Surgical strategies: noninsertional Achilles tendinopathy

Return to Sports and Functional Outcomes after Autologous Platelet-Rich Fibrin Matrix (PRFM) and Debridement in Midportion Achilles Tendinopathy: A Case Series with 24-Month Follow-Up

(1) Background: Achilles tendinopathy (AT) is characterized by load-induced tendon pain, stiffness, and functional impairment that may affect the tendon midportion or insertion. Platelet-rich fibrin matrix (PRFM) is a promising adjunctive therapy for AT. We analyzed 24-month pain and functional outcomes in a cohort of patients managed by tendon debridement and autologous PRFM application to determine whether the combined treatment ensured an early return to sports/work and satisfactory clinical outcomes and functional scores. (2) Methods: The 24-month outcomes of 32 sport-practicing patients with chronic midportion AT treated with debridement and autologous PRFM were evaluated in terms of time to return to sports/work. The AOFAS and VISA-A were computed preoperatively and at 6 and 24 months. Blazina scores were evaluated preoperatively and at 6 months; ankle range of motion was assessed at 1, 6, 12, 24 months; and patient satisfaction was assessed at 24 months. (3) Results: Altogether, all patients had resumed their sport(s) activity, at the same or higher level, after 25.41 days (±5.37). Regarding work, all patients were able to return to their jobs after 16.41 days (±2.43). Ankle dorsiflexion and plantarflexion increased significantly: the AOFAS rose from 54.56 (±6.47) to 97.06 (±4.06) and 98.88 (±2.21) at 6 and 12 months, respectively, and the mean VISA-A score rose from 69.16 (±7.35) preoperatively to 95.03 (±4.67) and 97.28 (±2.43) at 6 and 12 months, respectively, after treatment. There were no complications. Most (90.62%) patients were very satisfied. (4) Conclusions: In symptomatic midportion AT, surgical debridement and autologous PRFM ensured a fast return to sports/work (4 weeks), significantly improving AOFAS and VISA-A and Blazina scores already at 6 months and providing excellent clinical outcomes at 24 months.

Review of Achilles Tendon Reattachment Using Double-Row Knotted and Knotless Techniques in the Management of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy represents a chronic degenerative condition affecting the insertion of the Achilles. Surgery is indicated in recalcitrant cases and often involves extensive debridement followed by subsequent repair of the insertion. In the present study, we evaluate the results of knotted and knotless double-row suture systems for Achilles reattachment. Despite the popularity of double-row repairs, there is a relative paucity of clinic data regarding efficacy of the available implants. In a retrospective cohort study, 38 patients (40 Achilles tendons) who received double-row repairs between November 2012 and December 2016 were evaluated. In addition to demographic information, preoperative pain scores and symptom duration were recorded. Perioperative and postoperative records were reviewed, and telephone interviews were conducted to assess patient satisfaction, functional status, postoperative pain, and information regarding surgical complications. At a mean follow-up of 32.5 months, 35 (92.1%) patients reported satisfaction with the outcome. Decreased pain levels were reported in 38 (95%) ankles, with 21 (52.5%) ankles being rated pain-free postoperatively. Of the patients working prior to surgery, 20 (95.2%) were able to return to normal work duties, and all 11 (100%) patients who engaged in sports preoperatively were able to return to the same level of activity. Two patients developed postoperative infections, one of which required operative debridement. No Achilles avulsions were encountered. No significant differences were noted between the 2 operative techniques. Considering the available biomechanical data, along with high patient satisfaction rates and low rate of complications, double-row repair offers a viable option for recalcitrant insertional Achilles tendinopathy.

Failed Surgery for Achilles Tendinopathy

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

Minimally Invasive and Endoscopic Approach for the Treatment of Noninsertional Achilles Tendinopathy

Minimally invasive treatment can offer an earlier recovery with less pain and scarring compared with traditional open surgeries. The goals of minimally invasive surgery are to debride degenerative tendon, stimulate healing, and, when appropriate, repair damaged tendon. Sclerotherapy and prolotherapy have been shown to reduce neovascularization and pain. Percutaneous stripping and endoscopic debridement are better options for diffuse tendinopathy. Plantaris release can be useful in diffuse disease in patients with primarily medial-sided Achilles pain. Overall, minimally invasive surgery provides similar benefits as open procedures with reduced complications and morbidity.

Short-Term Results of Endoscopic Percutaneous Longitudinal Tenotomy for Noninsertional Achilles Tendinopathy and the Presentation of a Simplified Operative Method

PURPOSE

This study was aimed to review the short-term results of endoscopic percutaneous longitudinal tenotomy for noninsertional Achilles tendinopathy using the Centerline Endoscopic Carpal Tunnel Release instrument (Arthrex). This method simplifies the operation technique, allows a good endoscopic visualisation of the Achilles tendon with very promising results.

METHODS

We performed multiple percutaneous longitudinal tenotomies under local anesthesia in 24 patients (25 tendons) with Achilles tendinopathy or peritendinitis that had failed conservative treatment between January 2013 and September 2016. All ambulatory procedures consisted of paratenon release and longitudinal tenotomies. The results were reviewed in 22 patients (23 tendons) at an average follow-up period of 22.5 months (range 10-36 months). Patients' satisfaction and functional outcomes were evaluated using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, the pain visual analog scale (VAS), and the functional foot index.

RESULTS

Initial results are very promising with excellent results in 12 patients, good results in 9 patients, and fair result in 1 patient. One patient developed a postoperative thrombosis of the operated limb. Another patient developed a hypertrophic painful scar of the incision wound. The VAS for pain decreased drastically after the index procedure and averaged to 0.2 (SD 0.447). The VISA-A questionnaire score had improved from 42 ± 7.2 points preoperatively to 96.8 ± 14.3 points postoperatively (P = .004). The functional foot index decreased from 84 (SD 30.517) to 33.4 (SD 6.452) on the follow-up examination.

CONCLUSIONS

The endoscopic-assisted longitudinal tenotomies procedure of the Achilles tendon is easily feasible and can be performed on an outpatient basis, produces minimal complications and shows excellent results. The described technique is recommended for all surgeons especially for those familiar with endoscopy of the Achilles tendon.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Series.

Noninsertional Tendinopathy of the Achilles

Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.

Surgical treatment for achilles tendinopathy - a systematic review

Background

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

Methods

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

Results

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

Conclusion

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

Surgical treatment of non-insertional Achilles tendinitis

Noninsertional Achilles tendinitis is a distinct clinical entity, frequently characterized by swelling, pain, and lower limb dysfunction. This condition can be frustrating to treat, for the patient and the physician alike, as reflected in the various treatments, both conservative and surgical, that have been described. Although many patients with Achilles tendinitis can be successfully treated with nonoperative methods, persistent symptoms require surgical treatment, such as tenotomy, debridement, or repair.