. The mean recovery time was 11.8 (range=2-60) months, but one patient did not reach a symptom free status and thus was not included in the recovery time analysis. Postoperative control radiographs revealed signs of recurrence deformity in four patients. Recovery time showed a negative correlation with the age of the patients (r=-0.65). Postoperative scores and BMI showed no significant correlations with the recovery time on the basis of Spearman's rho test (p=0.196).

CONCLUSION

The results of this study have shown that open debridement and reattachment surgery may be an effective surgical method in relieving pain and improving functional status with high satisfaction rate and acceptable recovery time in the management of non-athletic patients with IAT.

LEVEL OF EVIDENCE

Level IV, Therapeutic 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.

A Radiographic Study of Biomechanical Relationship between the Achilles Tendon and Plantar Fascia

Background

Previously, scholars have concluded that the Achilles tendon and the plantar fascia were closely biomechanically related, although there is little clinical evidence of the relationship between the two. To investigate the biomechanical relationship between the Achilles tendon and the plantar fascia, the author used standing lateral ankle radiographs of patients with insertional Achilles tendonitis to determine the biomechanical relationship between the Achilles tendon and plantar fascia.

Methods

The author collected standing lateral ankle radiographs from patients with insertional Achilles tendonitis who accepted surgical treatment in the author's hospital from March 2009 to July 2018. According to whether there were bone spurs on the posterior side of the calcaneus, patients were divided into group A (spur present on the posterior side) and group B (spur not present on the posterior side). The positive rates of spurs on the plantar side of the calcaneus were determined in group A and group B. The chi-square test was used to compare the measurement results between the two groups.

Results

In group A, 13 heels were positive for calcaneal bone spurs, and the positive rate was 65.0%. In group B, 3 heels were positive for plantar calcaneal spurs, and the positive rate was 12%. Among all 16 patients with positive plantar calcaneal spurs, 13 had posterior calcaneal spurs (accounting for 81.3%), and 3 had negative results, accounting for 18.7%. There was a significant difference between the results in groups A and B (P < 0.05).

Conclusion

There is a relationship between posterior calcaneal spurs and plantar calcaneal spurs in patients with insertional Achilles tendonitis, which can be inferred as resulting from the increasing tension in the biomechanically complex relationship between the Achilles tendon and the plantar fascia.

Use of 3D-Printed Heel Support Insoles Based on Arch Lift Improves Foot Pressure Distribution in Healthy People

Background

3D-printed insoles are widely used. This study was conducted to test a customized three-dimensional (3D)-printed heel support insole based on arch lift and to investigate whether the pressure distribution on the sole was improved while maintaining foot function.

Material/Methods

The design was based on a 3D plantar contour scanning modeling technique. Thirty healthy male participants walked along a 10-m track under 3 self-controlled interventions. A customized 3D-printed heel support insole based on arch lift was inserted into the socks for the experimental condition A. For condition B, a customized 3D-printed heel-supporting insole was inserted into the socks, and a standardized pre-made heel-supporting insole was inserted into the socks as a control (condition C). We used the Footscan^® pressure plate to measure the plantar parameters in the forefoot contact and foot flange phases in each condition.

Results

Compared with condition B and the control condition, the peak pressure under the heel was significantly lower in condition A (P<0.05), and the peak pressure in the midfoot region was not significantly increased (P>0.05).

Conclusions

The biomechanical properties of the customized 3D-printed heel support are better than those of the traditional heel support insole, especially when there is a need for an additional increase in heel height. Patients do not decrease midfoot motion function while using this customized insole.

Platelet-rich plasma injection for the treatment of chronic Achilles tendinopathy: A meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) is used as an alternative therapy to reduce pain and improve functional restoration in patients with Achilles tendinopathy (AT). We evaluated the current evidence for the efficacy of PRP as a treatment for chronic AT.

METHODS

The PubMed, Embase, Web of Science, and The Cochrane Library databases were searched for articles on randomized controlled trials (RCTs) that compared the efficacy of PRP with that of with placebo injections plus eccentric training as treatment for AT. The articles were uploaded over the establishment of the databases to May 01, 2018. The Cochrane risk of bias (ROB) tool was used to assess methodological quality. Outcome measurements included the Victorian Institute of Sports Assessment-Achilles (VISA-A), visual analog scale (VAS) and Achilles tendon thickness. Statistical analysis was performed with RevMan 5.3.5 software.

RESULTS

Five RCTs (n = 189) were included in this meta-analysis. Significant differences in the VISA-A were not observed between the PRP and placebo groups after 12 weeks [standardized mean difference (SMD) = 0.2, 95% confidence interval (95% CI): 0.36 to 0.76, I = 71%], 24 weeks (SMD = 0.77, 95% CI: -0.10-1.65, I = 85%) and 1 year (SMD = 0.83, 95% CI: -0.76-2.42, I = 72%) of treatment. However, PRP exhibited better efficacy than the placebo treatment after 6 weeks (SMD = 0.46, 95% CI: 0.15-0.77, I = 34%). Two studies included VAS scores and tendon thickness. VAS scores after 6 weeks (SMD = 1.35, 95% CI: -0.1.04-3.74, I = 93%) and 24 weeks (SMD = 1.48, 95% CI: -0.1.59-4.55, I = 95%) were not significantly different. However, VAS scores at the 12th week (SMD = 1.10, 95% CI: 0.53-1.68, I = 83%) and tendon thickness (SMD = 1.51, 95% CI: 0.39-2.63, I = 53%) were significantly different.

CONCLUSION

PRP injection around the Achilles tendon is an option for the treatment of chronic AT. Limited evidence supports the conclusion that PRP is not superior to placebo treatment. These results still require verification by a large number of well designed, heterogeneous RCT studies.

[Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]

Achilles tendinopathy at the calcaneal insertion is classified into insertional tendinopathy, retrocalcaneal and superficial bursitis. The aim of this study was to present the current evidence on conservative and surgical treatment of insertional tendinopathy of the Achilles tendon. Conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization. In addition, further conservative therapy options are also available. Eccentric stretching exercises should be integral components of physiotherapy and can achieve a 40% reduction in pain. Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80%. Due to the limited evidence, injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) cannot currently be recommended. Operative therapy is indicated after 6 months of unsuccessful conservative therapy. Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis. The success rate of over 70% is contrasted by complication rates of up to 40%. The Achilles tendon should be reattached, if detached by >50%. No valid data are available for the transfer of the tendon of the flexor hallucis longus (FHL) muscle but it is frequently applied in cases of more than 50% debridement of the diameter of the Achilles tendon. Lengthening of the gastrocnemius muscle cannot be recommended because insufficient data are available. Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates.