Surgical Treatment of Insertional Achilles Tendinopathy: A Systematic Review

Clinical and biomechanical comparison of suture-external button versus interference screw associated with V-Y advancement or turndown flaps for flexor hallucis longus transfer in chronic Achilles tendon rupture

PURPOSE

Surgical treatment of chronic Achilles tendon rupture is a technically challenging procedure. We aimed to compare the clinical outcomes, range of motion, and strength of ankle plantar- and dorsiflexors between two techniques for fixation of flexor hallucis longus tendon to the calcaneus: interference screw and suture-external button.

METHODS

Twenty-five patients participated in this retrospective comparative study. All patients underwent short harvest FHL tendon transfer for chronic AT rupture were asked for a follow-up visit, at least one year following surgery. The outcomes were evaluated by visual analog scale (VAS), AOFAS ankle-hindfoot score, and VISA-A questionnaire. Ankle ROM with possible restriction in addition to isokinetic strength of ankle plantar- and dorsiflexors was assessed.

RESULTS

No statistically significant difference was observed between the groups for pain (P = 0.81), AOFAS ankle-hindfoot scale (P = 0.97), and VISA-A (P = 0.44). Notably, more decrease in ankle dorsiflexion was seen in interference screw group in comparison with suture-external button group (4.4 ± 6.6 vs. 9.5 ± 6.1 degrees, P = 0.06). The difference of active dorsiflexion between operated and non-operated side in interference screw group was statistically significant (P = 0.02). Biotenodesis screw imposed more limb asymmetry in comparison with suture-external button technique.

CONCLUSIONS

Fixation of transcalcaneal FHL tendon transfer for chronic AT either by interference screw or suture-external button has encouraging postoperative clinical results. Although ROM of the ankle joint reduced in both techniques, interference screw may result in more reduction in dorsiflexion of the ankle.

Impact of BMI on the Surgical Management of Chronic Insertional Achilles Tendinopathy

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.

Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis

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.

Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review

PURPOSE

This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy.

METHODS

A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria.

RESULTS

Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases.

CONCLUSION

The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment.

LEVEL OF EVIDENCE

Level IV.