Surgery for chronic Achilles tendinopathy. Review of 91 procedures over 10 years

Percutaneous Ultrasonic Tenotomy for Achilles Tendinopathy Is a Surgical Procedure With Similar Complications

Percutaneous ultrasonic tenotomy is a relatively new treatment option for multiple types of tendinopathy. However, a paucity of high-level data is available on its use for chronic Achilles tendinosis. The present case series details the complications associated with the use of this technique. When considering percutaneous ultrasonic tenotomy, the surgeon should be cognizant that it is a surgical procedure with complications similar to those of other Achilles tendon surgeries.

Peritenolysis and Debridement for Main Body (Mid-Portion) Achilles Tendinopathy in Athletic Patients: Results of 107 Procedures

Achilles tendinopathy in the main body (mid-portion) of the tendon is a common pathologic finding among active and athletic populations and can be debilitating without proper and adequate treatment. Numerous surgical approaches for this common pathologic finding have been reported, with variable outcomes. We evaluated the surgical outcomes of peritenolysis and debridement of main body Achilles tendinopathy among athletic populations using the return to activity (RTA) and decreased desired activity (DDA) as our primary outcome measures. A total of 100 patients underwent 107 procedures by the senior author (A.S.) from January 2001 through December 2015 met the inclusion criteria, 65 (65%) of whom were runners. The mean follow-up duration was 106.6 ± 55.5 months from the index procedure, and the mean interval necessary to RTA for the entire group was 10.9 ± 5.3 weeks. The average RTA after debridement was 14.1 ± 5.2 weeks and after peritenolysis was 7.3 ± 2.0 weeks (p = .00001). Of the 100 patients, 3 (3%) had experienced a DDA at the last follow-up visit. With >97% of the patients able to return to their desired activities, we have concluded that peritenolysis and debridement are favorable surgical techniques for main body Achilles tendinopathy.

Treatment Algorithm for Chronic Achilles Tendon LesionsReview of the Literature and Proposal of a New Classification

Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.

Macroscopic Anomalies and Pathological Findings in and Around the Achilles Tendon: Observations From 1661 Operations During a 40-Year Period

BACKGROUND

Nonsurgical treatments for chronic Achilles tendinopathy (AT) results in unpredictable success rates. Surgical treatment may be chosen as reports show mostly encouraging but variable success rates depending on the pathology. The distribution of surgically confirmed pathologies in AT is largely unknown.

PURPOSE

To ascertain the distributions of macroscopically observed anomalies in participants undergoing surgical treatment for chronic AT.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The main macroscopic pathologies of 1661 chronic Achilles tendon overuse injuries, which were diagnosed and surgically treated by a single surgeon, were reviewed. The surgeries were performed on professional and recreational athletes during the years 1976-1980, 1986-1990, 1996-2000, and 2006-2010. Surgical diagnoses, along with age- and sport-specific characteristics, were collected retrospectively from patient records.

RESULTS

The relative proportion of tendinosis increased during the study period from 4.2% to 21%, and paratenonitis decreased from 50% to 26%. Retrocalcaneal pathologies were the most common surgically confirmed lesions at 30%, while the mean age at surgery increased by 11 years over the entire study period.

CONCLUSION

Surgically confirmed pathologies in and around the Achilles tendon showed coherent changes, chronic paratenonitis, and retrocalcaneal problems as the most prevalent findings. The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis. During surgical evaluations, the diagnosis is further clarified as more specific pathologies may be identified.

Use of an anti-gravity treadmill in the rehabilitation of the operated achilles tendon: a pilot study

Achilles surgical patients were evaluated using an "anti-gravity" Alter-G (AG) treadmill that allows for reduction of weightbearing pressure on the lower extremity. We studied our hypothesis, which was based on our prior clinical findings, that being able to run on the AG treadmill at 85% of body weight is sufficient to clear patients to run with full body weight outside. Patients undergoing Achilles tendon rupture or insertional repair surgery were prospectively studied. They were compared with a control group that had similar surgeries and a similar rehabilitation program during the same time period: the variable was not using the AG treadmill. The criteria for the study group to be allowed to run outside was being able to run for at least 10 minutes on the AG at 85% of body weight. Each group had 8 patients who underwent surgery for 2 complete tendon ruptures and 6 insertional repairs. There was no significant difference between the AG and control group as to age and postoperative follow-up. AG patients began their initial run on the treadmill at 70% of their body weight at 13.9 ± 3.4 weeks, 85% at 17.6 ± 3.9 weeks, and outside running at 18.1 ± 3.9 weeks. The control group's return to running outside time was 20.4 ± 4.1 weeks. This was not significantly different (p = .27). We confirmed our hypothesis that being able to run at 85% of body weight after Achilles surgery was sufficient to clear patients to run outside.

[Surgical treatment for pain syndromes of the Achilles tendon]

Pain syndromes of the Achilles tendon (AT) include both insertional and non-insertional tendinopathy, two distinct disorders with different underlying pathophysiologies and management options, characterized by pain, impaired performance and swelling in and around the tendon. This article gives an overview of the operative treatment of pain syndromes of the Achilles tendon, including both insertional tendinopathy of the AT and tendinopathy of the main body of the AT. New minimally invasive techniques for the management of this condition, including endoscopy are also reported.

Rehabilitation of the operated achilles tendon: parameters for predicting return to activity

Return to activity (RTA) following Achilles tendon surgery assessment criteria has not been generally adopted. A well-defined postsurgical rehabilitation regimen with 3 distinct criteria, yet easy to measure, can be used to assess the ability of patients undergoing Achilles tendon surgery to return to activity. We studied whether if patients were able to meet all 3 criteria, would this show significance in predicting the ability to RTA within a normal range. A total of 219 patients undergoing surgery on the Achilles tendon from 1990 to 2005 were retrospectively studied to evaluate for the ability to perform 5 sets of 25 single-legged concentric heel raises, along with symmetry of calf girth and ankle range of motion. Time of RTA and the ability to meet all 3 parameters was studied. If patients could meet all 3 criteria, they were allowed to RTA. This time postsurgery was recorded in weeks. Of the 219 surgeries reviewed, 149 were on males and 70 on females. Fourteen patients were unable to meet all 3 parameters evaluated above within the proposed time frames. The inability to meet all 3 criteria resulted in a delay to RTA (P = .03). Eleven females had a delay in RTA as compared with 2 males (P < .0001). RTA was different based on procedure. Meeting all 3 criteria was helpful in assessing if patients were able to RTA in the normal range. Patients who were unable to meet all 3 had a delay in RTA. Females were more likely to have a delay in RTA.

The variability of the Achilles tendon insertion: a cadaveric examination

Pathology associated with the Achilles tendon is a common problem, particularly at the site of insertion. A better understanding of the anatomy in this area would assist in developing and fine-tuning treatment options. A cadaveric examination was conducted using 60 human lower extremities (40 cadavers) to determine the location for the terminal insertion site of the Achilles tendon on the posterior aspect of the calcaneus. The average age of the specimens was 67.8 years (range, 43-98 years). Three different investigators examined each specimen, and a consensus as to the site of termination of the Achilles tendon was made. Upon inspection, 55% (22/40) of the limbs had the Achilles tendon inserting on the superior 1/3 aspect of the calcaneus, 40% (16/40) of the limbs inserted on the middle 1/3, and 5% (2/40) of the limbs inserted on the inferior 1/3. The distribution of the insertion was statistically different from random (P = .000371). Further, 8% (3/40) of the specimens revealed a partially contiguous relationship between the Achilles tendon and the plantar fascia. This correlated with the younger specimens (P < .0001). This study provides a better understanding of the anatomical relationship between the Achilles tendon, the calcaneus, and the plantar fascia.

Tendon disorders of the foot and ankle, part 2: achilles tendon disorders

Disorders of the Achilles tendon include both acute and chronic ruptures as well as a spectrum of chronic overuse injuries involving inflammatory and degenerative changes within the tendon and surrounding tissues. These injuries are relatively common in athletes as well as among the general population. There is no consensus on the optimal treatment of Achilles tendon disorders. The goals of this review are to develop a current understanding of the anatomy and diagnostic evaluation of the Achilles tendon, and to present current treatment options and the authors' preferred surgical techniques for operative management of Achilles tendon disorders.

Surgical treatment of chronic Achilles tendon rupture

Chronic Achilles tendon ruptures are often challenging to repair because of muscle and tendon atrophy, retraction, and short distal stumps. We undertook a retrospective investigation of 14 patients who were treated with the Ligament Advanced Reinforcement System (LARS) ligament for the treatment of chronic, neglected rupture of the Achilles tendon. The patients pursued a course of early functional rehabilitation, and postoperative outcome scores were obtained at 3, 6, and 12 months, based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, and the Tegner Activity score. The minimum duration of follow-up was 36 months. After a minimum of 28 months postoperative, and up to 41 months postoperative, there was no observed incidence of rerupture or recurrent pain. The mean time to return to full activity was 18.3 +/- 2.7 weeks, and >90% of the patients scored > or =80 points on the AOFAS scoring scale. Specifically, the mean AOFAS score increased from 48.64 +/- 12.67 to 85.86 +/- 6.6 after the operation, and this difference was statistically significant (P = .001). Furthermore, the Tegner activity scale score improved from 2.58 +/- 0.31 to 1.73 +/- 0.29 after the operation, and this difference was also statistically significant (P = .001). The results of this retrospective clinical study suggest that augmentation with the LARS ligament offers a satisfactory reconstructive option for the neglected Achilles tendon rupture.

LEVEL OF CLINICAL EVIDENCE

4.

Achilles tendon repair with acellular tissue graft augmentation in neglected ruptures

Neglected Achilles tendon rupture injuries present surgical challenges because of the quality and quantity of tendon tissue during repair combined with the magnitude of mechanical forces placed on this tendon. The purpose of this study was to evaluate the effects of an acellular human dermal tissue matrix, GRAFTJACKET, as an augmentation material in neglected Achilles tendon repair. Nine patients with neglected Achilles tendon ruptures were evaluated and followed up for a minimum of 20 months. Primary repair was followed by augmentation with the graft and suturing circumferentially around the tendon. Patients were placed in an early, functional rehabilitation program with postoperative evaluation at 3, 6, and 12 months. Outcome scores were calculated based on the American Orthopaedic Foot and Ankle Society ankle-hindfoot scoring system. At 20 to 30 months postoperative follow-up range, there has been no incidence of re-rupture or recurrent pain. The average return-to-activity time was 15.2 +/- 1.7 weeks. The results from this retrospective clinical series suggest that using an acellular human dermal tissue matrix to augment neglected Achilles tendon rupture primary repair offers desirable return-to-activity time points and viable surgical alternative over previously reported surgical options.

Achilles tendon rupture following surgical management for tendinopathy: a case report

Background

Achilles tendinopathy is understood to be a failed healing response. Operative management is utilised following the failure of non-operative methods.

Case Presentation

We present a case of Achilles tendon rupture, sustained whilst isometrically loading the Achilles tendon during an eccentric loading exercise programme. Conclusion: Bilateral surgical exploration and debridement had previously been performed after conservative management of bilateral Achilles tendinopathy had been unsuccessful.

Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy)

The majority of patients with Achilles tendinopathy respond to nonoperative treatment. In patients with refractory symptoms, surgery can be considered. If paratenonitis is present, the paratenon is partially excised, and adhesions are released. Areas of symptomatic tendinosis are excised with repair of the residual defect in the Achilles tendon. An alternative for patients with tendinosis who are at increased risk for wound problems or who do not want a large open incision is percutaneous or endoscopic tenotomy. A symptomatic Haglund's deformity or inflamed retrocalcaneal bursa is excised. Augmentation of the Achilles tendon may be considered if debridement threatens the structural integrity of the tendon, in older patients, and in revision surgery.