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Ptak NA, Rigby RB. Impact of BMI on the Surgical Management of Chronic Insertional Achilles Tendinopathy. J Foot Ankle Surg 2024; 63:333-336. [PMID: 38151114 DOI: 10.1053/j.jfas.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/31/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023]
Abstract
Posterior heel pain secondary to insertional Achilles tendinopathy is a common condition that often times requires surgical management. Typically, this involves reflecting a portion of the Achilles tendon from its insertion to adequately debride devitalized or thickened tendon as well as any osseous prominence and then reattached into the calcaneus via suture anchors. Oftentimes, it is suggested that patients with an increased body mass index (BMI) have a higher risk of complications. However, there is no published evidence to support this claim. The present study is a retrospective review of 78 patients who underwent detachment/reattachment of the Achilles tendon for chronic insertional Achilles tendinopathy. Patients were separated into three groups based on BMI: normal, obese, and morbidly obese. The mean BMI of all patients included was 35.6 kg/m2 (range: 21.8-54.9, SD: 6.9). We compared complication rates between the groups and found no significant difference (p = .541). Patients in all groups also demonstrated statistically significant improvements in both American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores (Normal BMI: p = .002; Obese: p = <.001; Morbidly obese: p = <.001) and Patient-Recorded Outcomes Measurement Information System (PROMIS) scores (Normal BMI: p = .003; Obese: p = <.001; Morbidly obese: p = .001). In conclusion, the results of our study demonstrate that detachment/reattachment of the Achilles insertion in the management of insertional Achilles tendinopathy in obese and morbidly obese patients may be safe and effective without the risk of increased complications.
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Affiliation(s)
| | - Ryan B Rigby
- Logan Regional Orthopedics - Intermountain Healthcare, Logan, UT
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2
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DeVries JG, Scharer BM, Donnay RL, Romdenne TA. No Loss of Strength After Insertional Achilles Tendon Reconstruction With Single-Anchor or Double-Row Repair. J Foot Ankle Surg 2024; 63:22-26. [PMID: 37597583 DOI: 10.1053/j.jfas.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 08/01/2023] [Accepted: 08/13/2023] [Indexed: 08/21/2023]
Abstract
Many different types of surgical repair for insertional Achilles tendinosis have been described. Strength after surgery is an essential factor for patient function and satisfaction. A retrospective series of patients that underwent surgery for insertional Achilles tendon surgery were contacted to come in for prospective strength testing, with the tester blinded to the type of surgery performed. Thirty-seven patients came in for testing, 24 with a single-anchor repair and 13 with a double-row repair. Strength of plantarflexion was tested at 60°/s and 120°/s and was compared. First each operative leg was compared to the nonoperative leg as a control. Then the percentage change, or symmetry, from the control leg to the operative leg was compared between those with a single-anchor and double-row repair. Satisfaction was also assessed with a simple questionnaire and compared the types of repair. The results demonstrated there was no statistically significant change in strength after surgery compared to the nonoperative leg, and there was no difference in limb symmetry between types of repair. Similarly, there was no difference between the groups in satisfaction. Our study showed that there is, on average, no loss of strength after insertional Achilles tendon surgery at an average follow-up of nearly 2 years, regardless of type of repair.
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Kelsey LTJ, Mombell LKW, Fellars CTA. The Addition of a Krackow Rip Stop Suture Augment After Achilles Tendon Debridement for Insertional Achilles Tendinopathy: A Biomechanical Study. Foot Ankle Spec 2023; 16:356-362. [PMID: 34931550 DOI: 10.1177/19386400211033693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the operative treatment of insertional Achilles tendinopathy, the Achilles tendon is often released from its insertion to allow for adequate debridement of pathologic tissue. The use of a double row suture anchor construct has become increasingly favorable among surgeons after Achilles tendon debridement. This study hypothesized that the addition of a Krackow rip stop suture augment to the double row suture anchor construct would increase the repair's maximum load to failure. A biomechanically stronger repair would potentially decrease the risk of catastrophic failure with early weight-bearing or accidental forced dorsiflexion after operative management for insertional Achilles tendinopathy. METHODS Fourteen cadaveric specimens were used to compare the 2 repair techniques. Achilles tendons were debrided and repaired using either a double row suture anchor with and without the additional Krackow rip stop suture augment. The 2 repair techniques were compared using an axial-torsion testing system to measure average load to failure. RESULTS The average load to failure for the double row suture anchor repair alone was 152.00 N. The average load to failure for the tendons with the double row suture anchor with the Krackow rip stop augment was 383.08 N. An independent-samples Mann-Whitney U-test was conducted and the suture anchor plus Krackow augment group had a significantly higher load to failure (P = .011, Mann-Whitney U = 5.00, n1 = n2 = 7, P < .05, 2-tailed). CONCLUSION This study confirmed that the addition of a Krakow rip stop augment to the double row suture anchor is able to increase the maximum load to failure when compared to the double row suture anchor alone. These results suggest the potential of this added technique to decrease the risk of catastrophic failure.
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Affiliation(s)
- Lt Thomas J Kelsey
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, California
| | - Lt Kyle W Mombell
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, California
| | - Cdr Todd A Fellars
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, California
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Gaston TE, Skibicki HE, Cheesman QT, Chapter MC, Daniel JN. Excisional Debridement for Chronic Achilles Insertional Tendinosis: A Novel Technique and Case Review. Foot Ankle Spec 2023; 16:349-355. [PMID: 34689642 DOI: 10.1177/19386400211034680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Operative treatment of chronic Achilles insertional tendinosis (AIT) involves tendon debridement, removal of the retrocalcaneal bursitis, and excision of the calcaneal exostosis, often followed by repair of the Achilles tendon and deep tendon transfer. The literature describes a variety of techniques without a single standard of care. METHODS This is a retrospective review of 57 patients treated with an excisional debridement of the central portion of the Achilles tendon. The novelty of this technique is that instead of complete detachment of the tendon from its insertion, only the central portion is debrided and excised. This allows for enhanced visibility of the calcaneal exostosis and increased healing with apposition of viable tendon during side-to-side repair. RESULTS Patient-reported outcome scores and pain significantly improved from preoperatively to a minimum of 2 years postoperatively. Complications were similar to those previously reported, with superficial wound breakdown being the most common. CONCLUSION In conclusion, the use of this reliable, reproducible, and effective technique for the treatment of patients with chronic AIT is encouraged because it provides both enhanced visibility and allows complete resection of all pathological tissue. LEVELS OF EVIDENCE Level IV: Retrospective case series.
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Affiliation(s)
- Tara E Gaston
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey (TEG, HES, QTC); NYU Winthrop Hospital, Garden City, New York (MCC)
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania (JND)
| | - Hope E Skibicki
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey (TEG, HES, QTC); NYU Winthrop Hospital, Garden City, New York (MCC)
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania (JND)
| | - Quincy T Cheesman
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey (TEG, HES, QTC); NYU Winthrop Hospital, Garden City, New York (MCC)
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania (JND)
| | - Megan C Chapter
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey (TEG, HES, QTC); NYU Winthrop Hospital, Garden City, New York (MCC)
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania (JND)
| | - Joseph N Daniel
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey (TEG, HES, QTC); NYU Winthrop Hospital, Garden City, New York (MCC)
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania (JND)
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Tay AYW, Goh GS, Li Z, Yeo NEM, Tay KS. Two-Year Clinical and Radiologic Outcomes Following Surgical Treatment of Insertional Achilles Tendinopathy Using a Central Tendon-Splitting Approach. Foot Ankle Int 2023; 44:702-709. [PMID: 37272028 DOI: 10.1177/10711007231173679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND If conservative treatment of insertional Achilles tendinopathy (IAT) fails, surgery is often considered. Various surgical approaches have been used including the central Achilles tendon splitting approach. This study aimed to report the 2-year clinical and radiologic outcomes after surgical treatment of IAT with a central tendon-splitting approach. METHODS Seventy-five cases of IAT treated surgically via the open central tendon-splitting approach were analyzed. Clinical outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, visual analog scale (VAS), 36-Item Short Form Health Survey (SF-36) physical (PCS) and mental (MCS) component summary scores, all measured at baseline and 6 and 24 months postoperatively. Radiologic parameters measured included the Fowler-Philip angle (FPA) and parallel pitch lines (PPL). RESULTS Three patients had clinically significant wound issues but healed completely by 3 weeks. Mean AOFAS score improved from 45.63 preoperatively to 94.71 at 24 months. Mean VAS score improved from 6.73 preoperatively to 0.55, mean SF-36 PCS from 35.98 to 48.74, and mean SF-36 MCS from 53.04 to 55.43 at 24 months. Satisfaction at 2 years was 94.3%. Mean FPA decreased from 62.0 degrees preoperatively to 34.0 degrees postoperatively. PPL was positive in 82.7% (62 of 75) of cases preoperatively, decreasing to 1.3% (1 of 75) postoperatively. Increasing age and higher preoperative VAS and SF-36 MCS scores were significantly associated with improvements in postoperative AOFAS, SF-36 PCS, and MCS scores. CONCLUSION Surgical treatment of IAT via the central tendon-splitting approach achieved substantial improvements in all patient-reported outcome measures measured. These excellent clinical outcomes continued to show improvement 2 years postoperatively. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Adriel You Wei Tay
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Graham S Goh
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Zongxian Li
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - Kae Sian Tay
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Kunkle BF, Baxter NA, Caughman AM, Barcel JA, Scott DJ, Gross CE. Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis. Foot Ankle Spec 2023; 16:370-376. [PMID: 35583105 DOI: 10.1177/19386400221090358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT. METHODS A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups. RESULTS No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012). DISCUSSION Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bryce F Kunkle
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Nicholas A Baxter
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander M Caughman
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - John A Barcel
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel J Scott
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina
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Nakajima K. Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review. World J Orthop 2023; 14:369-378. [PMID: 37377992 PMCID: PMC10292061 DOI: 10.5312/wjo.v14.i6.369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 06/19/2023] Open
Abstract
Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.
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Affiliation(s)
- Kenichiro Nakajima
- Center for Foot and Ankle Surgery, Department of Orthopedic Surgery, YashioCentral General Hospital, Yashio-shi 340-0814, Saitama, Japan
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8
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Singh MS, Harna B, Singh S, Vishwakarma G. Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores. Foot (Edinb) 2023; 54:101969. [PMID: 36805957 DOI: 10.1016/j.foot.2023.101969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/16/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE Chronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores. METHOD It is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50-77 years) followed by over 35.6 months (Range 22-48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits. RESULTS All the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22-48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.300+ 4.90 and 12.50+ 4.70 respectively. Three patients had minor wound complications. All the patients returned to activities of daily living. CONCLUSION FHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.
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Affiliation(s)
- Maninder S Singh
- Department of Orthopaedics, Indian Spinal Injuries Centre, New Delhi, India
| | - Bushu Harna
- Department of Orthopaedics, Max Super speciality Hospital, New Delhi, India.
| | - Sukhmin Singh
- Department of Orthopedics, Gautam Buddha Chikitsa Mahavidyalaya, Dehradun, Uttarakhand, India
| | - Gyatri Vishwakarma
- Department of Biostatistics, Indian Spinal Injuries Centre, New Delhi, India
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9
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DeVries JG, Scharer BM. Double Row Fixation is More Costly and Does Not Have Clinical Benefit Over Single Anchor for Insertional Achilles Tendon Surgery. J Foot Ankle Surg 2023:S1067-2516(23)00007-8. [PMID: 36737321 DOI: 10.1053/j.jfas.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023]
Abstract
Surgical repair of insertional Achilles tendinosis is indicated in the face of failed conservative measures. Several methods for this repair have been described, and the optimal method is not universally agreed upon. In addition, the cost of medical care is important, and should be considered when determining the surgical repair for each patient. The purpose of this study is to compare implant costs between a single anchor or 4 anchor, double row repair, and evaluate associated outcomes. A retrospective comparative trial was performed for this purpose. The entire study encompassed 110 patients, 78 with a single anchor repair, and 32 with a double row repair. The average implant cost of the single anchor repair was $391.18 ± $272.10 and the double row repair was $1811.2 9 ± $169.47, p < .001. The groups did not have a statistically significant difference in complications (9% with single anchor vs 6.3% with double row, p = 1.0) or revisions 6.4% with single anchor vs 3.1% with double row, p = .67). The only difference in demographics between the groups was that the single anchor group had a higher percentage of female patients (p = .04). While the double row repair has been shown to have favorable biomechanical results, the present study did not show a benefit in complications or revisions and was a more costly repair technique. Surgeons should take these findings in consideration when choosing the repair technique when surgery is indicated.
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Lindén L, Granath M, Hedlund P, Spang C, Alfredson H. Ultrasonography- and Doppler-Guided Surgical Treatment for Insertional Achilles Tendinopathy: Results From a Case Series in a Southern Sweden County Hospital. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231165014. [PMID: 37021119 PMCID: PMC10068980 DOI: 10.1177/24730114231165014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Background: Treatment with ultrasonography (US)- and color Doppler (CD)-guided mini surgery for insertional Achilles tendinopathy has shown good clinical results in a sports medicine setting. The aim in this study was to introduce this new methodology at a county hospital and study the clinical results on a traditional orthopaedic population. Methods: Twenty-six consecutive patients (12 men, mean age 61 years; 14 women, mean age 56 years) with a long duration (>12 months) of pain symptoms from insertional Achilles tendinopathy (a combination of bursae, bone, and tendon pathology) were included. US- and CD-guided surgical removal of bursae, bone, and tendon pathology, performed with local anaesthesia, was used. After surgery, there was immediate weightbearing loading without immobilization, followed by a structured rehabilitation protocol for 12 weeks. The VISA-A and SEFAS scores plus a questionnaire evaluating satisfaction with treatment and activity level was used for evaluation. Results: At the 1-year follow-up, there were 3 dropouts. Twenty-one patients were satisfied. Their VISA-A score had increased significantly from 26 to 81 ( P < .001), and the SEFAS score from 17 to 38 ( P < .001). Two patients were not satisfied. There were 3 complications, 2 superficial skin infections, and 1 wound rupture. Conclusion: For patients with chronic painful insertional Achilles tendinopathy, the US- and CD-guided surgical treatment method followed by immediate weightbearing loading showed a high satisfaction rate and improved functional scores at the 1-year follow-up in a majority of the patients. There are advantages using this method compared to other more tendon invasive surgical methods in use for this condition. Level of Evidence: Level IV, case series.
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Affiliation(s)
| | | | | | - Christoph Spang
- Department of Integrative Medical
Biology, Anatomy Section, Umeå University, Umeå, Sweden
- Private Orthopaedic Spine Center,
Würzburg, Germany
| | - Håkan Alfredson
- Department of Community Research and
Rehabilitation, Sports Medicine Unit, Umeå University, Umeå, Sweden
- Alfredson Tendon Clinic, Ortho Center
Skåne, Malmö, Sweden
- Håkan Alfredson, MD, PhD, Professor, Senior
Consultant, Specialist in Orthopaedic Surgery, Department of Community Research
and Rehabilitation, Sports Medicine Unit, Umeå University, 901 87 Umeå, Sweden.
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Nakajima K. Fluoroscopic and Endoscopic Calcaneal Exostosis Resection and Achilles Tendon Debridement for Insertional Achilles Tendinopathy Results in Good Outcomes, Early Return to Sports Activities, and Few Wound Complications. Arthrosc Sports Med Rehabil 2022; 4:e1385-e1395. [PMID: 36033171 PMCID: PMC9402468 DOI: 10.1016/j.asmr.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/24/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose To review the outcomes of patients with insertional Achilles tendinopathy who underwent a minimally invasive surgery: fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement. Methods The medical records of consecutive patients who underwent this surgery from February 2017 to July 2019 were reviewed. The inclusion criterion was ≥2-year follow-up. The exclusion criterion was another surgery performed on the ipsilateral or contralateral foot. Haglund deformity resection was not combined with this surgery. The outcomes were assessed using the visual analog scale (VAS) score and the Japanese Society for Surgery of the Foot (JSSF) scores for all patients and the Victorian Institute of Sport Assessment self-administered Achilles (VISA-A) scores for patients participating in sports activities. The Wilcoxon signed-rank test and the thresholds of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were used for statistical analyses. Results Forty-four patients with a mean age of 55.7 ± 11.0 years and mean body mass index of 26.0 ± 4.0 kg/m2 were included. The mean follow-up duration was 2.8 ± 0.7 years. Of all participants, 22 participated in sports activities. The overall median VAS and JSSF scores improved from 64.5 to 6.5 mm and from 67.0 to 100 points, respectively (P < .001). The percentages of patients who achieved the MCID for the VAS, JSSF, and VISA-A scores were 100%, 93.2%, and 100%, respectively, and the percentages of patients who achieved the PASS for the VAS, JSSF, and VISA-A scores were 77.3%, 86.4%, and 81.8%, respectively. The median VISA-A scores improved from 40.5 to 95.0 points (P < .001). The median time to return to sport was 4.5 months. Complications included five cases of reoperation and two cases of scar sensitivity. Conclusion For patients with insertional Achilles tendinopathy, fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement resulted in good outcomes, early return to sports activities, and few wound complications. Level of Evidence IV, therapeutic case series
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12
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Phisitkul P, Mansur NSB, Netto CDC. Failed Surgery for Achilles Tendinopathy. Foot Ankle Clin 2022; 27:431-455. [PMID: 35680298 DOI: 10.1016/j.fcl.2021.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Phinit Phisitkul
- Tri-state Specialists, LLP, 2730 Pierce Street #300, Sioux City, IA 51104, USA.
| | - Nacime Salomao Barbachan Mansur
- Department of Orthopaedics and Rehabilitation, University of Iowa Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA
| | - Cesar de Cesar Netto
- Department of Orthopaedics and Rehabilitation, University of Iowa Carver College of Medicine, 200 Hawkins Drive, John PappaJohn Pavillion (JPP), Room 01066, Lower Level, Iowa City, IA 52242, USA
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13
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Management of Insertional Achilles Tendinopathy. J Am Acad Orthop Surg 2022; 30:e751-e759. [PMID: 35286285 DOI: 10.5435/jaaos-d-21-00679] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/29/2022] [Indexed: 02/01/2023] Open
Abstract
Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.
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Cengiz B, Karaoglu S. Clinical results of the Keck and Kelly Wedge Osteotomy approach in Haglund's deformity: Minimum 3-year follow-up. Foot Ankle Surg 2022; 28:269-275. [PMID: 34674937 DOI: 10.1016/j.fas.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/23/2021] [Accepted: 10/06/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE The Haglund's deformity, which may be difficult to treat non-surgically, is caused by a prominent bone hump in the posterosuperior region of the calcaneus and may be associated with bursitis and foot pain. Many surgical treatments for resistant Haglund deformities have been described. Here, we evaluate the AOFAS scores, pain and other characteristics of patients undergoing removal of the dorsally based wedge from the posterior calcaneus with the Keck and Kelly procedure. MATERIALS AND METHODS The study included 20 patients who had undergone the Keck and Kelly procedure at our center, from 2011 to 2019, and had attended follow-up for at least three years. Analyses were performed retrospectively. Preoperative (immediately before surgery) and postoperative (at last assessment) American Orthopedic Foot and Ankle Society (AOFAS) and visual analog pain scale scores (VAS) were determined, and calcaneal inclination angles were radiologically measured. Additionally, calcaneal pitch angle (CPA), Fowler and Philip angle (FPA), and Bohler angle were recorded. RESULTS Fourteen patients were female, and six were male, mean age was 45.8 ± 8.1 years. AOFAS scores were significantly increased, whereas VAS scores were significantly decreased after surgery. Postoperative AOFAS scores were correlated with preoperative VAS, CPA, and FPA values. Preoperative VAS scores were correlated with CPA, FPA, and Bohler angle values. FPA and CPA values were correlated positively. CONCLUSIONS It was found that ankle functions improved, and pain levels decreased after Keck and Kelly Wedge Osteotomy was applied for the treatment of Haglund's deformity. CPA and FPA were associated with both pain levels and ankle function. The Keck and Kelly Wedge Osteotomy procedure appears to be a preferable approach for the surgical treatment of Haglund's deformity.
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Affiliation(s)
- Bertan Cengiz
- Department of Orthopedics and Traumatology, Acibadem Kayseri Hospital, Kayseri, Turkey.
| | - Sinan Karaoglu
- Department of Orthopedics and Traumatology, Acibadem Kayseri Hospital, Kayseri, Turkey
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15
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Mora KE, Mlawer SJ, Bae AJ, Richards MS, Loiselle AE, Buckley MR. Ultrasound strain mapping of the mouse Achilles tendon during passive dorsiflexion. J Biomech 2022; 132:110920. [PMID: 34998182 PMCID: PMC10564406 DOI: 10.1016/j.jbiomech.2021.110920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/21/2022]
Abstract
Immediately prior to inserting into bone, many healthy tendons experience impingement from nearby bony structures. However, super-physiological levels of impingement are implicated in insertional tendinopathies. Unfortunately, the mechanisms underlying the connection between impingement and tendon pathology remain poorly understood, in part due to the shortage of well-characterized animal models of impingement at clinically relevant sites. As a first step towards developing a model of excessive tendon impingement, the objective of this study was to characterize the mechanical strain environment in the mouse Achilles tendon insertion under passive dorsiflexion and confirm that - like humans - mice experience impingement of the tendon insertion from the calcaneus (heel bone) in dorsiflexed ankle positions. Based on previous work in humans, we hypothesized that during dorsiflexion, the mouse Achilles tendon insertion would experience high levels of transverse compressive strain due to calcaneal impingement. A custom-built loading platform was used to apply passive dorsiflexion, while an ultrasound transducer positioned over the Achilles tendon captured radiofrequency images. A non-rigid image registration algorithm was then used to map the transverse compressive strain based on the acquired ultrasound image sequences. Our results demonstrate that during passive dorsiflexion, transverse compressive strains were produced throughout the Achilles tendon, with significantly larger strain magnitudes at the tendon insertion than at the midsubstance. Furthermore, there was increasing transverse compressive strain observed within the Achilles tendon as a function of increasing dorsiflexion angle. This study enhances our understanding of the unique mechanical loading environment of the Achilles tendon under physiologically relevant conditions.
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Affiliation(s)
- Keshia E Mora
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA.
| | - Samuel J Mlawer
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Albert J Bae
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Michael S Richards
- Department of Biomedical Engineering, Rochester Institute of Technology, Rochester, NY 14623, USA
| | - Alayna E Loiselle
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
| | - Mark R Buckley
- Department of Biomedical Engineering, University of Rochester, Rochester, NY 14620, USA; Center for Musculoskeletal Research, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY 14620, USA
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16
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Do pre-operative radiologic assessment predict postoperative outcomes in patients with insertional Achilles tendinopathy?: a retrospective database study. Arch Orthop Trauma Surg 2022; 142:3045-3052. [PMID: 33891177 PMCID: PMC9522703 DOI: 10.1007/s00402-021-03897-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/03/2021] [Indexed: 12/29/2022]
Abstract
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).
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17
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Miller CP, McWilliam JR, Michalski MP, Acevedo J. Endoscopic Haglund's Resection and Percutaneous Double-Row Insertional Achilles Repair. Foot Ankle Spec 2021; 14:534-543. [PMID: 33840259 DOI: 10.1177/19386400211002707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with nonsurgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double-row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infection. The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using minimally invasive surgery techniques while also incorporating a percutaneous double-row suture anchor repair. The technique utilizes 4 portals to access 2 endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double-row suture anchor repair.Levels of Evidence: Level V.
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Affiliation(s)
- Christopher P Miller
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - James R McWilliam
- New York Medical College, Valhalla, New York.,White Plains Hospital Physicians Associates, White Plains, New York
| | - Max P Michalski
- Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jorge Acevedo
- Department of Orthopedics, Southeast Orthopedic Specialists, Jacksonville, Florida
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18
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Cates NK, Wagler EC, Chen S, Rubin LG. Retrocalcaneal Enthesophyte Resection With Functional Lengthening of the Achilles Tendon and Buried Knot Technique: A Case Series. J Foot Ankle Surg 2021; 60:1308-1314. [PMID: 34389217 DOI: 10.1053/j.jfas.2021.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 02/03/2023]
Abstract
Retrocalcaneal exostosis can be debilitating and in severe cases, surgical resection is indicated. Complications can arise from surgical resection of the exostosis and reattachment of the Achilles tendon, including irritation of the suture knot, recurrence of the bony prominence, and dehiscence. The use of a buried knot technique with functional lengthening of the Achilles tendon and gastroc-soleal muscle complex can minimize these complications. Complete detachment of the Achilles tendon allows for aggressive and thorough resection of the exostosis and functional lengthening with reattachment. The buried cruciate knot technique allows for firm reattachment with buried knots to prevent soft tissue irritation. A total of fourteen patients (14 limbs) underwent retrocalcaneal enthesophyte resection with functional Achilles tendon lengthening, (8/14) of which had difficultly wearing shoe gear, (10/14) had edema, and (2/14) had erythema preoperatively. Postoperatively, (11/14) of patients returned to full activities and sports, and (11/14) returned to normal shoe gear. Complications included (1/14) of patients with Achilles tendon avulsion and (3/14) of patients with surgical site dehiscence requiring revisional surgery. Overall, this technique helps prevent short-term complications and long-term recurrence due to the functional lengthening mitigating insertional forces on the Achilles tendon.
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Affiliation(s)
- Nicole K Cates
- Fellowship Trained Foot and Ankle Surgeon, Hand & Microsurgery Surgery Medical Group, San Francisco, CA.
| | - Emily C Wagler
- Foot and Ankle Reconstruction Fellow, Department of Podiatric Surgery, CHI Franciscan Health, Federal Way, WA
| | - Shirley Chen
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Laurence G Rubin
- Teaching Faculty, MedStar Washington Hospital Center Podiatric Surgery Residency, Mechanicsville, VA
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19
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Thompson JM, Nguyen K, Ahluwalia J, Casciato D, Tewilliager T, So E, Prissel M. Surgical Takedown Approaches to Insertional Achilles Tendinopathy: A Systematic Review. J Foot Ankle Surg 2021; 60:1217-1221. [PMID: 34108118 DOI: 10.1053/j.jfas.2021.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/06/2020] [Accepted: 04/22/2021] [Indexed: 02/03/2023]
Abstract
Various techniques of surgical detachment for treatment of insertional Achilles tendinopathy have been described, including lateral release, medial release, central tendon splitting (CTS), and complete detachment. A systematic review of electronic databases was performed, encompassing 17 studies involving 703 patients and 746 feet, to compare outcomes associated with surgical takedown techniques. Observed results include wound complication rates (CTS 2.8%; Lateral 0%; Medial 0.4%; Complete 1.3%), postoperative rupture rates (CTS 0.7%; Lateral 0.8%; Medial 0.7%; Complete 2.6%), rate of revision (CTS 0.4%; Lateral 0.9%; Medial 4.2%; Complete 2.6%), rate of infection (CTS 1.1%; Lateral 1.7%; Medial 3.7%; Complete 6.5%). Lateral takedown group was found to have a statistically significant lower rate of complications compared to the complete takedown group (p = .0029). In light of these results, it is recommended that patient characteristics such as case specific tendon pathology and calcaneal morphology take precedent in determining the surgical approach to Achilles takedown.
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Affiliation(s)
- John M Thompson
- Division of Foot and Ankle Surgery, OhioHealth Grant Medical Center, Columbus, OH.
| | - Kevin Nguyen
- Division of Foot and Ankle Surgery, OhioHealth Grant Medical Center, Columbus, OH
| | - Jaime Ahluwalia
- Division of Foot and Ankle Surgery, OhioHealth Grant Medical Center, Columbus, OH
| | - Dominick Casciato
- Division of Foot and Ankle Surgery, OhioHealth Grant Medical Center, Columbus, OH
| | - Tyler Tewilliager
- Division of Foot and Ankle Surgery, OhioHealth Grant Medical Center, Columbus, OH
| | - Eric So
- Fellowship-Trained Foot and Ankle Surgeon, Bryan Health, Lincoln, NE
| | - Mark Prissel
- Fellowship-Trained Foot and Ankle Surgeon, Orthopedic Foot and Ankle Center, Worthington, OH
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20
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Lopes R, Ngbilo C, Padiolleau G, Boniface O. Endoscopic speed bridge: A new treatment for insertional Achilles tendinopathy. Orthop Traumatol Surg Res 2021; 107:102854. [PMID: 33578040 DOI: 10.1016/j.otsr.2021.102854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/26/2020] [Accepted: 06/10/2020] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ronny Lopes
- Pied Cheville Nantes Atlantique, Clinique Brétéché, 3 Rue de la Béraudière, 44000 Nantes, France; Pied Cheville Nantes Atlantique, Santé Atlantique, Avenue Claude Bernard, 44800 Saint-Herblain, France.
| | - Cedric Ngbilo
- Centre Orthopédique SANTY, 24 Avenue Paul Santy, 69008 Lyon, France
| | - Giovany Padiolleau
- Pied Cheville Nantes Atlantique, Santé Atlantique, Avenue Claude Bernard, 44800 Saint-Herblain, France
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21
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Greiner F, Trnka HJ, Chraim M, Neunteufel E, Bock P. Clinical and Radiological Outcomes of Operative Therapy in Insertional Achilles Tendinopathy With Debridement and Double-Row Refixation. Foot Ankle Int 2021; 42:1115-1120. [PMID: 33843294 PMCID: PMC8446883 DOI: 10.1177/10711007211002814] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Insertional Achilles tendinopathy (IAT) is a painful pathology in which the strongest and thickest tendon of the human body is affected. Different conservative and operative treatments have been described to address this pathology. This study aimed to evaluate the medium-term clinical and radiological outcomes of patients who underwent a surgical therapy via a longitudinal tendon-splitting approach with debridement and double-row refixation. METHODS All patients were assessed pre- and postoperatively using a visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score, the Foot and Ankle Outcome Score (FAOS), and the Foot Function Index (FFI). Additionally, a lateral radiograph of the foot was performed to assess the postoperative result. Forty-two patients with confirmed IAT who underwent surgery between 2013 and 2017 with a longitudinal tendon-splitting approach and tendon refixation using a double-row refixation system were evaluated. The average follow-up was 32.8 (range, 18-52) months. We included 26 female and 16 male patients with an average age of 56.8 (range, 27-73) years. RESULTS The mean VAS improved from 8.91 ± 1.0 preoperatively to 1.47 ± 2.5 postoperatively (P< .01). AOFAS scores improved significantly from 51.0 ± 12.5 preoperatively to 91.3 ± 14.3 postoperatively (P< .01). All total and subscores of the FFI and FAOS saw a significant improvement at follow-up (P< .01). Lateral radiographs showed recurrent calcification in 30 patients (71.4%). CONCLUSION We found that, at an average of 33 months posttreatment, insertional Achilles tendinopathy via a longitudinal tendon-splitting approach resulted in good outcomes for patients after failure of initial conservative therapy. Recurrent calcification seems to be very common but shows no association with inferior outcomes or the return of symptoms. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Fabian Greiner
- Department of Orthopaedics and
Trauma-Surgery, Medical University of Vienna, Vienna, Austria,Department of Paediatric Orthopaedics,
Adult Foot and Ankle Surgery, Speising Orthopaedic Hospital, Vienna, Austria,Fabian Greiner, MD, Department of
Orthopaedics and Trauma-Surgery, Medical University of Vienna, Waehringer
Guertel 18-20, Vienna, 1090, Austria.
| | | | - Michel Chraim
- Department of Paediatric Orthopaedics,
Adult Foot and Ankle Surgery, Speising Orthopaedic Hospital, Vienna, Austria,Fusszentrum Vienna, Vienna,
Austria
| | - Elena Neunteufel
- Department of Paediatric Orthopaedics,
Adult Foot and Ankle Surgery, Speising Orthopaedic Hospital, Vienna, Austria
| | - Peter Bock
- Department of Paediatric Orthopaedics,
Adult Foot and Ankle Surgery, Speising Orthopaedic Hospital, Vienna, Austria,Orthopoint Vienna, Vienna,
Austria
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22
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Strasser NL, Farina KA. Haglund's Syndrome and Insertional Achilles Tendinopathy. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Laumonerie P, Mattesi L, Patrick C, Tibbo ME, Ancelin D. Endoscopic resection of enthesopathy via a direct midline transtendinous approach with associated reattachment of the Achilles tendon (endo-REDMTART): a cadaveric feasibility study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1237-1245. [PMID: 34417896 DOI: 10.1007/s00590-021-03098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of our study was to determine the feasibility of an all-posterior endoscopic resection of enthesopathy via direct midline transtendinous approach with detachment and reattachment of the Achilles tendon (endo-REDMTART). MATERIALS & METHODS Endo-REDMTART was performed in 10 ankles by two foot and ankle surgeons. Posterolateral and posteromedial portals were utilized. Three accessory, more distal portals were utilized (one posterolateral, one posteromedial, and one midline transtendinous). We measured the quality of the resection of the calcaneal spur and the length of tendon that was able to be reattached to the calcaneus. RESULTS The procedure was successful in all 10 cases. The mean minimum thickness of resected calcaneal spur was 7 mm (5-9 mm) thick, and the mean anteroposterior distance was 23 mm (20-25 mm). In all 10 cases, the maximum distance between the distal Achilles tendon and calcaneus was 1 mm (0-1 mm), with good tendon-bone contact. CONCLUSIONS The data here suggest that endo-REDMTART is feasible. This procedure provides all of the advantages of endoscopic technique without compromising the efficacy of Haglund deformity resection. TRIAL REGISTRATION No Clinical Trials Registration or IRB is required. LEVEL OF EVIDENCE Anatomy study; cadaveric dissection.
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Affiliation(s)
- P Laumonerie
- Department of Orthopaedic Surgery, Hôpital Pellegrin, Place Amélie Raba-léon, 33076, Bordeaux, France.
| | - L Mattesi
- I2R, Institut de Recherche Riquet, 31059, Toulouse, France.,Anatomy Laboratory, Faculty of Medicine, 31062, Toulouse, France
| | - Chaynes Patrick
- Anatomy Laboratory, Faculty of Medicine, 31062, Toulouse, France
| | - M E Tibbo
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - D Ancelin
- I2R, Institut de Recherche Riquet, 31059, Toulouse, France.,Anatomy Laboratory, Faculty of Medicine, 31062, Toulouse, France
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24
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Alessio-Mazzola M, Russo A, Capello AG, Lovisolo S, Repetto I, Formica M, Felli L. Endoscopic calcaneoplasty for the treatment of Haglund's deformity provides better clinical functional outcomes, lower complication rate, and shorter recovery time compared to open procedures: a systematic review. Knee Surg Sports Traumatol Arthrosc 2021; 29:2462-2484. [PMID: 33216187 DOI: 10.1007/s00167-020-06362-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this research is to report the clinical outcome following surgical correction of Haglund's deformity summarising different surgical strategies and comparing clinical outcomes, failures, complications and return to activities of patients underwent open and endoscopic techniques. METHODS A systematic search of the literature was conducted using eight different databases. Thirty-five studies were included in the systematic review. A total of 1260 ankles of 1147 patients were grouped in accordance with the surgical approach (open, endoscopic, or percutaneous). RESULTS The overall mean age was 44.8 ± 8.2 (range 14.9-82) years with a mean follow-up of 30.9 ± 17.1 (range 3-132) months. Analysis of clinical outcomes of open and endoscopic techniques demonstrated significant differences of AOFAS (87.1 ± 5.9 versus 90.7 ± 4.2 points; P < 0.001), complications (15.5% versus 4.1%; P < 0.001), failures (6.0% versus 1.2%; P < 0.001), time to return to daily activities (17.2 ± 9.3 versus 6.3 ± 1.0 weeks; P < 0.001) and time to return to sport (20.7 ± 3.3 versus 11.9 ± 0.3 weeks; P < 0.001) in the studies that reported these specific outcome measures. CONCLUSION Surgical correction of Haglund's deformity provides overall good clinical results and high subjective satisfaction. Endoscopic procedures demonstrated better final AOFAS, a lower rate of complications and failures, and shorter recovery time when compared to open techniques. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Mattia Alessio-Mazzola
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genova, Italy. .,Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy.
| | - Antonio Russo
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Andrea Giorgio Capello
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Stefano Lovisolo
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Ilaria Repetto
- Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Matteo Formica
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genova, Italy.,Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Lamberto Felli
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, 16132, Genova, Italy.,Orthopaedic Clinic, Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
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25
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Jarin IJ, Bäcker HC, Vosseller JT. Functional Outcomes of Insertional Achilles Tendinopathy Treatment: A Systematic Review. JBJS Rev 2021; 9:01874474-202106000-00008. [PMID: 34125735 DOI: 10.2106/jbjs.rvw.20.00110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Ian J Jarin
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
| | - Henrik C Bäcker
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
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26
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Güler Y, Birinci M, Hakyemez ÖS, Buyukdogan K, Çaçan MA, Arslanoglu F, Mermerkaya MU. Achilles tendon-splitting approach and double-row suture anchor repair for Haglund syndrome. Foot Ankle Surg 2021; 27:421-426. [PMID: 32792246 DOI: 10.1016/j.fas.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 05/14/2020] [Accepted: 05/21/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Haglund syndrom is characterized as a painful posterosuperior deformity of the heel with possible causes as tight Achilles tendon, high-arched foot and tendency to walk on the outside of the heel. Surgical treatment may be recommended in cases where of insufficient response to nonoperative treatment. This study aims to evaluate the clinical and radiographic results of central Achilles tendon splitting and double-row suture anchor technique in the surgical treatment of patients with Haglund syndrome. METHODS 27 patients with Haglund syndrome who underwent central Achilles tendon splitting and double-row suture anchor were retrospectively evaluated. The results were evaluated by the pre- and post-operative American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and visual analogue scale (VAS). All patients were evaluated radiographically to assess lateral talus-first metatarsal angle (TMTA), Calcaneal pitch angle (CPA), and the Fowler-Philip angle (FPA) preoperatively and postoperatively. RESULTS The mean preoperative AOFAS score was 47 ± 7 points; at the end of the follow-up period, it increased to 92 ± 4 points (p < 0.001). The mean preoperative VAS score was 9 ± 0.9 points; at the end of the follow-up period, it was 2 ± 0.6 points (p < 0.001). The lateral TMTA (preoperative: 5° ± 2°; follow-up: 4° ± 2°; p < 0.001), CPA (preoperative: 21° ± 5°; follow-up: 20° ± 5°; p = 0.005) and FPA (preoperative: 55° ± 6°; follow-up: 32° ± 3°; p < 0.001) values decreased at the end of the follow-up period. CONCLUSION In the absence of an improvement to nonoperative treatment methods, central Achilles tendon-splitting approach appears to be an effective and safe treatment option. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Yasin Güler
- Medipol University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey
| | - Murat Birinci
- Medipol University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey.
| | - Ömer Serdar Hakyemez
- Medipol University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey
| | - Kadir Buyukdogan
- Koc University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey
| | - Mehmet Akif Çaçan
- Medipol University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey
| | - Fatih Arslanoglu
- Medipol University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey
| | - Musa Uğur Mermerkaya
- Medipol University, Medical School, Department of Orthopaedics and Traumatology, İstanbul, Turkey
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Retrocalcaneal Spur Removal and Achilles Tendon Reattachment for the Treatment of Haglund Deformity. TECHNIQUES IN FOOT & ANKLE SURGERY 2021. [DOI: 10.1097/btf.0000000000000279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Postoperative complications can be burdensome on both the patient and the surgeon. Attention in literature is often directed toward different forms of treatment and successful outcomes in surgery. The incentive of this article is to bring insight toward postoperative complications in rearfoot surgery, more specifically, the repair of the Achilles tendon with suture tape and suture anchors. This article directs attention to the recent reports on hypersensitivity reactions seen with the use of suture tape and nonabsorbable suture anchors and may encourage physicians to make patients aware of this potential complication when using these materials.
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Abarquero-Diezhandino A, Vacas-Sánchez E, Hernanz-González Y, Vilá-Rico J. Study of the clinical and functional results of open calcaneoplasty and tendinous repair for the treatment of the insertional tendinopathy of the Achilles’ tendon. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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30
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Gaston TE, Daniel JN. Achilles Insertional Tendinopathy- Is There a Gold Standard? THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:5-8. [PMID: 33778110 DOI: 10.22038/abjs.2020.53988.2704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tara E Gaston
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
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Hörterer H, Baumbach SF, Oppelt S, Böcker W, Harrasser N, Walther M, Polzer H. Complications Associated With Midline Incision for Insertional Achilles Tendinopathy. Foot Ankle Int 2020; 41:1502-1509. [PMID: 32819163 DOI: 10.1177/1071100720943836] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Hubert Hörterer
- Center for Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany.,Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Sebastian Felix Baumbach
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Sonja Oppelt
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Norbert Harrasser
- Center for Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany
| | - Markus Walther
- Center for Foot and Ankle Surgery, Schön Klinik München Harlaching, Munich, Germany.,Department of Orthopedics and Orthopedic Surgery, Julius Maximilian University, Würzburg, Germany
| | - Hans Polzer
- Department of General, Trauma, and Reconstructive Surgery, University Hospital Munich, Munich, Germany
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Xu Y, Duan D, He L, Ouyang L. Suture Anchor Versus Allogenic Tendon Suture in Treatment of Haglund Syndrome. Med Sci Monit 2020; 26:e927501. [PMID: 33208723 PMCID: PMC7684847 DOI: 10.12659/msm.927501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Haglund’s deformity is an abnormal bony enlargement on the back of the heel. It can cause the impact of the posterior calcaneal bursa and Achilles tendon insertion, and finally result in pain. This syndrome is called Haglund syndrome. The purpose of this study was to explore the effect of the suture anchor and allogeneic tendon suture in the treatment of Haglund syndrome. Material/Methods We retrospectively studied 20 patients with Haglund syndrome treated from January 2015 to December 2016. The patients were randomly divided into Group 1 (the suture anchor group) and Group 2 (the allogeneic tendon group), with 10 patients in each group and an average follow-up of 32 months after surgery. The AOFAS, VAS, and Arner-Lindholm scales were used to summarize the patient follow-up results and complications. Results In the 2 groups of patients, the postoperative AOFAS, VAS scores, and the Arner-Lindholm scale showed good results. However, the postoperative AOFAS score and VAS of the suture anchor group were better than those of the allogeneic tendon group, with shorter operation times. No Achilles tendon rupture or wound infection occurred during the entire postoperative period in either group. These results show the superiority of suture anchors. Conclusions The higher AOFAS and VAS score and shorter operation time in the suture anchor group suggest it is the better alternative for treatment of Haglund syndrome.
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Affiliation(s)
- Yan Xu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Deyu Duan
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Lei He
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Liu Ouyang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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Abarquero-Diezhandino A, Vacas-Sánchez E, Hernanz-González Y, Vilá-Rico J. Study of the clinical and functional results of open calcaneoplasty and tendinous repair for the treatment of the insertional tendinopathy of the Achilles' tendon. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 65:47-53. [PMID: 33177011 DOI: 10.1016/j.recot.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- A Abarquero-Diezhandino
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Complejo Hospitalario Quirón Ruber Juan Bravo, Madrid, España.
| | - E Vacas-Sánchez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Complejo Hospitalario Quirón Ruber Juan Bravo, Madrid, España
| | - Y Hernanz-González
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - J Vilá-Rico
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España; Complejo Hospitalario Quirón Ruber Juan Bravo, Madrid, España; Universidad Complutense de Madrid, Madrid, España
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Yontar NS, Aslan L, Can A, Öğüt T. Mid-term results of open debridement and reattachment surgery for insertional Achilles tendinopathy: A retrospective clinical study. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:567-571. [PMID: 33423985 DOI: 10.5152/j.aott.2020.18426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Necip Selçuk Yontar
- Department of Foot-Ankle Surgery, Nişantaşı Orthopaedics Center, İstanbul, Turkey
| | - Lercan Aslan
- Department of Orthopaedics and Traumatology, Koç University Hospital, İstanbul, Turkey
| | - Ata Can
- Department of Orthopaedics and Traumatology, Nişantaşı Orthopaedics Center, İstanbul, Turkey
| | - Tahir Öğüt
- Department of Foot-Ankle Surgery, Nişantaşı Orthopaedics Center, İstanbul, Turkey
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35
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Effects of Achilles Tendon Moment Arm Length on Insertional Achilles Tendinopathy. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10196631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Insertional Achilles tendinopathy (IAT) is caused by traction force of the tendon. The effectiveness of the suture bridge technique in correcting it is unknown. We examined the moment arm in patients with IAT before and after surgery using the suture bridge technique, in comparison to that of healthy individuals. We hypothesized that the suture bridge method influences the moment arm length. An IAT group comprising 10 feet belonging to 8 patients requiring surgical treatment for IAT were followed up postoperatively and compared with a control group comprising 15 feet of 15 healthy individuals with no ankle complaints or history of trauma or surgery. The ratio of the moment arm (MA) length/foot length was found to be statistically significant between the control group, the IAT group preoperatively and the IAT group postoperatively (p < 0.01). Despite no significant difference in the force between the control and preoperative IAT groups, a significantly higher force to the Achilles tendon was observed in the IAT group postoperatively compared to the other groups (p < 0.05). This study demonstrates that a long moment arm may be one of the causes of IAT, and the suture bridge technique may reduce the Achilles tendon moment arm.
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Okewunmi J, Guzman J, Vulcano E. Achilles Tendinosis Injuries-Tendinosis to Rupture (Getting the Athlete Back to Play). Clin Sports Med 2020; 39:877-891. [PMID: 32892973 DOI: 10.1016/j.csm.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recreational athletes are susceptible to experiencing pain in the Achilles tendon, affecting their ability to complete daily activities. Achilles tendinosis is a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation, which can be categorized by location into insertional and noninsertional tendinosis. This condition is one that can be treated conservatively with great success or surgically for refractory cases. Currently, there is a lack of consensus regarding the best treatment options. This review aims to explore both conservative and operative treatment options for Achilles tendinopathy and Achilles tendon rupture.
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Affiliation(s)
- Jeffrey Okewunmi
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Javier Guzman
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Ettore Vulcano
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
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Bah I, Fernandes NRJ, Chimenti RL, Ketz J, Flemister AS, Buckley MR. Tensile mechanical changes in the Achilles tendon due to Insertional Achilles tendinopathy. J Mech Behav Biomed Mater 2020; 112:104031. [PMID: 32882677 DOI: 10.1016/j.jmbbm.2020.104031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 03/05/2020] [Accepted: 08/07/2020] [Indexed: 01/20/2023]
Abstract
Insertional Achilles tendinopathy (IAT) is a painful condition that is challenging to treat non-operatively. Although previous studies have characterized the gross histological features, in vivo strain patterns and transverse compressive mechanical properties of tissue affected by IAT, it is not known how IAT impacts the tensile mechanical properties of the Achilles tendon insertion along the axial/longitudinal direction (i.e., along the predominant direction of loading). To address this knowledge gap, the objectives of this study were to 1) apply ex vivo mechanical testing, nonlinear elastic analysis and quasilinear viscoelastic (QLV) analysis to compare the axial tensile mechanical properties of the Achilles tendon insertion in individuals with and without IAT; and 2) use biochemical analysis and second harmonic generation (SHG) imaging to assess structural and compositional changes induced by IAT in order to help explain IAT-associated tensile mechanical changes. Tissue from the Achilles tendon insertion was acquired from healthy donors and from patients undergoing debridement surgery for IAT. Tissue specimens were mechanically tested using a uniaxial tensile (stress relaxation) test applied in the axial direction. A subset of the donor specimens was used for SHG imaging and biochemical analysis. Linear and non-linear elastic analyses of the stress relaxation tests showed no significant tensile mechanical changes in IAT specimens compared to healthy controls. However, SHG analysis showed that fibrillar collagen was significantly more disorganized in IAT tissue as compared with healthy controls, and biochemical analysis showed that sulfated glycosaminoglycan (sGAG) content and water content were higher in IAT specimens. Collectively, these findings suggest that conservative interventions for IAT should target restoration of ultrastructural organization, reduced GAG content, and reduced resistance to transverse compressive strain.
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Affiliation(s)
- Ibrahima Bah
- University of Rochester Department of Biomedical Engineering, United States.
| | | | - Ruth L Chimenti
- University of Iowa Department of Physical Therapy and Rehabilitation Science, United States
| | - John Ketz
- University of Rochester Department of Orthopaedics, United States
| | | | - Mark R Buckley
- University of Rochester Department of Biomedical Engineering, United States.
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Moen R, Hagenbucher JR, Shinabarger AB. Surgical Treatment of Insertional Achilles Tendinopathy: A Systematic Review. J Am Podiatr Med Assoc 2020; 110:447712. [PMID: 33179068 DOI: 10.7547/17-052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Insertional Achilles tendinopathy is a common complaint among patients. Oftentimes, conservative treatment is inadequate, and surgical treatment is required. However, there is no published consensus regarding surgical intervention in reference to insertional Achilles tendinopathy. METHODS The purpose of this systematic review was to evaluate the surgical management of insertional Achilles tendinopathy and report which surgical procedures provide the greatest pain reduction and improvement in functional outcome. A review of PubMed, OVID, Google Scholar, and Cochrane Controlled Trials Register was performed using a defined search strategy and inclusion criteria. RESULTS Of 2,863 articles identified using the defined strategy, 20 met the inclusion criteria (three prospective and 17 retrospective). Operative interventions included Achilles tendon debridement, reattachment with suture anchors, reconstruction with flexor hallucis longus tendon autograft or bone-patellar tendon autograft, and gastrocnemius recession. All of the studies, regardless of intervention, showed generalized improvement after surgery. Wide variation in outcome scoring systems prevented direct comparison between studies and interventions. CONCLUSIONS This systematic review did not identify a superior treatment for insertional Achilles tendinopathy but rather found that the surgical treatment should be based on the extent of tendon injury.
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Del Vecchio JJ, Dealbera ED, Ghioldi ME, Chemes LN. Letter Regarding: Biomechanical Comparison of Achilles Tendon Pullout Strength Following Midline Tendon-Splitting and Endoscopic Approaches for Calcaneoplasty. Foot Ankle Int 2020; 41:885-886. [PMID: 32628891 DOI: 10.1177/1071100720929346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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40
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Michalski MP, Gonzalez TA, Metzger MF, Nelson TJ, Eberlein S, Pfeffer GB. Response to "Letter Regarding: Biomechanical Comparison of Achilles Tendon Pullout Strength Following Midline Tendon-Splitting and Endoscopic Approaches for Calcaneoplasty". Foot Ankle Int 2020; 41:887-888. [PMID: 32628892 DOI: 10.1177/1071100720929345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Alfredson H, Spang C. Surgical treatment of insertional Achilles tendinopathy: results after removal of the subcutaneous bursa alone-a case series. BMJ Open Sport Exerc Med 2020; 6:e000769. [PMID: 32549997 PMCID: PMC7287493 DOI: 10.1136/bmjsem-2020-000769] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 11/04/2022] Open
Abstract
Background Insertional Achilles tendinopathy is well known to be difficult to treat, especially when there is intra-tendinous bone pathology. This study is a case series on patients with chronic insertional Achilles tendon pain and major intra-tendinous bony pathology together with bursa and tendon pathology, treated with excision of the subcutaneous bursa alone. Methods Eleven patients (eight men and three women) with a mean age of 44 years (range 24–62) and a chronic (>6 months) painful condition from altogether 15 Achilles tendon insertions were included. In all patients, ultrasound examination showed intra-tendinous bone pathology together with pathology in the tendon and subcutaneous bursa, and all were surgically treated with an open excision of the whole subcutaneous bursa alone. This was followed by full weight-bearing walking in a shoe with open heel for 6 weeks. Results At follow-up 21 (median, range 12–108) months after surgery, 9/11 patients (12/15 tendons) were satisfied with the result of the operation and 10/11 (13/15 tendons) were back in their previous sport and recreational activities. The median VISA-A score had improved from 41 (range 0–52) to 91 (range 33–100) (p<0.01). Conclusion In patients with chronic painful insertional Achilles tendinopathy with intra-tendinous bone pathology, tendon and bursa pathology, open removal of the subcutaneous bursa alone can relieve the pain and allow for Achilles tendon loading activities. The results in this case series highlight the need for more studies on the pain mechanisms in insertional Achilles tendinopathy and the need for randomised studies to strengthen the conclusions. Level of evidence IV Case series.
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Affiliation(s)
- Håkan Alfredson
- ISEH, University College London Hospitals, London, UK.,Department of Community Research and Rehablilitation, Sports Medicine Unit, Umeå University, Umeå, Sweden
| | - Christoph Spang
- Department of Integrative Medical Biology, Anatomy Section, Umeå University, Umeå, Sweden.,Alfen Spine Center, Würzburg, Germany
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Batista JP, Del Vecchio JJ, van Dijk N, Pereira H. Endoscopic FHL transfer to augment Achilles disorders. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ricci AG, Stewart M, Thompson D, Watson BC, Ashmyan R. The Central-Splitting Approach for Achilles Insertional Tendinopathy and Haglund Deformity. JBJS Essent Surg Tech 2020; 10:e0035. [PMID: 32368411 DOI: 10.2106/jbjs.st.19.00035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Insertional Achilles tendinopathy causes posterior heel pain at the insertion of the Achilles tendon, often in combination with a calcaneal exostosis, or Haglund deformity. Insertional Achilles tendinopathy often presents with a posterior osseous prominence and leads to calcification of the Achilles tendon1. Nonoperative treatment of these conditions includes activity modification, nonsteroidal anti-inflammatory agents, heel lifts, shoe modification, physical therapy focused on eccentric strengthening exercises, iontophoresis, and shock wave therapy. Nonoperative treatment will fail in approximately 50% of these cases, and such patients become candidates for surgical intervention2,3. Multiple surgical approaches have been described, including the medial J-shaped, lateral, Cincinnati transverse, double incision, and central-splitting approaches4. Currently, there is no consensus regarding the ideal approach. Recent literature has suggested that the central-splitting approach allows for adequate exposure of both the most commonly diseased area of the tendon and the calcaneal exostosis, with excellent postoperative pain and functional results5-13. Description Place the patient in the prone position with the feet at the edge of the operating table. Make a full-thickness, 5 to 7-cm longitudinal incision centered over the Achilles tendon and the posterior aspect of the calcaneus. Make a central incision through the Achilles tendon. Sharply mobilize the medial and lateral slips and excise the diseased portion of the Achilles tendon. Expose the calcaneal exostosis and perform the calcaneal exostectomy with a microsagittal saw. Repair the remaining healthy-appearing Achilles tendon to the calcaneus with 2 suture anchors. An additional suture anchor or, alternatively, the double-row technique for the Achilles tendon repair may be used. Repair the central split in the Achilles tendon with absorbable suture. Close the soft tissue and skin in layers. Alternatives Alternative approaches include the medial, lateral, or Cincinnati transverse incisions. The central-splitting approach is favored because of the excellent exposure of both the diseased tendon and the calcaneal exostosis. Additional augmentations to this procedure include a flexor hallucis longus transfer and a gastrocnemius recession. Rationale This technique provides adequate exposure to the diseased Achilles tendon, calcific deposits, and calcaneal exostosis. Recent studies have demonstrated it to be a safe and effective technique with high patient-satisfaction scores5-13.
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Affiliation(s)
- A Gianni Ricci
- The Hughston Clinic, Columbus, Georgia.,Jack Hughston Memorial Hospital, Phenix City, Alabama
| | - Matthew Stewart
- The Hughston Clinic, Columbus, Georgia.,Jack Hughston Memorial Hospital, Phenix City, Alabama
| | - David Thompson
- The Hughston Clinic, Columbus, Georgia.,Jack Hughston Memorial Hospital, Phenix City, Alabama
| | - Benjamin Collier Watson
- The Hughston Clinic, Columbus, Georgia.,Jack Hughston Memorial Hospital, Phenix City, Alabama
| | - Roman Ashmyan
- The Hughston Clinic, Columbus, Georgia.,Jack Hughston Memorial Hospital, Phenix City, Alabama
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Michalski MP, Gonzalez TA, Metzger MF, Nelson TJ, Eberlein S, Pfeffer GB. Biomechanical Comparison of Achilles Tendon Pullout Strength Following Midline Tendon-Splitting and Endoscopic Approaches for Calcaneoplasty. Foot Ankle Int 2019; 40:1219-1225. [PMID: 31203670 DOI: 10.1177/1071100719856939] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Calcaneoplasty is a common procedure performed for the management of Haglund's syndrome when nonoperative management fails. Midline tendon-splitting and endoscopy are 2 common approaches to calcaneoplasty. Studies have suggested that an endoscopic approach may allow earlier return to activity and superior outcomes, but there are no biomechanical or clinical studies to validate these claims. The goal of this study was to quantify and compare Achilles tendon pullout strength following midline tendon-splitting and endoscopic calcaneoplasty in cadaveric specimens. METHODS Twelve match-paired cadaveric specimens were randomly divided into 2 groups: endoscopic and midline tendon-split. Following calcaneoplasty, fluoroscopy was used to match bone resection and the Achilles was loaded to failure in a mechanical testing system. A paired-samples t test was conducted to compare bone resection height, bone resection angle, load to failure, and mode of failure. RESULTS The endoscopic approach yielded a 204% greater postsurgical pullout strength for the Achilles tendon than the midline tendon-split (1368 ± 370 N vs 450 ± 192 N, respectively) (P < .05). There were no differences in resection angle or resection height. All specimens failed due to bone or tendon avulsion. CONCLUSION Endoscopic calcaneoplasty had more than 3 times greater pullout strength than the midline tendon-splitting approach. CLINICAL RELEVANCE This may allow earlier return to functional rehabilitation following endoscopic calcaneoplasty, but further studies are needed to determine if these differences are clinically significant. Further understanding of the time-zero biomechanics following calcaneoplasty may provide guidance regarding postoperative management with respect to surgical approach.
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Affiliation(s)
- Max P Michalski
- Cedars-Sinai Medical Center, Orthopaedic Surgery, Los Angeles, CA, USA
| | - Tyler A Gonzalez
- Cedars-Sinai Medical Center, Orthopaedic Surgery, Los Angeles, CA, USA
| | | | - Trevor J Nelson
- The Metzger Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Samuel Eberlein
- The Metzger Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Glenn B Pfeffer
- Cedars-Sinai Medical Center, Orthopaedic Surgery, Los Angeles, CA, USA
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Wang CL, Chen PY, Yang KC, Wu HC, Wang CC. Ultrasound-Guided Minimally Invasive Surgical Resection of Retrocalcaneal Bursitis: A Preliminary Comparison With Traditional Open Surgery. J Foot Ankle Surg 2019; 58:855-860. [PMID: 31345762 DOI: 10.1053/j.jfas.2018.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Indexed: 02/03/2023]
Abstract
Posterior heel pain is a common complaint that is often caused by overuse injuries. In such cases, the retrocalcaneal bursa is compressed and chafed repeatedly, leading to local inflammation. Sonography is a popular imaging tool used to study the pathology of soft tissues, and it can be used to assist in diagnosing bursitis because of its accuracy. Herein, we report an innovative method to treat retrocalcaneal bursitis under ultrasound guidance. Ten patients with posterior heel pain for >6 months who failed conservative treatment received this ultrasound-guided minimally invasive surgery. An endoscopic puncher and burr were inserted under ultrasound guidance via a stabbing wound, and the swollen retrocalcaneal bursa and bony prominence were resected. The patients were able to ambulate and undergo a rehabilitation program 2 weeks postoperatively. In the patients who underwent this ultrasound-guided minimally invasive surgery, both the average surgical time and average hospital stay were shorter than in those (n = 12) who underwent open surgery. In outcome rating assessment, the American Orthopaedic Foot & Ankle Society (AOFAS) pain score and total AOFAS ankle-hindfoot score were improved in the ultrasound-guided minimally invasive surgery group compared to the open surgery group at 2 months postoperatively. Other advantages included lesser wound pain, shorter hospital stay, faster recovery time, and minimal blood loss. Accordingly, ultrasound-guided surgery appears to be a good option for the treatment of retrocalcaneal bursitis.
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Affiliation(s)
- Chung-Li Wang
- Professor, Department of Orthopedic Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Yu Chen
- Attending, Department of Orthopedic Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kai-Chiang Yang
- Associate Professor, School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsing-Cheng Wu
- Attending, Department of Orthopedic Surgery, Taipei City Hospital, Taipei, Taiwan
| | - Chen-Chie Wang
- Attending, Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; Associate Professor, Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Abstract
Insertional Achilles tendinopathy is one of the most common Achilles tendon disorders and often results in substantial heel pain and functional disability. There is consensus that treatment of insertional Achilles tendinopathy should start with nonoperative modalities. Surgery should be reserved for patients who fail exhaustive conservative treatment for a period of 3 months to 6 months and include débridement of insertional calcifications. Intratendinous degenerative tissue should be débrided and any Haglund deformity resected. Different surgical techniques have been described for reattachment of the distal Achilles tendon. The authors' preferred surgical technique includes the knotless double-row footprint reconstruction. Postoperative complications are not rare.
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Affiliation(s)
- Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
| | - Todd Ludwig
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
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Zhuang Z, Yang Y, Chhantyal K, Chen J, Yuan G, Ni Y, Liu D, Shi D. Central Tendon-Splitting Approach and Double Row Suturing for the Treatment of Insertional Achilles Tendinopathy. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4920647. [PMID: 31531355 PMCID: PMC6720369 DOI: 10.1155/2019/4920647] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/13/2019] [Accepted: 07/28/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND To assess the clinical outcomes of central tendon-splitting approach and double row anchor suturing for the treatment of insertional Achilles tendinopathy. METHODS 28 patients (28 feet) diagnosed with insertional Achilles tendinopathy were included in this study. The inclusions were symptom of hindfoot pain around the insertion of the Achilles tendon, radiographic demonstration of calcification, or degeneration of the Achilles tendon, showing no symptom improvement even after standard nonsurgical treatment for more than six months. The X-ray revealed that patients had obvious posterior superior calcaneal exostosis with the possibility of friction with the Achilles tendon or intratendinous calcification. Surgical correction by the central tendon-splitting approach and double row Achilles tendon suturing was performed. The ankles were immobilized with plaster for four weeks postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue score (VAS) were assessed preoperatively and at 2 years postoperatively. At final follow-up, the Manchester-Oxford Foot Questionnaire (MOXFQ) as patient-reported outcome measures (PROMs) was also evaluated. RESULTS No complication, including postoperative wound infection and tendon rupture, was not found. All the patients resumed their daily activities with no high level of daily activities, such as jumping and jogging after 6 weeks postoperatively. 27 patients were available for follow-up for at least 2 years, while only one patient was lost to follow-up. At postoperative 2 years, the postoperative AOFAS score increased significantly, while the VAS score decreased statistically when compared with preoperative values. At final follow-up, 24 patients had complete alleviation of pain, whereas the remaining 3 patients complained of mild heel pain after walking for a long time. The MOXFQ score showed obvious relief of previous symptoms for all included cases. CONCLUSIONS Central tendon-splitting approach and double row Achilles tendon suture provide excellent intraoperative visual field, larger tendon-bone contact area, and stronger pullout strength and, thus, facilitate early rehabilitation. It can be a safe and effective method for the treatment of insertional Achilles tendinopathy.
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Affiliation(s)
- Ze Zhuang
- Departments of Joint Surgery and Orthopedic Trauma, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
| | - Yang Yang
- Departments of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
| | - Kishor Chhantyal
- Departments of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
| | - Jianning Chen
- Departments of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
| | - Guohui Yuan
- Departments of Joint Surgery and Orthopedic Trauma, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
| | - Yirong Ni
- MOE Key Laboratory of Laser Life Science & SATCM Third Grade Laboratory of Chinese Medicine and Photonics Technology, College of Biophotonics, South China Normal University, Guangzhou 510631, China
| | - Dezhao Liu
- Departments of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
| | - Dehai Shi
- Departments of Joint Surgery and Orthopedic Trauma, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong, China
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Xia Z, Yew KSA, Zhang TK, Rikhraj IS. Lateral versus central tendon-splitting approach to insertional Achilles tendinopathy: a retrospective study. Singapore Med J 2019; 60:626-630. [PMID: 31044256 DOI: 10.11622/smedj.2019038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION This study aimed to compare operative outcomes between the lateral approach (LA) and the central approach (CA) to insertional Achilles tendinopathy (IAT). METHODS We retrospectively reviewed patients who underwent surgical treatment for IAT using the LA or CA. Patients' demographic data, postoperative complications and satisfaction rate were reviewed. Clinical outcomes were prospectively assessed preoperatively, at three months postoperatively and at the last visit, including patients' visual analogue scale (VAS) scores for pain, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale scores and 36-item Short Form Health Survey (SF-36) scores. RESULTS There were 39 patients in the LA group and 32 in the CA group. In each group, average VAS and AOFAS Scale scores improved significantly. SF-36 scores improved in most parameters. No significant difference in baseline score; average AOFAS Scale score at each visit; and mean VAS score preoperatively and at last visit; satisfaction rate; and overall complication rate were observed between the groups. The mean VAS score in the LA group at postoperative three months was significantly lower than that in the CA group (2.7 ± 2.5 vs. 4.4 ± 3.0; p = 0.016). There were significantly more cases of delayed wound healing in the LA group than in the CA group (2.6% vs. 15.6%; p = 0.049). CONCLUSION Both approaches had comparable outcomes for IAT in terms of functional improvement, pain relief, overall enhancement of patients' health condition and overall postoperative complication rate. The LA provided better short-term pain relief and reduced delayed wound healing compared with the CA.
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Affiliation(s)
- Zhan Xia
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Khye Soon Andy Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Ting Karen Zhang
- Orthopaedic Diagnostic Centre, Singapore General Hospital, Singapore
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Ferguson A, Christophersen C, Elattar O, Farber DC. Achilles Tendinopathy and Associated Disorders. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419838294. [PMID: 35097320 PMCID: PMC8696945 DOI: 10.1177/2473011419838294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Degenerative disorders of the Achilles tendon are common, affecting up to 18% of the adult population. A thorough evaluation including a focused history, physical examination, and diagnostic studies helps in choosing the appropriate treatment. Initial treatment is usually nonoperative, consisting of activity modification, bracing, and physical therapy. Patents who fail nonoperative management may be treated operatively with a wide range of procedures from endoscopic surgery to open debridement and tendon transfer. Understanding a patient’s expectations and educating patients about potential treatments and their outcomes enables informed collaborative decision making. This article will review the evaluation and management Achilles tendinopathy and associated disorders.
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Affiliation(s)
- Adam Ferguson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Osama Elattar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel C. Farber
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Baumbach SF, Braunstein M, Mack MG, Maßen F, Böcker W, Polzer S, Polzer H. [Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]. Unfallchirurg 2019; 120:1044-1053. [PMID: 28980027 DOI: 10.1007/s00113-017-0415-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- S F Baumbach
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - M Braunstein
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - M G Mack
- Radiologie München, München, Deutschland
| | - F Maßen
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - W Böcker
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland
| | - S Polzer
- Praxis für Hand‑, Ellenbogen- und Fußchirurgie, ATOS-Klinik Heidelberg, Heidelberg, Deutschland
| | - H Polzer
- Klinik für Allgemeine, Unfall‑, Hand- und Wiederherstellungschirurgie, Ludwig-Maximilians-Universität, Nußbaumstr. 20, 80336, München, Deutschland.
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