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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 t...
Citations
... Advantages of these include larger surface area for contact between bone and tendon which improves both local biology and strength of fixation. The anatomical proof and rationale behind double row repair than single row repair are that the area of insertion on calcaneal tuberosity is that various parts of tendoachilles such as medial and lateral head of gastrocnemius (MG and LG) and soleus insert at different part on tuberosity so double row repair ensures better reattachment of all the three components to their footprint and elderly patients have poor bone quality which decrease the pull out strength of anchor [9,10]. ...
Introduction: Achilles’ tendon is the largest tendon in the body, Tendon is an anatomical structure with inherent less blood supply and so more prone to injury and notorious healing outcomes. The management options for tendoachilles injury depend on the location of the tear, degree of retraction of the torn ends, and patient-related factors. Intraosseous lipoma is very rare benign tumor of bone accounting for 0.1% of all bone tumors. Most common site being proximal femur involvement of calcaneum is very rare presentation. Symptomatic patients with significant heel pain need operative intervention in the form of curettage alone or in combination with filling cavity with bone graft or bone graft substitutes. Many people use PMMA bone cement to fill the void.
Case Report: A 65-year-old male presented with chronic heal pain and difficulty in walking. On clinical examination and radiological investigation, calcaneal intraosseous lipoma was confirmed along with insertional tendinopathy of tendoachilles and haglund syndrome causing tear at insertion into calcaneal tuberosity. We managed this patient in single-stage surgery using tendoachilles split approach for removing haglund deformity and double row anchor suturing for tendon reattachment. Repair was augmented with flexor hallucis longus (FHL) graft fixed using interference screw in the calcaneum. Lipoma was approached with separate medial approach. Cortical window created, lipoma curettage was done, and cavity filled with hydroxyapatite bone graft substitute.
... In IAT patients whose symptoms are not alleviated by conservative management, surgery is indicated 12,13 . Several surgical procedures for refractory IAT have been described [14][15][16] . However, regardless to the surgical intervention, up to 20% of patients experience poor outcomes [17][18][19] . ...
The present study reports the outcomes of revision surgery using a Cincinnati incision with tendon debridement and calcaneoplasty for insertional Achilles tendinopathy (IAT) in a cohort of patients at 24-month follow-up. Patients undergoing revision surgery following failed previous surgery for IAT were prospectively recruited. Patients were assessed pre-operatively and at 3, 6,12 and 24 months. The Victorian Institute of Sport Assessment Scale for Achilles Tendinopathy (VISA-A), the EQ5D questionnaire and the visual analogue scale (VAS) were used for evaluation. Data from 33 patients with a mean age of 43.9 years old are reported. 27% (9 of 33 patients) were female. The left side was involved in 58% (19/33) of patients. No clinically relevant complications were reported in any of the patients. Most of subscales of EQ5D improved at last follow-up: Usual Activities (P = 0.01), Mobility (P = 0.03), Pain/Discomfort (P = 0.001), Thermometer (P = 0.04). No statistically significant change for the subscales Self-Care (P = 0.08) and Anxiety-Depression (P = 0.1) was evidenced. The VISA-A score improved significantly at last follow-up (P < 0.0001), as did the VAS score (P < 0.0001). These results indicated that a Cincinnati incision followed by tendon debridement and calcaneoplasty for revision surgery for IAT is feasible and reliable, achieving clinically relevant improvement in the VISA-A, EQ5D and VAS at 24 months follow-up.
... Open surgery is a well-accepted method with good to excellent results [6,12,13,14]. In cases with an accumulation of calcium salts inside the Achilles tendon or in the extremely painful insertional tendinopathies, "open" surgery has its advantages compared to the arthroscopic one [2,15]. The most frequently used surgical approaches are the lateral and Achilles tendon-splitting approach. ...
Introduction. Haglund?s deformity represents a reactive enlargement of the posterosuperior aspect of the calcaneus and often causes pain that can significantly disturb everyday activities. If the patient?s condition did not improve after six months of non-surgical treatment, the surgical treatment could be taken into consideration. Although Haglund?s deformity is successfully treated by endoscopic calcaneoplasty with two portal techniques we decided to apply a slightly newer technique - arthroscopic surgery with three portal techniques. Case outline. Patient with clinically and radiographically confirmed Haglund?s deformity was operated on using arthroscopic calcaneoplasty with three portal techniques. The postoperative recovery went without complications and full weight-bearing was allowed after 4 weeks. Completely return to sports activities was allowed after 4 months. Conclusion. Arthroscopic calcaneoplasty with three portal techniques turned out to be a safe and cost-effective surgical method in the treatment of Haglund?s deformity. There is still not enough data in the literature regarding this type of surgical treatment, but the good postoperative functional results are extremely encouraging since this surgical technique enables faster recovery and fewer postoperative complications.
... There are different treatment modalities in the literature (4, 6 ,12, 14). Each of these modalities has advantages and disadvantages (3,15). The central Achilles tendonsplitting approach in the treatment of Haglund's disease, which was first described by McGarvey et al., allows rapid and comprehensive debridement because optimal visualization of the surgical area is provided at all stages of the operation (7). ...
... This results in more rapid postoperative tissue healing, less pain, earlier patient mobilisation, and an earlier return to daily activities. Therefore patient satisfaction rates are high (15) (1,14,15). In studies of patients who require surgery, VAS scores have been reported to decrease independently of the surgical technique used (1,4,6,10,14). ...
... This results in more rapid postoperative tissue healing, less pain, earlier patient mobilisation, and an earlier return to daily activities. Therefore patient satisfaction rates are high (15) (1,14,15). In studies of patients who require surgery, VAS scores have been reported to decrease independently of the surgical technique used (1,4,6,10,14). ...
PURPOSE OF THE STUDY To evaluate the mid-term clinical results of patients with Haglund's deformity treated with the central tendon-splitting procedure, and to determine the factors related to patient satisfaction. A retrospective evaluation was made of 20 patients treated with the central tendon-splitting procedure for Haglund's deformity by a single surgeon over a 5-year period. MATERIAL AND METHODS The patients were evaluated preoperatively and in the postoperative follow-up examinations with the American Orthopedic Foot and Ankle Society (AOFAS) scores and visual analog pain scale scores (VAS). Satisfaction with the surgical results was assessed at 3, 6, 12 months and the final follow-up visit, and the factors affecting patient satisfaction were examined. RESULTS Evaluation was made of 13 (65%) females and 7 (35%) males with a mean age of 45.8±8.1 years (range, 37-53 years). The AOFAS values were mean 44.4±8.4 preoperatively, and increased statistically significantly to 89.2±3.2 at the final follow-up examination (p<0.001). At 3 months postoperatively, 65% of the patients evaluated the results as good or excellent and this rate was 100% at the final follow-up examination. According to the correlation analysis, the main determinant of patient satisfaction was pain (r:-0.749, p<0.001), and a strong positive relationship was determined between the AOFAS score and satisfaction (r: 0.892, p<0.001). DISCUSSION The results of this study showed that the central tendon-splitting approach can be used in the treatment of Haglund's triad, with low complication rates, and high success and patient satisfaction rates. CONCLUSIONS In addition, the two components underlying patient satisfaction with Haglund's surgery were found to be the elimination of pain and the ability to return to normal daily activities. Key words: Haglund's triad, patient satisfaction, central tendon-splitting approach.
... Studies show that the initial treatment for insertional tendinopathy should be conservative (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15) . Surgery should be considered only when conservative treatment (a maximum of six months) has failed or in cases of persistent pain and limitations in daily and sports activities (1,14,16) . ...
... J Foot Ankle. 2021;15(1): [8][9][10][11][12][13] The double-row technique was developed to produce greater stability of the tendon insertion and allow earlier rehabilitation without increasing the complication rate (18,19) . However, the single-row method also has good functional results and a low rate of complications. ...
... Both distal anchors were tensioned. This process was repeated for the other distal anchor using the remaining 2 suture tails from the proximal row (12,25,26). A single 0-Vicryl suture with was used to approximate the debrided area of the Achilles tendon. ...
Objective: This retrospective study compared the clinical and functional results of single- and double-row surgical techniques for insertional Achilles tendinopathy in the postoperative period. Methods: In this case series, 29 patients who underwent surgery with one of the two techniques were followed up for one year postoperatively. Data were collected from medical records, imaging exams, and visual analog scale (VAS), Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, 12-item Short Form Health Survey (SF-12), and Foot and Ankle Ability Measure (FAAM) scores. Results: The following mean values (5% significance level) were found for single- and double-row techniques, respectively: postoperative VAS (2.9/2.2), FAAM-ADL (71.9/74.4), FAAM-Sports (28.3/29.8), SF-12 physical component (45.2/47.0), SF-12 mental component (44.9/48.2), and VISA-A (72.1/75.9). The complication rate did not differ significantly between the techniques. Conclusion: No significant differences were found in any of the scores between the two surgical techniques. Level of Evidence III; Therapeutic Studies, Comparative Retrospective Study.
... In the case of failed non-operative treatment, surgery can be considered [11]. As it remains unknown which of the pathologies identified by radiographs and MRI are responsible for painful IAT, open debridement of all pathologies is regularly performed [9,[12][13][14]. Open debridement is performed through extensile approaches and often necessitates a (partial) detachment of the Achilles tendon from its calcaneal insertion. ...
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).
... For patients with severe ossi cation of the distal insertion of the Achilles tendon, it is often necessary to detach the tendon from the calcaneus, remove the heterotopic ossi cation, and then reattach the tendon to the calcaneus [12]. Reports on patient recovery and clinical effects vary greatly, and patients are often greatly delayed in their return to sports [13][14][15]. The insertion of the Achilles tendon is commonly reconstructed with a single or double row of anchors. ...
... In the early postoperative period, the resistance to pull-out is not high, and the joint often needs to be xed with a plaster cast, which usually causes ankle joint stiffness and a high risk of Achilles tendon rerupture. Double-row reconstruction has good initial stability, but the current methods do not consider the shape of the footprint that the Achilles tendon forms on the calcaneus; therefore, the biomechanical properties of the Achilles tendon may change after reconstruction, delaying the patient's return to sports [15][16][17][18]. ...
... At the 7-year follow-up, 96% of the patients were pain free. Zhuang et al. [15]reported that the central tendon-splitting approach was an effective surgical method for the treatment of Achilles tendon disease. However, there are no reports on reconstructing the footprint of the Achilles tendon on the calcaneus. ...
Background
The aims of this study were to investigate the clinical outcomes of anatomical footprint reconstruction for the treatment of insertional Achilles tendinopathy (IAT) with heterotopic ossification and to provide an effective surgical method for the treatment of this condition.Methods
From October 2016 to October 2019, 10 patients underwent anatomical footprint reconstruction for the treatment of IAT with heterotopic ossification at our institution. The operation time and intraoperative bleeding volume were recorded. X-ray and MRI examinations of the calcaneus were performed after the operation. The American Orthopaedic Foot and Ankle Society (AOFAS), visual analog scale (VAS) and Victorian Institute of Sports Assessment–Achilles (VISA-A) scores were used to evaluate the clinical effects on the patients; the time to normal walking and exercise recovery was recorded; and the recovery rate of exercise was recorded at 6 months after the operation.ResultsThe average operation time was 64.4 min (45-74 min), the average bleeding volume was 29.7 ml (5-100 ml), and the average follow-up time was 22.4 months (12-48 months). The patients' wounds healed without infection, splitting, necrosis of the skin margin or other complications. The mean AOFAS score (± SD) was 70.3 ± 11.39 preoperatively and 94.2 ± 5.00 at the last follow-up, showing a significant difference between timepoints (P = 0.00; t = 7.657). The VAS score was 5.4 ± 1.71 preoperatively and 0.4 ± 0.51 at the last follow-up; this decrease was statistically significant (P = 0.00; t = 11.859). The mean VISA-A scores at the preoperative baseline and the last follow-up were 37.6 ± 16.39 and 81.4 ± 8.83, presenting a significant difference between the two timepoints (P = 0.00; t = 9.906). The average time to recover normal walking ability was 9.1 weeks (4-15 weeks), and the average time to resume exercise was 10 weeks (8-12 weeks). At 6 months after the operation, the rate of exercise recovery was 80%.Conclusion
In IAT with heterotopic ossification, anatomical footprint reconstruction enables patients to return to normal life and exercise quickly. The rate of return to sports is high, and the procedure offers satisfactory clinical effects.
... Because the identification of the pain-causing pathology is often difficult, open debridement of all pathologies is regularly performed. 1,7,9,15,26,27,32,36,39 Open debridement necessitates extensile approaches to allow sufficient exposure to address all pathologies present. 1,9,10,27,32,39 In case of a dorsal spur, a (partial) detachment of the Achilles tendon might be necessary. ...
... 1,7,9,15,26,27,32,36,39 Open debridement necessitates extensile approaches to allow sufficient exposure to address all pathologies present. 1,9,10,27,32,39 In case of a dorsal spur, a (partial) detachment of the Achilles tendon might be necessary. If more than 50% of the Achilles tendon insertion is detached, reattachment should be considered. ...
... Most studies reporting predominantly on the outcome of the surgical treatment do not perform any further analysis of complication rates and are limited by small sample sizes. 6,10,11,15,18,23,[25][26][27]30,32,[36][37][38][39] Our hypothesis was that the extent of the surgical procedure would influence complication rates. Therefore, the aim of this study was to assess the complication rate and possible influencing factors following the midline-incision trans-Achilles approach (MITA) for IAT. ...
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.
Background
Although double-row suture-anchored (DRSA) techniques for Achilles insertional tendinosis has proven successful, a reoccurring failure mode not yet addressed is suture tearing through the tendon. This study aims to address suture tearing by incorporating a rip-stop element. Authors hypothesized that the Rip-Stop group would demonstrate increased strength compared with more traditional techniques.
Methods
12 paired cadaveric feet were used in this study (n = 24). One sample from each pair was assigned to receive the standard double-row (SDR) Achilles repair with 4.75-mm knotless anchors (n = 12). The control’s matched sides were divided between 2 DRSA bridge groups: modified double-row (MDR) bridge with 3.9-mm anchors or rip-stop double-row (RS-DR) bridge repair with soft proximal anchors and 3.9-mm anchored distal row. In neutral position, specimens underwent 1000 cycles (20-100 N) followed by load to failure. Displacements, stiffness, ultimate load, and failure mode were recorded.
Results
RS-DR had the lowest initial displacement values followed by SDR and MDR (1.3 ± 0.4, 2.7 ± 1.4, and 3.2 ± 1.3 mm, respectively). Significance was detected when comparing initial displacement of RS-DR to MDR ( P = .038). Cyclic displacement was lowest for RS-DR, followed by MDR and SDR (1.6 ± 0.9, 2.2 ± 1.1, and 4.5 ± 3.2 mm, respectively). Cyclic stiffness was similar for RS-DR and MDR (89.1 ± 24.6 and 81.9 ± 5.6 N/mm, respectively). RS-DR ultimate load (1116.8 ± 405.7 N) was statistically greater than SDR (465.6 ± 352.7, P = .003).
Conclusion
RS-DR–repaired specimens demonstrated a decrease in displacement values and increased ultimate load and stiffness when compared to other groups. Results of this cadaveric model suggest that the addition of a rip-stop to DRSA Achilles repair is more impactful than anchor size. Limitations include that this was a time-zero biomechanical study, which cannot simulate the performance of the repairs during postoperative healing and recovery.
Clinical Relevance
A rip-stop technique for Achilles repair effectively improves dynamic mechanical characteristics and may mitigate suture tearing through tendon in a patient cohort.
