Central Tendon-Splitting Approach and Double Row Suturing for the Treatment of Insertional Achilles Tendinopathy

Abstract

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 the Achilles tendon, radiographic demonstration of calcification, or degeneration of the Achilles tendon, showing no symptom improvement even after standard nonsurgical treatment for more than six months. The X-ray revealed that patients had obvious posterior superior calcaneal exostosis with the possibility of friction with the Achilles tendon or intratendinous calcification. Surgical correction by the central tendon-splitting approach and double row Achilles tendon suturing was performed. The ankles were immobilized with plaster for four weeks postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue score (VAS) were assessed preoperatively and at 2 years postoperatively. At final follow-up, the Manchester-Oxford Foot Questionnaire (MOXFQ) as patient-reported outcome measures (PROMs) was also evaluated. Results. No complication, including postoperative wound infection and tendon rupture, was not found. All the patients resumed their daily activities with no high level of daily activities, such as jumping and jogging after 6 weeks postoperatively. 27 patients were available for follow-up for at least 2 years, while only one patient was lost to follow-up. At postoperative 2 years, the postoperative AOFAS score increased significantly, while the VAS score decreased statistically when compared with preoperative values. At final follow-up, 24 patients had complete alleviation of pain, whereas the remaining 3 patients complained of mild heel pain after walking for a long time. The MOXFQ score showed obvious relief of previous symptoms for all included cases. Conclusions. Central tendon-splitting approach and double row Achilles tendon suture provide excellent intraoperative visual field, larger tendon-bone contact area, and stronger pullout strength and, thus, facilitate early rehabilitation. It can be a safe and effective method for the treatment of insertional Achilles tendinopathy.

Anatomical footprint reconstruction for the treatment of insertional Achilles tendinopathy with heterotopic ossification

“…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.…”

“…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].…”

Complications Associated With Midline Incision for Insertional Achilles Tendinopathy

“…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.…”

“…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.…”