Safety and outcome of surgical debridement of insertional Achilles tendinopathy using a transverse (Cincinnati) incision

Abstract

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative followup of three years, the Victorian Institute of Sports Assessment scale -Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less softtissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.In insertional Achilles tendinopathy, symptoms occur at the bone-tendon junction. The distal portion is affected in 24% of patients, 1 but the actual incidence of insertional Achilles tendinopathy is unknown. Conservative measures are helpful in most patients, and include rest, ice, non-steroidal anti-inflammatory drugs, careful selection of footwear and activity modification. 2 Eccentric exercises of the gastro-soleus complex are effective in only 32% of patients, with 67% of promising clinical results in patients undergoing a new model of painful eccentric calf-muscle training. 3

The Cincinnati incision is safe and effective for revision surgery for insertional tendinopathy of the Achilles tendon

“…Furthermore, longitudinal posterior AT splitting approaches may produce hypertrophic scars and AT adherences, resulting in unfavourable outcomes. As the Cincinnati incision for the purposes of surgery on the insertion of the Achilles tendon is centred over the calcaneal tuberosity and does not extend anteriorly as much as it would be required if club foot surgery were to be undertaken, the chances of nerve damage are minimised, and, as demonstrated by the present and previous studies, resolve spontaneously if and when they occur 20 . It is theoretically possible to encounter some of the branches of the sural and posterior tibial nerves.…”

“…Curvilinear, midline and the lateral longitudinal incisions are alternatives to the Cincinnati transverse incision 4 , 28 , but are prone to complications of wound healing and breakdown and iatrogenic nerve injury 29 . The Cincinnati approach allows adequate exposure of the distal Achilles tendon and the posterior aspect of the calcaneous, enabling debridement of the pathological tissue and of the subcutaneous bursa 20 . In comparison to medial and/or lateral incisions, the Cincinnati incision allows full exposure of both the medial and lateral aspects of the insertion of the AT on the calcaneus.…”

“…The surgical interventions were performed by one experienced surgeon (NM) using the technique previously published in the setting of primary surgery for IAT 20 . Under general or spinal anesthesia, the patients were positioned prone.…”

“…Subcutaneous tissues and skin were sutured in a standard fashion. We advise against the use of drains 20 .

Figure 1 Failed lateral open approach revised with Cincinnati incision.

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“…Moreover, current evidence concerning the management and outcomes of those patients are lacking. Surgical debridement through a transverse Cincinnati incision has been successfully used for primary IAT 20 . The Cincinnati incision allows to expose the whole of the insertion area of the Achilles tendon, with full access to the posterior aspect of the calcaneus, and the regions medially and laterally to it.…”