Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series

Achilles tendinopathy is a clinical diagnosis characterized as a triad of symptoms including pain, swelling, and impaired performance of the diseased tendon. Achilles tendinopathy is divided into Achilles tendonitis and tendinosis based on histopathological examination. Achilles tendinosis is viewed microscopically as disorganized collagen, abnormal neovascularization, necrosis, and mucoid degeneration. Insertional Achilles tendinosis is a degenerative process of the tendon at the junction of the tendon and calcaneus. This disease is initially treated conservatively with activity modification, custom orthotic devices, heel lifts, and immobilization. After 3 to 6 months of conservative therapy has failed to alleviate symptoms, surgical management is indicated. Surgical management of insertional Achilles tendinosis includes Achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision. In this case series, we present 4 patients who underwent surgical management of insertional Achilles tendinosis with complete tendon detachment. All patients underwent reattachment of the Achilles tendon with the suture bridge technique. The Arthrex SutureBridge^® (Arthrex, Inc., Naples, FL) device uses a series of 4 suture anchors and FiberWire^® (Arthrex Inc.) to reattach the Achilles tendon to its calcaneal insertion. This hourglass pattern of FiberWire^® provides a greater area of tendon compression, consequently allowing greater stability and possible earlier return to weightbearing activities. The patients were followed up for approximately 2 years’ duration. There were no intraoperative or postoperative complications. At final follow-up there was no evidence of Achilles tendon ruptures or device failures. All patients were able to return to their activities of daily living without the use of assistive devices. The patients’ average visual analog pain scale was 1 (range 0 to 4), and their average foot functional index score was 3.41 (range 0 to 10.71). The suture bridge technique is a viable option for Achilles tendon repair after surgical management of insertional Achilles tendinosis.     

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review

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.     

Early Weightbearing Using Achilles Suture Bridge Technique for Insertional Achilles Tendinosis: A Review of 43 Patients

Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the surgical treatment of insertional Achilles tendinosis.     

Retrocalcaneal Enthesophyte Resection With Functional Lengthening of the Achilles Tendon and Buried Knot Technique: A Case Series

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.     

Endoscopic treatment of insertional Achilles tendinopathy: Surgical techniques and indications

Haglund syndrome is a common cause of heel pain that can affect either young and middle-aged patients. When indicated, surgical treatment can be performed using an open, percutaneous or endoscopic technique. A high rate of complications rate, especially due to healing of skin incisions, has been reported by open techniques, for this reason minimally invasive procedures treating insertional Achilles tendinopathy has recently gained popularity. Endoscopy allows to perform several procedures such as bursectomy, calcaneoplasty, Achilles tendon reattachment with anchors and Flexor Hallucis Longus transfer. Aim of this work is to provide an update on existing endoscopic techniques for the Achilles tendon pathologies treatment. These techniques represent an important tool for the orthopedic surgeon when treating Achilles tendon pathologies.     

Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis

BACKGROUND: Insertional Achilles tendinosis is a clinical entity that commonly occurs with other posterior heel disorders such as retrocalcaneal bursitis, Haglund deformity, intratendinous ossification and pretendinous bursitis. Complete detachment and reconstruction of the Achilles tendon was evaluated as a method of treatment for this condition. METHODS: Seventy-five patients (81 heels) were treated over a 5-year period for chronic insertional Achilles tendinosis. These were divided in two groups: a nondetached group (26 patients, 31 heels, average age 55 years) included all patients with debridement of the Achilles tendon with no or partial detachment of the tendon, and a detached group (49 patients, 50 heels, average age 56.1 years) that included all patients with complete detachment, debridement, and reattachment with suture anchors of the Achilles tendon associated with proximal V-Y lengthening of the proximal aponeurosis. Sixty-one patients (65 heels) were contacted for an interview questionnaire, 22 patients from the nondetached group (26 heels) and 39 patients from the detached group (39 heels). The average followup for the nondetached group was 47 months and for the detached group 33 months. Items evaluated included pain, activity limitation, gait change, walking distance, return to sport or work, and level of satisfaction. RESULTS: No statistically significant differences were noted in relation to any of the items evaluated. In the nondetached group, the satisfaction rate was 92%, and 8% were dissatisfied. In the detached group, 74% were completely satisfied and 18% were satisfied with reservations. Eight percent were dissatisfied. Complications included minor wound dehiscence (one in the nondetached, five in the detached group), wound infection (one in the nondetached group, two in the detached group) and sural neuritis (two in the detached group). CONCLUSIONS: Complete detachment of the Achilles tendon and reattachment with suture anchors and a proximal V-Y lengthening was a reliable and effective method of treatment for severe chronic insertional Achilles tendinosis as was debridement of the tendon insertion without detachment for less severe involvement.     

Outcomes and Material Cost Comparison of Transosseous Versus Suture Anchor Fixation of the Achilles Tendon: A Retrospective Study

Insertional Achilles tendinopathy is a common pathology that may be resistant to conservative treatment requiring surgical intervention. Treatment often involves partial to complete detachment of the Achilles tendon, debridement, and reattachment. Although 50% of the tendon may be safely resected without significantly compromising strength, the addition of a lengthening procedure requires further reinforcement. We conducted a retrospective review of 43 procedures comparing outcomes of 16 single suture anchor procedures with 27 transosseous fixation procedures for reattachment of the Achilles. The suture anchor group utilized one of 2 different industry anchors while the transosseous group utilized sutures ranging in size from 2-0 to #2. Female patients contributed 67% of the procedures with 53% occurring on the left side. For each group the median preoperative pain score (scale 0-10) was 8 and the median of the lowest reported postoperative pain score was 0. The typical time to lowest postoperative pain was 10 weeks for the suture anchor group and 4 weeks for the transosseous group. Tourniquet time averaged 59.3 (12.9) minutes for the suture anchor group and 65.1 (16.4) for the transosseous group. There was a large difference in material costs between the suture anchor and transosseous groups which ranged from $364.51 to $448.51 and $99.80 to $104.00 respectively. With similar results on postoperative pain and adverse event rate to suture anchor fixation and lower material costs than anchor fixation, transosseous fixation remains a viable option for fixating the Achilles tendon to bone in treatment of insertional Achilles tendinopathy.     

The management of lower extremity soft tissue and tendon trauma

This article discusses the treatment of soft tissue injuries in the ankle and foot, including rupture of the Achilles tendon, Achilles tendonitis, peroneal tendonitis, peroneal tendon syndromes, and ankle sprain. It also discusses the causes, treatment, and reconstruction of soft tissue defects in the foot.     

Insertional Achilles tendinopathy

There has been significant progress in our understanding of Achilles insertional tendinopathy since Clain and Baxter divided Achilles tendon disorders into noninsertional and insertional tendinopathy in 1992. In this article we specifically concentrate on Achilles insertional tendinopathy. Classically, overuse and poor training habits are considered to be the main etiology of Achilles insertional tendinopathy. This article discusses Achilles insertional tendinopathy from the anatomy of to its management.     

Spiked metallic washer and screw for reattachment of the Achilles tendon after repair of a distal rupture.

The authors review Achilles tendon ruptures and treatment options for the acute and chronic rupture. A case is described involving reattachment of a chronic distal Achilles tendon rupture repair with a spiked metal washer and fully threaded cannulated cancellous screw. Spiked metal washers and their effects on soft-tissue pullout strength, and possible complications are discussed. In review of the literature, the authors have not found this type of fixation used to anchor the Achilles tendon, and feel it may be a viable option when faced with distal Achilles reattachment for the acute and chronic rupture.     

Chronic Achilles paratendonitis with tendonitis

We describe the case of a 43-year-old woman with a history of bilateral Achilles tendon pain. Ultrasound scanning revealed chronic Achilles paratendonitis with tendonitis. Conservative measures failed but surgical intervention under local anaesthesia was successful.     

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.     

Modified flexor hallucis longus transfer for Achilles insertional rupture in elderly patients

Elderly patients with symptomatic Achilles tendinopathy who develop insertional ruptures develop are at risk of persistent pain and poor functional outcome. Extensive debridement of the tendinopathy creates a defect that adds to the difficulty of Achilles insertional rupture repair. Complete excision of the tendinopathy segment was proposed to minimize persistent pain. Reconstruction of the defect using modified flexor hallucis longus transfer might better restore Achilles function. Five patients older than 50 years (mean age, 58.8 years) who had symptomatic Achilles tendinopathy and subsequently had insertional ruptures were treated. The outcome was assessed at an average of 28.8 months after the reconstruction. There was good pain relief. All patients were able to do single-leg stance. Cybex isokinetic testing showed plantar flexion peak torque deficits of 10.9% and 3.9% when tested at 60 degrees /second and 120 degrees /second, respectively. The Functional Ambulation Performance score indicated a near normal gait pattern. The American Orthopaedic Foot and Ankle Society hindfoot score improved from 64.4 to 94.4. There was no major surgical complication and no re-rupture. Excision of Achilles tendinopathy segment followed by modified flexor hallucis longus transfer can achieve good pain relief and functional recovery in elderly patients with symptomatic Achilles tendinopathy who have Achilles insertional ruptures develop.     

Epidemiologic investigation of 1394 feet: Coincidence of hindfoot malalignment and Achilles tendon disorders

BackgroundThe aim of this epidemiologic study was to evaluate the incidence of the Achilles tendinopathy in non athletes and the coincidence with varus alignment of the hindfoot.MethodsSix hundred ninety-seven patients (1394 feet) have been analysed. The tibiocalcaneal axis was goniometrically measured. The presence of a non insertional and insertional Achilles tendinopathy was clinically determined.ResultsAchilles tendinopathy was found in 5.6% of the patients (4% insertional, 3.6% non insertional, 1.9% both forms). The average tibiocalcaneal angle was calculated with ?0.76° for the tendinopathy group and ?0.96° for the insertional tendinopathy whereas the control group showed an average angle of 1.77°. For the total group the average tibiocalcaneal axis was calculated with 1.62°. Out of 1394 feet 38.3% showed a varus axis of the hindfoot and 61.7% a valgus alignment.ConclusionsThe coincidence of varus alignment and Achilles tendinopathy could be validated.     

Achilles tendon rupture following coblation for insertional Achilles tendinosis

Radiofrequency microdebridement for Achilles tendinosis is a relatively new technique. We report a case of Achilles tendon rupture in a patient eight weeks after coblation for his right insertional Achilles tendinosis. We believe that this is the first reported case of Achilles tendon rupture following this new treatment of radiofrequency microdebridement for chronic Achilles tendinosis.     

Single-row Versus Double-row Repair of the Distal Achilles Tendon: A Biomechanical Comparison

Surgery for recalcitrant insertional Achilles tendinopathy often consists of partial or total release of the insertion site, debridement of the diseased portion of the tendon, calcaneal ostectomy, and reattachment of the Achilles to the calcaneus. Although single-row and double-row techniques exist for repair of the detached Achilles tendon, biomechanical data are lacking to support one technique over the other. Based on data extrapolated from the study of rotator cuff repairs, we hypothesized that a double-row construct would provide superior fixation strength over a single-row repair. Eighteen human cadaveric Achilles tendons (9 matched pairs) with attached calcanei were repaired with single-row or double-row techniques. Specimens were mounted in a servohydraulic materials testing machine, subjected to a preconditioning cycle, and loaded to failure. Failure was defined as suture breakage or pullout, midsubstance tendon rupture, or anchor pullout. Among the failures were 12 suture failures, 5 proximal-row anchor failures, and 1 distal-row anchor failure. No midsubstance tendon ruptures or testing apparatus failures were observed. There were no statistically significant differences in the peak load to failure between the single-row and double-row repairs (p = .46). Similarly, no significant differences were observed with regards to mean energy expenditure to failure (p = .069). The present study demonstrated no biomechanical advantages of the double-row repair over a single-row repair. Despite the lack of a clear biomechanical advantage, there may exist clinical advantages of a double-row repair, such as reduction in knot prominence and restoration of the Achilles footprint.     

Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores

PurposeChronic 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.MethodIt 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.ResultsAll 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.ConclusionFHL 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.     

Extrakorporale Stoßwellentherapie zur Behandlung der Achillessehnentendinopathie

PURPOSE: The purpose of this study was to determine the efficacy of extracorporeal shock wave therapy (ESWT) for the treatment of adults with chronic insertional Achilles tendinopathy. METHODS: 68 patients with chronic insertional Achilles tendinopathy were enrolled in this study. A total of 35 patients were treated with a single dose of ESWT (3000 shocks of 0.20 mJ/mm(2), ESWT group), while 33 patients were treated with traditional non-operative measures (control group). RESULTS: At 3 months post treatment, the mean VAS for the control and ESWT groups were 2.9 and 7.2 respectively. Using the Roles and Maudsley scale, 39% of the control patients and 51% of the ESWT patients were assigned an excellent or good result. CONCLUSIONS: ESWT as applied is a safe and effective treatment for chronic insertional Achilles tendinopathy.     

Change in plantarflexion strength after complete detachment and reconstruction of the Achilles tendon

BACKGROUND: Chronic insertional tendinitis of the Achilles tendon is an overuse injury seen with increasing frequency because of an aging population and an increased interest in sports. We evaluated the change in plantarflexion strength in patients after our surgical technique for chronic insertional Achilles tendinitis. METHODS: From our previous clinical series of detachment and reconstruction of the Achilles tendon for the treatment of insertional tendinitis, ten patients were evaluated with an average followup of 32.1 (range 18 to 52) months. The average age was 65.7 years. We developed a mathematical model to predict the difference in plantarflexion strength between a reconstructed ankle and a healthy contralateral one. Isokinetic testing at 60 degrees/second was performed, measuring plantarflexion peak torque, dorsiflexion peak torque, and total work. RESULTS: Our mathematical model predicted a decrease of 4% in plantarflexion torque after the surgery. Isokinetic testing found no significant differences in plantarflexion torque, dorsiflexion torque, or total work between the operated and nonoperated ankles. CONCLUSIONS: Complete detachment and reconstruction of the Achilles tendon do not decrease the working capacity of the gastrocsoleus muscle.     

Is Calcaneal Inclination Higher in Patients with Insertional Achilles Tendinosis? A Case-controlled,Cross-sectional Study

Insertional Achilles tendinosis is a condition where a patient complains of isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. It has been suggested that this condition is associated with cavus foot deformity. However, to our knowledge, there is no study that has confirmed this observation. We carried out a cross-sectional, case-controlled study to explore the association of increased calcaneal inclination—a surgically important characteristic of cavus foot deformity—with insertional Achilles tendinosis. Patients with Achilles tendinosis and matched controls without the pathology were compared. Although a statistically significant difference was detected in calcaneal inclination angle between these 2 groups (p = .038), we felt that the difference was not clinically significant (calcaneal inclination angle = 20.9 vs. 18.9, respectively). Within the limitations of the study, we conclude that there is no clinically significant difference in calcaneal inclination between those with or without insertional Achilles tendinosis.