Results of operative treatment for recalcitrant retrocalcaneal bursitis and midportion Achilles tendinopathy in athletes

Biomechanical consequences of Zadek osteotomy in insertional achilles tendinopathy: A virtual surgical simulation study

BACKGROUND

The Zadek osteotomy modified by Taylor (ZO) is a surgical technique used to treat insertional Achilles tendinopathy (IAT) by reducing the heel's prominence and elevating the Achilles tendon insertion. This study aims to analyze the biomechanical consequences of IAT after ZO using a virtual surgical simulation with a specific software.

METHODS

A retrospective analysis of 20 wtbearing computed tomography (WBCT) scans of IAT patients was conducted. Using Disior's BonelogicTM software, 3D models were created from WBCT images. Virtual ZO was performed on these models, and various biomechanical parameters were measured before and after the virtual osteotomy.

RESULTS

The virtual ZO showed significant statistical differences in the average of the calcaneal length (p < 0.001), Fowler Philips angle (p < 0.001), calcaneal pitch (p < 0.001), and the sagittal talocalcaneal angle (p < 0.001).

CONCLUSIONS

The virtual ZO analysis suggests that this procedure can decrease the Fowler Philips angle, shorten the calcaneus, modifying specifically the sagittal alignment.

LEVEL OF EVIDENCE

IV; case series.

Posterior Heel Pain in Cavovarus Foot: How to Approach It

When a patient presents with posterior heel pain on the background of a cavovarus foot, there are many different aspects to take into account. The morphology of the foot and the specific cause of the patient's pain lead the practitioner to alter the treatment appropriately. Some patients should only receive physiotherapy, but the majority should receive more invasive treatments, including calcaneal osteotomies or tendon debridement, depending on their particular presentation and pathology. This review examines the various different facets of posterior heel pain that must be dealt with and the most up-to-date treatments for the same.

Level of Evidence for the Treatment of Chronic Noninsertional Achilles Tendinopathy

BACKGROUND

Noninsertional Achilles tendinopathy affects both athletes and sedentary individuals, and its incidence is rising. Conservative management is the mainstay of treatment, but a variety of operative techniques have been described to treat recalcitrant cases. We seek to outline the current available evidence for surgical management of noninsertional Achilles tendinopathy.

STUDY DESIGN AND METHODS

A systematic review was performed using the MEDLINE and EMBASE databases, and all articles were reviewed by at least 2 authors. Each article was assigned a level of evidence in accordance with the standards of Journal of Bone and Joint Surgery. The available data were reviewed and a level of evidence was assigned to each intervention of interest, based on the revised classifications of Wright.

RESULTS AND CONCLUSION

A total of 46 articles met inclusion and exclusion criteria. There is fair evidence (grade B) in support of open debridement with 1 level II study, 1 level III study, and 8 level IV studies. There is fair evidence (grade B) in support of arthroscopic or minimally invasive surgical techniques. There is poor evidence (grade C) in support of flexor hallucis longus transfer, longitudinal tenotomy, peritenolysis, gastrocnemius recession, and plantaris excision. There is insufficient evidence (grade I) to provide a recommendation about other surgical treatment methods for noninsertional Achilles tendinopathy.Levels of Evidence: Level III: Systematic review.

Septic retrocalcaneal bursitis in a young soccer player treated with hindfoot endoscopic bursectomy: a case report

Septic retrocalcaneal bursitis (RB) is extremely rare with no reports on surgical treatment. Here, we describe a rare case of septic RB in a 14-year-old male soccer player who was treated with hindfoot endoscopic bursectomy. A 14-year-old male soccer player complained of right heel pain without trauma histories when he was playing a soccer. Based on physical examination, radiological findings and laboratory results, we diagnosed the patient with septic RB and started to treat with conservative treatment including a non-weightbearing splint and intravenous antibiotics therapy. However, his symptoms and laboratory results did not improve at 4 days after starting intravenous antibiotics therapy, and so we applied hindfoot endoscopic bursectomy for him. At 4 weeks after the surgery, he could return to the original sport at preinjury level without symptoms and complications. Septic RB in a 14-year-old male soccer player was successfully treated with hindfoot endoscopic bursectomy.

Failed Surgery for Achilles Tendinopathy

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Systematic Review of Outcome Measures Reported in Clinical Trials of Achilles Tendinopathy

BACKGROUND

Nine core domains for tendinopathy have been identified. For Achilles tendinopathy there is large variation in outcome measures used, and how these fit into the core domains has not been investigated.

OBJECTIVE

To identify all available outcome measures outcome measures used to assess the clinical phenotype of Achilles tendinopathy in prospective studies and to map the outcomes measures into predefined health-related core domains.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE (Ovid), Web of Science, CINAHL, The Cochrane Library, SPORTDiscus and Google Scholar.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Clinical diagnosis of Achilles tendinopathy, sample size ≥ ten participants, age ≥ 16 years, and the study design was a randomized or non-randomized clinical trial, observational cohort, single-arm intervention, or case series.

RESULTS

9376 studies were initially screened and 307 studies were finally included, totaling 13,248 participants. There were 233 (177 core domain) different outcome measures identified across all domains. For each core domain outcome measures were identified, with a range between 8 and 35 unique outcome measures utilized for each domain. The proportion of studies that included outcomes for predefined core domains ranged from 4% for the psychological factors domain to 72% for the disability domain.

CONCLUSION

233 unique outcome measures for Achilles tendinopathy were identified. Most frequently, outcome measures were used within the disability domain. Outcome measures assessing psychological factors were scarcely used. The next step in developing a core outcome set for Achilles tendinopathy is to engage patients, clinicians and researchers to reach consensus on key outcomes measures.

PROSPERO REGISTRATION

CRD42020156763.

[Method of surgical treatment of patients with a chronic rupture of the Achilles tendon]

OBJECTIVE

To improve treatment outcomes in patients with long-standing Achilles tendon ruptures with severe diastasis and dysfunction of the calf muscle via the use of a new method of surgical treatment.

MATERIAL AND METHODS

The authors proposed a new method of Achilles tendon repair for diastasis from 5 to 10 cm. This technique consists in elimination of diastasis with a tendon of the long peroneal muscle on the distal base. Surgical stages are described. The authors also report a patient with long-standing Achilles tendon rupture. Surgical treatment and postoperative outcomes are described.

RESULTS

Postoperative outcomes were assessed in 23 patients. The control group consisted of 21 patients who underwent reconstruction according to Chernavsky's and Krasnov's methods. Assessment was carried out using clinical and biomechanical methods. The authors analyzed gait asymmetry and functional myography data. Their data indicate the advantage of treatment in the main group.

[A new method of surgical treatment of patients with chronic distal Achilles tendon rupture]

OBJECTIVE

To improve postoperative outcomes in patients with distal Achilles tendon rupture by using of a new method of surgical treatment.

MATERIAL AND METHODS

The authors proposed a new method to restore the Achilles tendon for its distal rupture (within 2 cm from attachment to the calcaneus). This approach implies forming a canal in the calcaneus and minimally invasive harvesting of the plantar tendon. At the next stage, the plantar tendon is passed through the canal of the calcaneus in U-shaped fashion and proximal part of Achilles tendon with maximum approximation of its fragments and imposing of interrupted sutures on the plantar and Achilles tendons to hold the position. The end of plantar tendon is used to reinforce damaged area. The schemes and surgical stages are shown in the figures. We reported a patient with distal Achilles tendon rupture and postoperative outcome.

RESULTS

An above-mentioned approach was applied in 26 patients. The control group consisted of 21 patients who underwent recovery with anchor fixers. Early and long-term postoperative results, as well as adverse events were analyzed in both groups. Biomechanical parameters of gait were evaluated from the standpoint of evidence-based medicine using podography and functional myography. We confirmed an advantage of treatment in the main group.

Partial Achilles Tendon Rupture-A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options

Partial ruptures in the Achilles tendon are rather uncommon and are often misinterpreted as aggravated Achilles tendinopathy, and not always considered as a differential diagnosis. The aim of this literature review was to characterize typical symptoms, to provide an overview of available diagnosis and treatment options, and to give reference points for future research. There were few studies and sparse knowledge of scientific value, making it difficult to give evidence-based recommendations. Based on the few studies and the authors’ clinical experience, a diagnosis should be based on a patient’s history with a typical sharp onset of pain and inability to fully load the tendon. Previous intratendinous cortisone injections might be present. Clinical findings are a localized tender region in the tendon and often weakness during heel raises. Ultrasound and Doppler examinations show a region with an irregular and bulging superficial tendon line, often together with localized high blood flow. Magnetic resonance Imaging (MRI) shows a hyperintense signal in the tendon on T1 and T2-weighted sequences. First-line therapy should be a conservative approach using a 2 cm heel lift for the first 6 weeks and avoiding tendon stretching (for 12 weeks). This is followed by a reduced heel lift of 1 cm and progressive tendon loading at weeks 7–12. After 12 weeks, the heel lift can be removed if pain-free, and the patient can gradually start eccentric exercises lowering the heel below floor level and gradually returning to previous sport level. If conservative management has a poor effect, surgical exploration and the excision of the partial rupture and suturing is required. Augmentation procedures or anchor applications might be useful for partial ruptures in the Achilles insertion, but this depends on the size and exact location. After surgery, the 12 to 14-week rehabilitation program used in conservative management can be recommended before the patient’s return to full tendon loading activities.

Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area

BACKGROUND

Achilles tendon partial tears are not easy to diagnose and to manage. Most frequently, they are located in the midportion and insertional area. These entities result from different pathologic pathways, and different treatment strategies are applied. The outcome is rarely investigated.

METHODS

This study includes patients who underwent surgery for partial tears in the midportion or retrocalcaneal Achilles tendon area between the years 2009 and 2015 by a single surgeon. Patients were prospectively assessed preoperatively and 3, 6, and 12 months postoperatively, using the VISA-A-G questionnaire. The final retrospective follow-up was performed after a minimum of 3.5 years postoperatively. Forty-eight Achilles tendon partial tears at the level of the retrocalcaneal bursa (impingement lesions) and 27 midportion Achilles tendon partial tears were identified. After applying rigorous exclusion criteria, 21 and 16 cases, respectively, remained for the final follow-up. Results were analysed by inferential and descriptive statistics.

RESULTS

The VISA-A-G outcome scores improved significantly from preoperative to 6 months, 12 months, and final postoperative assessment. Preoperatively, the average VISA-A-G score was 42.1 (range, 18-73) for patients operated for Achilles tendon partial tears at the level of the retrocalcaneal bursa and 44.6 (range, 10-73) for the midportion Achilles tendon partial tear group, respectively. At final follow-up 88.8 (range, 15 to 100) and 96.9 (range, 71 to 100) were scored in the respective treatment groups. A repeated measures ANOVA determined that mean performance levels showed a statistically significant difference between measurements (p < 0.001). There was no systematic effect found between groups (p = 0.836).

CONCLUSIONS

In Achilles tendon partial tears recalcitrant to conservative treatment, operative intervention is highly successful in most cases, irrespective of the level of the injury. Results were statistically equal when comparing the midportion and retrocalcaneal Achilles tendon partial tear groups.

TRIAL REGISTRATION

DRKS, DRKS00014266. Registered 06 April 2018. 'Retrospectively registered', https://www.drks.de/drks_web/navigate.do?navigationId=results .

MRI in patients with Haglund's deformity and its influence on therapy

INTRODUCTION

Heel pain is one of the common reasons why patients consult orthopaedic surgeons in an outpatient setting. The dorsal heel pain is often caused by a Haglund's deformity which is an exostosis of the posterior superior calcaneus. It often leads to Haglund's syndrome with calcaneal bursitis and Achilles tendinosis. This study aims to investigate the roll of MRI in diagnosis of Haglund's syndrome and its influence on therapy.

MATERIALS AND METHODS

We retrospectively analysed data of 45 patients which clinically and radiologically confirmed Haglund's deformity. Patients were divided into two groups that either did not receive MRI (MRI_0) or received MRI (MRI_1). To evaluate the significance, Fisher´s test was used. A statistical significance was assumed at p < 0.05.

RESULTS

The average age was 57.0 years. There was no significant difference in therapy comparing the groups MRI_0 and MRI_1. Haglund's syndrome was detected in 86.7% of all patients with Haglund's deformity.

CONCLUSION

MRI does not influence the therapy of patients with Haglund's deformity. Therefore, the resources of this cost-intensive and limited type of investigation should be used elsewhere. In cases of atypical heel pain, the MRI might be useful.

[New surgical method for chronic rupture of the Achilles tendon]

AIM

To improve the outcomes in patients with chronic ruptures of the Achilles tendon followed by advanced diastase and reduced function of the gastrocnemius muscle by using of new surgical method.

MATERIAL AND METHODS

The authors proposed a new method of Achilles tendon repair for diastase over 10 cm. It imposes transposition of the tendons of short fibular muscle and posterior tibial muscle. Schemes and stages of surgery are presented in figures. The authors described clinical example of patient with chronic rupture of the Achilles tendon, illustrations of surgical stages and the outcome.

RESULTS

New surgical approach was applied in 16 patients. The control group consisted of 21 patients who underwent repair by Chernavsky, Krasnov. Clinical and biomechanical methods were used for evaluation. Functional myography and podography to assess the asymmetry of gait were performed. Our data confirmed the advantage of new approach.

Achilles Impingement Tendinopathy on Magnetic Resonance Imaging

Haglund's syndrome is impingement of the retrocalcaneal bursa and Achilles tendon caused by a prominence of the posterosuperior calcaneus. Radiographic measurements are not sensitive or specific for diagnosing Haglund's deformity. Localization of a bone deformity and tendinopathy in the same sagittal section of a magnetic resonance imaging scan can assist with the diagnosis in equivocal cases. The aim of the present cross-sectional study was to determine the prevalence of Haglund's syndrome in patients presenting with Achilles tendinopathy and note any associated findings to determine the criteria for a diagnosis of Haglund's syndrome. We reviewed 40 magnetic resonance imaging scans with Achilles tendinopathy and 19 magnetic resonance imaging scans with Achilles high-grade tears and/or ruptures. Achilles tendinopathy was often in close proximity to the superior aspect of the calcaneal tuberosity, consistent with impingement (67.5%). Patients with Achilles impingement tendinopathy were more often female (p < .04) and were significantly heavier than patients presenting with noninsertional Achilles tendinopathy (p = .014) or Achilles tendon rupture (p = .010). Impingement tendinopathy occurred medially (8 of 20) and centrally (10 of 20) more often than laterally (2 of 20) and was associated with a posterior prominence or hyperconvexity with a loss of calcaneal recess more often than a superior projection (22 of 27 versus 8 of 27; p < .001). Haglund's deformity should be reserved for defining a posterior prominence or hyperconvexity with loss of calcaneal recess because this corresponds with impingement. Achilles impingement tendinopathy might be more appropriate terminology for Haglund's syndrome, because the bone deformity is often subtle. Of the 27 images with Achilles impingement tendinopathy, 10 (37.0%) extended to a location prone to Achilles tendon rupture. Given these findings, insertional and noninsertional Achilles tendinopathy are not mutually exclusive and impingement might be a subtle, unrecognized cause of Achilles tendinopathy and subsequent rupture.

Surgical treatment for midportion Achilles tendinopathy: a systematic review

PURPOSE

The aim of this study was to systematically evaluate the available literature on surgical treatment for midportion Achilles tendinopathy and to provide an overview of the different surgical techniques.

METHODS

A systematic review of the literature available in MEDLINE, EMBASE and the Cochrane database of controlled trials was performed. The primary outcome measure in terms of patient satisfaction and the secondary outcome measures that consisted of complication rate, pain score, functional outcome score and success rate were evaluated. The Downs & Black checklist and the Coleman methodology scale were used to assess the methodological quality of included articles.

RESULTS

Of 1090 reviewed articles, 23 met the inclusion criteria. The included studies reported on the results of 1285 procedures in 1177 patients. The surgical techniques were divided into five categories. Eleven studies evaluated open surgical debridement, seven studies described minimally invasive procedures, three studies evaluated endoscopic procedures, one study evaluated open gastrocnemius lengthening, and one study reported on open autologous tendon transfer. Results regarding patient satisfaction (69-100 %) and complication rate (0-85.7 %) varied widely.

CONCLUSIONS

This study demonstrates the large variation in surgical techniques available for treatment of midportion Achilles tendinopathy. None of the included studies compared surgical intervention with nonsurgical or placebo intervention. Minimally invasive and endoscopic procedures yield lower complication rates with similar patient satisfaction in comparison with open procedures. Minimally invasive and endoscopic procedures might therefore prove to be the future of surgical treatment of Achilles midportion tendinopathy.

LEVEL OF EVIDENCE

IV.

Midsubstance Tendinopathy, Surgical Management

Noninsertional Achilles tendinopathy often responds to nonoperative treatment. When nonoperative treatment fails, the clinician must distinguish between paratendinopathy and noninsertional tendinopathy. In paratendinopathy, myofibroblasts synthesize collagen, causing adhesions, and the paratenon may be released or excised. If a core area of tendinopathy is identified on MRI, the area is excised longitudinally and repaired with a side-to-side suture. If greater than 50% of the tendon diameter is excised, the authors recommend a short flexor hallucis longus tendon transfer with an interference screw. A turndown flap of the gastrocnemius aponeurosis is also described with good results.

Follow-up of surgical and minimally invasive treatment of Achilles tendon pathology: a brief diagnostic imaging review

The follow-up of an operated tendon is primarily clinical, although clinical examination may not be sufficient in the presence of certain complications. The imaging techniques are of great value not only in the diagnosis of tendon pathologies, but also as an adjunct to clinical evaluation. This is particularly true in the follow-up of patients submitted to surgical tendon reconstruction, by monitoring morphological effects of different interventions and evaluating tendon healing processes. Interpretation of imaging findings requires knowledge of the imaging appearance of the operated tendon during the healing phase, to distinguish between normal postsurgical changes and real pathology, as well as knowledge of surgical technique, postoperative course (including type of prescribed therapy) and possible postoperative complications. The most important imaging modalities to examine the Achilles tendon are ultrasound and magnetic resonance imaging. This article gives a review of some of the most common treatment strategies for Achilles tendon pathology, expected postoperative imaging findings and postoperative complications.

Haglund's Syndrome: A Commonly Seen Mysterious Condition

Haglund's deformity was first described by Patrick Haglund in 1927. It is also known as retrocalcaneal exostosis, Mulholland deformity, and 'pump bump.' It is a very common clinical condition, but still poorly understood. Haglund's deformity is an abnormality of the bone and soft tissues in the foot. An enlargement of the bony section of the heel (where the Achilles tendon is inserted) triggers this condition. The soft tissue near the back of the heel can become irritated when the large, bony lump rubs against rigid shoes. The aetiology is not well known, but some probable causes like a tight Achilles tendon, a high arch of the foot, and heredity have been suggested as causes. Middle age is the most common age of affection, females are more affected than males, and the occurence is often bilateral. A clinical feature of this condition is pain in the back of the heel, which is more after rest. Clinical evaluation and lateral radiographs of the ankle are mostly enough to make a diagnosis of Haglund's syndrome. Haglund's syndrome is often treated conservatively by altering the heel height in shoe wear, orthosis, physiotherapy, and anti-inflammatory drugs. Surgical excision of the bony exostoses of the calcaneum is only required in resistant cases.

Surgical treatment for achilles tendinopathy - a systematic review

Background

The purpose of this systematic review is to analyse the results of operative treatment for midportion Achilles tendinopathy and to provide evidence based recommendation for the indication of the individual published techniques.

Methods

MEDLINE, Cochrane Database, ISI Web of Knowledge and Google databases (1945 till September 2014) were electronically searched. The quality of the included articles was evaluated using the Coleman Methodology Score. Success rates, patient satisfaction, and the complication rates were determined.

Results

Twenty studies met our inclusion criteria. A total of 801 tendons were treated in 714 patients with open or minimally invasive techniques. The mean success rate was 83.4 %. Complications were reported in 6.3 % of the cases. The articles on minimally invasive techniques and open procedures reported on an average success rate of 83.6 % and 78.9 (p = 0.987). Patient satisfaction rates for minimally invasive techniques and open procedures were 78.5 % and 78.1 % (p = 0.211). The complication rate was 5.3 % for the minimally invasive techniques and 10.5 % for the open procedures (p = 0.053).

Conclusion

We conclude that success rates of minimally invasive and open treatments are not different and that there is no difference in patient satisfaction but there is a tendency for more complications to occur in open procedures.