Treatment of Achilles insertional tendinopathy: our surgical procedure and medium-term results
Keywords:
Achilles insertional calcific tendinosis, Achilles insertional tendinosis, Haglund’s deformity, Achilles calcific tendinitis, Tendon, Ankle, Achilles Suture Bridge™Abstract
Background and aim: Achilles insertional tendinopathy (AIT) is a common injury and its pathogenesis is still not entirely clear. It manifests with worsening pain and functional limitations. When conservative treatment fails, surgical treatment is indicated. The purpose of our research is to evaluate the outcome after one year in patients affected by AIT (calcific and non-calcific AIT) who were treated at our centre. Methods: Between 2014 and 2021, 42 patients suffering from AIT – a total of 47 feet – underwent surgery at our centre. The patients filled in the VISA-A and AOFAS questionnaires at the pre-operative consultation and at the clinical check-up after one year of follow up. Results: Of the 47 feet treated, 28 were calcific AITs treated by medial access and tendon reinsertion using a knotless double suture anchor system (Achilles Suture Bridge™) and 19 were non-calcific tendinopathies treated using a lateral paratendinous approach. The one-year clinical results show an increase in VISA-A scores of 48.6 and AOFAS scores of 44.1 and the absence of complications. Only one patient reported a recurrence of certain symptoms and none of the patients were hospitalized for recurrence. Conclusions: The literature is unable to establish a gold standard of treatment for AIT. The method we have used has shown excellent short- and medium-term results without any complications. Further studies are needed to prove its effectiveness in the long term.
References
Grambart ST, Lechner J, Wentz J. Differentiating Achilles Insertional Calcific Tendinosis and Haglund’s Deformity. Clin Podiatr Med Surg. 2021 Apr;38(4):165-4. doi: 10.1016/j.cpm.2020.12.003. Epub 2021 Apr 13. PMID: 33745649.
Irwin TA. Current concepts review: insertional achilles tendinopathy. Foot ankle Int. 2010 Oct;31(10):933-9. doi: 10.3113/FAI.2010.0933. PMID: 20964977.
Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund’s deformity. Foot ankle Int. 2012 Jun;33(6):487-91. doi: 10.3113/FAI.2012.0487. PMID: 22735321.
Barg A, Ludwig T. Surgical Strategies for the Treatment of Insertional Achilles Tendinopathy. Foot Ankle Clin. 2019 Sep;24(3):533-559. doi: 10.1016/j.fcl.2019.04.005. Epub 2019 Dec 18. PMID: 31371002.
Solan M, Davies M. Management of insertional tendinopathy of the Achilles tendon. Foot Ankle Clin. 2007 Dec;12(4):597-615,. doi: 10.1016/j.fcl.2007.07.005. PMID: 17996618.
Krishna Sayana M, Maffulli N. Insertional Achilles tendinopathy. Foot Ankle Clin. 2005 Jun;10(2):309-20. doi: 10.1016/j.fcl.2005.01.010. PMID: 15922921.
Den Hartog BD. Insertional Achilles tendinosis: pathogenesis and treatment. Foot Ankle Clin. 2009 Dec;14(4):639-50. doi: 10.1016/j.fcl.2009.08.005. PMID: 19857838.
Shakked RJ, Raikin SM. Insertional Tendinopathy of the Achilles: Debridement, Primary Repair, and When to Augment. Foot Ankle Clin. 2017 Dec;22(4):761-780. doi: 10.1016/j.fcl.2017.07.005. Epub 2017 Sep 27. PMID: 29078827.
Chimenti RL, Cychosz CC, Hall MM, Phisitkul P. Current Concepts Review Update: Insertional Achilles Tendinopathy. Foot ankle Int. 2017 Oct;38(10):1160-1169. doi: 10.1177/1071100717723127. Epub 2017 Aug 8. PMID: 28789557; PMCID: PMC5956523.
Roche AJ, Calder JD. Achilles tendinopathy: a review of the current concepts of treatment. Bone Joint J 2013;95-b(10):1299-307.
Scott AT, Long CS, Jaramillo TJ, Lara DL, Marois AJ, Juneja P. Review of Achilles Tendon Reattachment Using Double-Row Knotted and Knotless Techniques in the Management of Insertional Achilles Tendinopathy. J Foot Ankle Surg. 2021 Dec 12:S1067-2516(21)00506-8. doi: 10.1053/j.jfas.2021.12.015. Epub ahead of print. PMID: 34998679.
Maffulli N, Gougoulias N, D'Addona A, Oliva F, Maffulli GD. Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy. Chirurgo. 2021 Dec;19(6):e344-e352. doi: 10.1016/j.surge.2020.08.018. Epub 2020 Oct 22. PMID: 33268299.
Witt BL, Hyer CF. Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series. J Foot Ankle Surg. 2012 Jul-Aug;51(4):487-93. doi: 10.1053/j.jfas.2012.03.006. Epub 2012 May 10. PMID: 22579354.
Thompson JM, Nguyen K, Ahluwalia J, et al. Surgical Takedown Approaches to Insertional Achilles Tendinopathy: A Systematic Review. J Foot Ankle Surg. 2021 Nov-Dec;60(6):1217-1221. doi: 10.1053/j.jfas.2021.04.015. Epub 2021 Apr 30. PMID: 34108118.
Leigheb M, Janicka P, Andorno S, Marcuzzi A, Magnani C, Grassi F. Italian translation, cultural adaptation and validation of the “American Orthopaedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale”. Acta Biomed. 2016 May 6;87(1):38-45. PMID: 27163894.
Andersson G, Backman LJ, Christensen J, Alfredson H. Nerve distributions in insertional Achilles tendinopathy - a comparison of bone, bursae and tendon. Histol Histopathol. 2017 Mar;32(3):263-270. doi: 10.14670/HH-11-790. Epub 2016 Dec 20. PMID: 27320798.
Fahlstrom M, Jonsson P, Lorentzon R, et al. Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surg Sports Traumatol Arthrosc 2003; 11(5):327-33.
Henning PR, Grear BJ. Platelet-rich plasma in the foot and ankle. Curr Rev Musculoskelet Med. 2018 Dec;11(4):616-623. doi: 10.1007/s12178-018-9522-z. PMID: 30259330; PMCID: PMC6220005.
Urits I, Smoots D, Franscioni H, et al. Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review. Pain Ther. 2020 Jun;9(1):145-160. doi: 10.1007/s40122-020-00157-5. Epub 2020 Apr 27. PMID: 32107725; PMCID: PMC7203280.
Filardo G, Di Matteo B, Kon E, Merli G, Marcacci M. Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc. 2018 Jul;26(7):1984-1999. doi: 10.1007/s00167-016-4261-4. Epub 2016 Sep 24. PMID: 27665095.
Furia JP. Extrakorporale Stosswellentherapie zur Behandlung der Achillessehnentendinopathie [Extracorporeal shockwave therapy in the treatment of chronic insertional Achilles tendinopathy]. Orthopade. 2005 Jun;34(6):571-8. German. doi: 10.1007/s00132-005-0806-9. PMID: 15909176.
Rompe JD, Furia J, Maffulli N (2008) Eccentric loading compared with shock wave treatment for chronic insertional achilles tendinopathy. A randomized, controlled trial. J Bone Joint Surg Am. 90:52-61).
Waldecker U, Hofmann G, Drewitz S. Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg. 2012 Jun;18(2):119-23. doi: 10.1016/j.fas.2011.04.007. Epub 2011 Dec 8. PMID: 22443999.
Costantino C, Pogliacomi F, Vaienti E (2005) Cryoultrasound therapy and tendonitis in athletes: a comparative evaluation versus laser CO2 and t.e.ca.r. therapy. Acta Biomed 76:37-41.
Gaston TE, Daniel JN. Achilles Insertional Tendinopathy- Is There a Gold Standard? Arch Bone Jt Surg. 2021 Jan;9(1):5-8. doi: 10.22038/abjs.2020.53988.2704. PMID: 33778110; PMCID: PMC7957111.
DeOrio MJ, Easley ME. Surgical strategies: insertional achilles tendinopathy. Foot ankle Int. 2008 May;29(5):542-50. doi: 10.3113/FAI-2008-0542. PMID: 18510913.
Martin RL, Manning CM, Carcia CR, Conti SF. An outcome study of chronic Achilles tendinosis after excision of the Achilles tendon and flexor hallucis longus tendon transfer. Foot ankle Int. 2005 Sep;26(9):691-7. doi: 10.1177/107110070502600905. PMID: 16174498.
Wagner E, Gould JS, Kneidel M, Fleisig GS, Fowler R. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot ankle Int. 2006 Sep;27(9):677-84. doi: 10.1177/107110070602700904. PMID: 17038277.
DeVries JG, Summerhays B, Guehlstorf DW. Surgical correction of Haglund's triad using complete detachment and reattachment of the Achilles tendon. J Foot Ankle Surg. 2009 Jul-Aug;48(4):447-51. doi: 10.1053/j.jfas.2009.03.004. PMID: 19577720.
Ettinger S, Razzaq R, Waizy H, et al. Operative Treatment of the Insertional Achilles Tendinopathy Through a Transtendinous Approach. Foot ankle Int. 2016 Mar;37(3):288-93. doi: 10.1177/1071100715609921. Epub 2015 Oct 6. PMID: 26443697.
McGarvey WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot ankle Int. 2002 Jan;23(1):19-25. doi: 10.1177/107110070202300104. PMID: 11822688.
Nunley JA, Ruskin G, Horst F. Long-term clinical outcomes following the central incision technique for insertional Achilles tendinopathy. Foot ankle Int. 2011; 32(9):850-5.
Kolodziej P, Glisson RR, Nunley JA. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund’s deformity: a biomechanical study. Foot ankle Int. 1999; 20(7):433-437.
Brady PC, Arrigoni P, Burkhart SS. Evaluation of residual rotator cuff defects after in vivo single- versus double-row rotator cuff repairs. Arthroscopy. 2006 Oct;22(10):1070-5. doi: 10.1016/j.arthro.2006.05.007. PMID: 17027404.
Ma CB, Comerford L, Wilson J, et al. Biomechanical evaluation of arthroscopic rotator cuff repairs: double-row compared with single-row fixation. J Bone Joint Surg Am 2006; 88(4):403-4
Pilson H, Brown P, Stitzel J, Scott A. Single-row versus double-row repair of the distal Achilles tendon: a biomechanical comparison. J Foot Ankle Surg. 2012 Nov-Dec;51(6):762-6. doi: 10.1053/j.jfas.2012.07.001. Epub 2012 Aug 3. PMID: 22863754.
Beitzel K, Mazzocca AD, Obopilwe, et al. Biomechanical properties of double- and single-row suture anchor repair for surgical treatment of insertional Achilles tendinopathy. Am J Sports Med. 2013 Jul;41(7):1642-8. doi: 10.1177/0363546513487061. Epub 2013 May 3. PMID: 23644147.
Schepsis AA, Wagner C, Leach RE. Surgical management of Achilles tendon overuse injuries. A long-term follow-up study. Am J Sports Med. 1994 Sep-Oct;22(5):611-9. doi: 10.1177/036354659402200508. PMID: 7810784.
Vega J, Baduell A, Malagelada F, Allmendinger J, Dalmau-Pastor M. Endoscopic Achilles Tendon Augmentation With Suture Anchors After Calcaneal Exostectomy in Haglund Syndrome. Foot ankle Int. 2018 May;39(5):551-559. doi: 10.1177/1071100717750888. Epub 2018 Dec 9. PMID: 29519149.
Lui TH, Lo CY, Siu YC. Minimally Invasive and Endoscopic Treatment of Haglund Syndrome. Foot Ankle Clin. 2019 Sep;24(3):515-531. doi: 10.1016/j.fcl.2019.04.006. Epub 2019 May 18. PMID: 31371001.
Downloads
Published
Issue
Section
License
Copyright (c) 2023 Giovanni Lugani, Alessandro Santandrea, Domenico Mercurio, Leonardo Puddu, Jessica Silvestri, Fabrizio Cortese
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.
How to Cite
