Insertional Achilles tendinopathy is located at the junction of the Achilles tendon and the calcaneus. Pain, stiffness and occasionally swelling are the most common complaints. On physical examination, visible swelling or redness, tenderness at the insertion site, and palpable bony spur are common. Calcaneal exostosis (Haglund's deformity) and tendon calcification may be found in lateral view radiography.
For painful insertional Achilles tendinopathy, conservative treatment is always recommended first. Conservative treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs), immobilization, heel lift, orthoses, local corticosteroid injection, and activity modification. However, conservative therapy may sometimes not be effective and tendinopathy shows a high recurrence rate.1,2 Surgery is indicated after failure of a reasonable trial of conservative treatment.
The goals of surgery for insertional Achilles tendinopathy are pain relief and restoration of function. To achieve these goals, the irritated retrocalcaneal bursitis should be excised, and the posterosuperior calcaneal exostosis and degenerative and calcified tissue of the Achilles tendon should also be removed. The partially or completely detached Achilles tendon should be reattached and augmented onto the calcaneus. Surgical treatment can be performed conventionally or endoscopically.3–5 An endoscopic approach is effective in decompression of the retrocalcaneal space, and even in reattachment of Achilles tendon4; however, it has trouble eliminating the degenerative and calcified tissue from the Achilles tendon. Hence, an open approach is acceptable for surgical treatment of insertional Achilles tendinopathy.
In open surgery, excision of the calcaneal exostosis and debridement of the Achilles tendon can be achieved by partial or complete detachment of the Achilles tendon. What extent of Achilles tendon detachment can increase the risk of complete rupture? This is a controversial issue. To avoid the potential risk of postoperative Achilles tendon avulsion, tendon reattachment was performed in cases in which more than one-third of the tendon was detached.
In the current study, a new suture technique was used to reconstruct the partially or completely detached Achilles tendon. The SutureBridge device enabled an hourglass pattern of FiberWire suture to be laid over the detached portion of the Achilles tendon. This four-anchor structure provided a large area of contact for the Achilles tendon on the calcaneus, improving stability and possibly allowing for early load-bearing of the affected limb.
From April 2010 to October 2012, 13 feet in 10 patients who suffered from insertional Achilles tendinopathy underwent debridement of the retrocalcaneal space and reattachment of the Achilles tendon through the central tendon-splitting approach. We retrospectively reviewed these patients.
None of the patients had achieved relief after at least six months of conservative treatment, which included oral NSAIDs, ankle immobilization, heel lift, and corticosteroid injection. They had typical manifestations including pain, swelling and stiffness in their hind foot. The tenderness was near the insertion site of the Achilles tendon or lateral or medial to the Achilles tendon at the level of the posterosuperior calcaneal tuberosity. Lateral radiography and magnetic resonance imaging (MRI) of the affected foot were obtained. Ten feet demonstrated exostosis at the posterosuperior calcaneal tuberosity on lateral radiography (Figure 1). On T2-weighted MRI, increased signal intensity was seen within the retrocalcaneal bursae and the insertion site of the Achilles tendon in all the patients.
All the operations were performed by the same surgeon (Lin Y). Preoperative visual analog scale (VAS) pain score was obtained from the medical records. At the end of follow-up, the postoperative VAS pain scores and Maryland foot scores (MFS) were obtained using the retrospective review forms during the final follow-up visit. Relevant complications were also recorded. Clinical evaluation and data gathering were performed by two surgeons (Wang ZW and Zhang B) independently. The current retrospective survey obtained informed consent from the patients, and was approved by the Hospital Ethics Committee.
The procedures were performed with the patient in a prone position under either general or spinal anesthesia. The affected leg was elevated and exsanguinated by wrapping a rubber bandage before pneumatic tourniquet inflation.
A direct midline longitudinal incision was made from Achilles tendon insertion up to 12 cm proximally, and the full thickness of the Achilles tendon was split at the midline. Debridement of the Achilles tendon was carried out and all tendinopathic tissue was excised (Figure 2). The Achilles tendon was released gently and reflected medially and laterally, exposing the posterosuperior calcaneal exostosis if present. Care had to be taken to maintain some residual medial and lateral attachments to assist in restoring the Achilles tendon length accurately. Complete tendon detachment, however, may be necessary to satisfy the requirement of thorough debridement. The calcaneal exostosis was excised using an oscillating saw and the bilateral residual edge was smoothed with a rongeur (Figure 3).
After Achilles tendon debridement and calcaneoplasty were completed, the Achilles tendon was reattached to its native insertion point using the Arthrex SutureBridge device (Arthrex, Naples, FL, USA). First, two pilot holes were created using the punch and cutting tap device consecutively, which were located 1 cm proximal to the distal insertion of the Achilles tendon and central to each of the tendon flaps. Two Arthrex 4.5-mm Bio-Corkscrew FT Anchors (Arthrex) were twisted into the pivot holes, and the anchors were fully seated only if the laser line on the driver shaft reached the level of the bone surface. The FiberWire sutures were released, and the driver handles were detached from the anchors (Figure 4). The two 4.5-mm Bio-Corkscrew FT Anchors were double-loaded with four #1 FiberWire sutures: two in blue and two in white. The Achilles tendon was tensioned and approximated to its native location. With the assistance of a Lasso, the eight FiberWire sutures were threaded through the Achilles tendon flap at the corresponding points, in a horizontal mattress pattern. When each knot was fastened, the foot was held in a plantar flexion position to decrease the tension of the Achilles tendon (Figure 5). Next, just distal to the end of the Achilles tendon insertion and directly inferior to the Bio-Corkscrew FT Anchors, the 4.5-mm PushLock anchor (Arthrex) punch was used to create two holes for the distal row. Two blue and two white sutures were selected from each of the proximal knots and passed through the eyelet of the 4.5-mm Bio-PushLock anchor. The 4.5-mm Bio-PushLock anchor was inserted to the level of the laser line. With appropriate tension maintained on the sutures, the medial button on the back of the handle was tapped with a mallet to drive the absorbable anchor into the hole and lock the sutures in place. In the same way, the other distal anchor was placed (Figure 6). Finally, the longitudinal incision of the Achilles tendon was closed using a 0-Vicryl suture (Figure 7). The wound was closed in layers, a sterile dressing was applied, and a mold anterior plaster splint was placed to keep the foot in the mild plantar flexion position.
All the patients had to stay in the hospital for two days observation. Wound bleeding, swelling, numbness and tightness of the sterile dressing should be given special attention. At two days postoperatively, the sterile dressing was changed and the incision inspected before hospital discharge. The non-weight-bearing plaster splint was used with the ankle in a mild plantar flexion after hospitalization. At two weeks postoperatively, the sutures were removed, and the affected limb was placed in the non-weight-bearing splint for an additional week. At three weeks postoperatively, the splint was removed, and partial weight bearing with the help of crutches was permitted as tolerated. The patients were followed up at three months postoperatively, at which time, range of motion recovery was begun. Full weight-bearing and physical activities were encouraged to achieve better postoperative function.
The measurement data including preoperative and postoperative VAS pain scores and MFSs were collected using medical records or retrospective questionnaires. The comparison of pre- and postoperative VAS pain score was analyzed by using the matched t test with Microsoft Excel 2007 (Microsoft, Redmond, WA, USA). Statistical significance was defined as P <0.05 (two-tailed).
Ten patients with insertional Achilles tendinopathy underwent tendon reattachment using the central-splitting approach combined with the SutureBridge double-row technique. One patient declined to participate in the survey because she moved to another city. Of the nine patients involved in the study, seven were female and two were male, with an average age of 46.7 years (range 38-62 years) at the time of surgery. Insertional Achilles tendinopathy frequently involved the right side (left/right=5:7). Exostosis was observed by preoperative lateral radiography in 10 of the 12 feet, and calcification near the insertion site was seen in nine feet.
Preoperative conservative treatment was administered for an average duration of 16 months (range 6-32 months). The modality of conservative treatment differed among the patients, and immobilization combined with local corticosteroid injection was the most common. During the procedure, after thorough debridement of the Achilles insertion site, partial and complete detachment of the tendon were found in nine and three feet, respectively. The average follow-up was 14.6 months (range 6-30 months). The result of matched t test (two-tailed) showed that the difference between the preoperative and postoperative VAS pain scores was significant (P <0.001, Table 1).
MFS was used to evaluate postoperative outcome. The MFS questionnaire consisted of three parts: pain, function and cosmesis. According to the MFS scale standard proposed by Sanders,6 seven patients achieved an excellent outcome (92-100), one good (85) and one fair (74). There were no intraoperative or postoperative complications, except for delayed healing of the incision in one patient. Wound dehiscence slowly healed without further operation. All the affected ankles achieved their full range of joint motion at the end of follow-up. Above all, there was no evidence of tendon rupture or SutureBridge failure throughout follow-up.
The terminology concerning the pathological changes in the Achilles tendon has been confusing over the years. In 1976, Puddu et al7 proposed a classification of Achilles tendon disorders ranging from peritendinitis, to peritendinitis with tendinosis, to tendinosis. To ensure the reliability and comparability between studies, a new and more uniform terminology has recently been introduced.8 This comprises the following definitions: midportion Achilles tendinopathy, Achilles paratendinopathy, insertional Achilles tendinopathy, retrocalcaneal bursitis, and superficial calcaneal bursitis. The authors suggested that the former terms, such as Haglund's deformity, should not be used any more. Kang et al9 reported that Haglund's deformity was not completely indicative of insertional Achilles tendinitis, and rather, calcification at the tendon insertion was present in most cases. Their findings were consistent with the current study. All patients involved in our survey were diagnosed with insertional Achilles tendinopathy using preoperative MRI, which showed the inflammatory changes at the insertion site of the Achilles tendon. Meanwhile, 10 of the 12 feet demonstrated exostosis at the posterosuperior tubercle of the calcaneus, and retrocalcaneal bursitis could be detected in all cases.
For the treatment of insertional Achilles tendinopathy, surgery is warranted after failure of conservative treatment for 3-6 months.10 Previous approaches include medial and J shaped skin incisions, lateral incision, and transverse incision.11 Recently, a central tendon-splitting approach has been described that allows for optimal access to the degenerative portion of the tendon, as well as the exostosis and retrocalcaneal bursitis.12,13 In a long-term follow-up study, Nunley et al13 demonstrated that the central tendon splitting technique had minimal or no impact on the plantar flexion strength using the isokinetic test. Anderson et al12 compared the postoperative outcomes of the tendonsplitting approach and the lateral approach. They found that patients in the tendon-splitting group returned to daily activity quicker than those in the lateral group, although the mean time for resumption of sports activities was similar between the groups. The central tendon-splitting approach was also adopted in the current study. It was more feasible for thorough excision of degenerative tissue or calcification, especially within the Achilles tendon or at the insertion site. The key elements for successful surgical treatment of insertional Achilles tendinopathy can be summarized as follows: excision of retrocalcaneal bursitis, calcaneoplasty of the posterosuperior portion of the calcaneus, and debridement of degenerative Achilles tendon. Calcaneoplasty, including triangular resection of exostosis and closing wedge osteotomy of the calcaneus,14 could be performed using either open or endoscopic techniques. Endoscopic bony and soft tissue decompression of the retrocalcaneal space has been proposed for many years.2–5 Endoscopic techniques can provide sufficient exposure of the Achilles tendon and excision of the calcaneal exostosis, with a similar or even better recovery time, fewer complications, and a better cosmetic appearance. Although endoscopic techniques have advantages in terms of decompression of the retrocalcaneal space, they are not able to debride the degenerative tissue and calcification in the Achilles tendon. A disappointing result concerning the surgical treatment of Haglund's syndrome indicated that simple decompression of the retrocalcaneal space may not significantly relieve the symptoms.1 This implies that the endoscopic technique cannot completely replace conventional open surgery for treatment of insertional Achilles tendinopathy.
When taking debridement of the Achilles tendon into account, partial or complete detachment of the tendon and related tendon repair pose challenges to surgeons. Tendon reattachment is essential for maintenance of plantar flexion strength of the foot, but there is still controversy concerning how much tendon detachment needs to be repaired. Calder and Saxby15 conducted a retrospective clinical trial involving 52 patients with Achilles tendinosis, and suggested tendon reattachment with sutures if >50% of the tendon is detached. Wagner et al16 performed a retrospective review of 65 feet with insertional Achilles tendinosis, and divided the patients into two groups: no or partial detachment, and complete detachment. Different extents of tendon detachment underwent reconstruction using varied numbers of suture anchors, and combined with V-Y lengthening of the proximal aponeurosis. They concluded that complete detachment of the Achilles tendon and reattachment using suture anchors was a reliable and effective method of treatment for insertional Achilles tendinosis, as was debridement without tendon detachment for mild involvement. However, whether reattachment of the Achilles tendon weakens the contraction capacity of the gastrocnemius muscle may still be debated. Wagner et al17 evaluated the change of plantar flexion strength in 10 patients with insertional Achilles tendinitis. All patients received complete detachment of the Achilles tendon, proximal V-Y lengthening of aponeurosis, and reattachment of the tendon using anchor sutures. Plantar flexion torque, dorsiflexion torque, and total work were used as isokinetic testing parameters. The results of isokinetic testing showed that there was no difference between the operative feet and the contralateral healthy feet. However, five of 20 patients could not return to their original level of physical activities in another case series,18 in which the patients underwent detachment and reconstruction of the Achilles tendon for treatment of insertional tendinitis, and two to five bone anchors were used for different degrees of detachment. Although no Achilles tendon rupture was reported in this case series, the results suggested that reattachment of the Achilles tendon may somehow affect the plantar flexion strength of the affected foot.
Reconstruction of Achilles tendon detachment can be performed using either the suture anchor technique or tendon transfer/augmentation with autografting.19 Reattachment of the distal end of the Achilles tendon onto the calcaneus with various numbers of suture anchors is the most commonly used technique. Most researchers recommended that the number of suture anchors used should depend on the extent of the detachment.9,15 The SutureBridge double-row technique, initially designed for repair of rotator cuff tearing,20 has been used widely in other ways recently, for example, tibial spine fractures,21 malunion of the greater tubercle of the humerus,22 and insertional Achilles tendinosis.23 In the current study, the SutureBridge device was used for reconstruction of insertional Achilles tendinopathy after partial or complete detachment of the insertion site. Theoretically, it provides a large area of compression of the Achilles tendon onto the calcaneus, avoids postoperative heel-lift to achieve a wide range of motion, and allows possible early return to weight-bearing activities. Our results demonstrated encouraging outcomes. There were no intraoperative complications with the use of the SutureBridge device. No major complications occurred throughout postoperative follow-up. All patients claimed marked pain relief and functional improvement, and resumed daily activities after three months postoperatively. One case series23 concerning the surgical treatment of insertional Achilles tendinosis with the SutureBridge technique was a little earlier than ours. In their study, four involved patients all received complete tendon detachment for the purpose of thorough debridement. After a mean final follow-up of two years, all patients achieved satisfactory pain relief and functional improvement without any complications. The clinical findings of that study were comparable with our study.
There were several limitations in the current study. First, a retrospective study has its inherent limitations. Second, the small number of patients and lack of preoperative MFS data may weaken the reliability of our results. More patients and preoperative MFS data should be included in further studies. Last, we did not have a control group with other methods of Achilles tendon reconstruction. Despite these drawbacks, our results do demonstrate that central tendon-splitting combined with the SutureBridge technique is a safe and reliable method of treatment for insertional Achilles tendinopathy. The procedure is effective for pain relief and functional improvement, and the risk of major complications is minimal. The SutureBridge double-row technique can provide excellent security for tendon fixation, avoid immobilization over a long period of time, maximize ankle flexibility, and speed up the process of rehabilitation.
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