J Korean Foot Ankle Soc.  2021 Jun;25(2):95-99. 10.14193/jkfas.2021.25.2.95.

Surgical Strategies for Achilles Tendinopathy

• Park HW

• KMID: 2516647
• DOI: http://doi.org/10.14193/jkfas.2021.25.2.95

Abstract

The surgical treatment of Achilles tendinopathy can be considered after the failure of conservative treatment, and the surgical methods may be divided into two groups; treatments for insertional and non-insertional tendinopathy. In the case of insertional tendinopathy, debridement including tendon and calcification of the diseased lesion, reattachment of the tendon, and calcaneal ostectomy of the Haglund lesion are the primary treatments. If reattachment is not possible, reconstruction should be performed by other methods such as tendon transfer. As a result of surgery for insertional tendinopathy, there is an improvement in the pain and function after surgery, but there are some patients whose pain does not completely disappear. Some residual pain may persist; therefore, the overall success rate of the surgery can be expected to be 80% to 90%. For the patients of non-insertional tendinopathy, conservative treatment through eccentric exercise is the primary treatment, and most of them have reported good results. In case of failure after various conservative treatments, debridement of the diseased lesion and repair of the remaining tendon would be the primary surgical treatments. If the remaining tendon is not sufficient, reconstruction such as tendon transfer should be considered.

Keyword

Achilles tendon; Tendinopathy; Enthesopathy; Osteophyte; Minimally invasive surgical procedures

Figure

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  Figure. 1 Skin incisions for Achilles tendinopathy. (A) Midline incision. (B) Hockey stick J incision. (C) Medial longitudinal incision. Lateral longitudinal short incision could be made additionally. (D) Cincinnati incision.

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  Figure. 2 Radiographic findings. (A) Preoperative plain X-ray. (B) Preoperative magnetic resonance imaging scan.

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  Figure. 3 Intraoperative findings. (A) Ossified bone fragment was removed from the diseased tendinous insertion of Achilles tendon. (B) Posterosuperior portion as the Haglund lesion of calcaneus was removed with osteotome. (C) A suture anchor was placed near the detached area of Achilles tendon insertion. (D) Detached portion of Achilles was reattached firmly by a suture anchor with strands.

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  Figure. 4 Radiologic images of preoperative and postoperative plain X-ray. (A) Preoperative C-arm image shows ossifications at the insertion area of Achilles tendon. (B) The ossifications and posterosuperior portion of calcaneus were found removed on the postoperative X-ray. (C) Skin incision was healed well.

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  Figure. 5 (A) Ruptured and hypertrophic tendinous lesion of Achilles tendon was found on preoperative ankle magnetic resonance imaging. (B) Fibrosis portion of Achilles tendon was found distal to the ruptured site.

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  Figure. 6 (A) Flexor hallucis longus tendon was harvested by tenotomy at the plantar midfoot level. (B) The harvested flexor hallucis longus (FHL) tendon was passed from medial to lateral direction through the tunnel of calcaneal tuberosity. (C) Reconstruction of Achilles tendon was finished by FHL transfer.

Reference

1. Clain MR, Baxter DE. 1992; Achilles tendinitis. Foot Ankle. 13:482–7. doi: 10.1177/107110079201300810. DOI: 10.1177/107110079201300810. PMID: 26688993.

2. Kearney R, Costa ML. 2010; Insertional Achilles tendinopathy management: a systematic review. Foot Ankle Int. 31:689–94. doi: 10.3113/FAI.2010.0689. DOI: 10.3113/FAI.2010.0689. PMID: 20727317.

3. Barg A, Ludwig T. 2019; Surgical strategies for the treatment of insertional Achilles tendinopathy. Foot Ankle Clin. 24:533–59. doi: 10.1016/j.fcl.2019.04.005. DOI: 10.1016/j.fcl.2019.04.005. PMID: 31371002.

4. Calder JD, Saxby TS. 2003; Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int. 24:119–21. doi: 10.1177/107110070302400203. DOI: 10.1177/107110070302400203.

5. DeOrio MJ, Easley ME. 2008; Surgical strategies: insertional Achilles tendinopathy. Foot Ankle Int. 29:542–50. doi: 10.3113/FAI-2008-0542. DOI: 10.3113/FAI-2008-0542. PMID: 18510913.

6. Krishna Sayana M, Maffulli N. 2005; Insertional Achilles tendinopathy. Foot Ankle Clin. 10:309–20. doi: 10.1016/j.fcl.2005.01.010. DOI: 10.1016/j.fcl.2005.01.010. PMID: 31371000. PMCID: PMC7216975.

7. Hunt KJ, Cohen BE, Davis WH, Anderson RB, Jones CP. 2015; Surgical treatment of insertional Achilles tendinopathy with or without flexor hallucis longus tendon transfer: a prospective, randomized study. Foot Ankle Int. 36:998–1005. doi: 10.1177/1071100715586182. DOI: 10.1177/1071100715586182.

8. Kang S, Thordarson DB, Charlton TP. 2012; Insertional Achilles tendinitis and Haglund's deformity. Foot Ankle Int. 33:487–91. doi: 10.3113/FAI.2012.0487. DOI: 10.3113/FAI.2012.0487.

9. Andersson G, Backman LJ, Christensen J, Alfredson H. 2017; Nerve distributions in insertional Achilles tendinopathy - a comparison of bone, bursae and tendon. Histol Histopathol. 32:263–70. doi: 10.14670/HH-11-790. DOI: 10.14670/HH-11-790. PMID: 27320798.

10. Georgiannos D, Lampridis V, Vasiliadis A, Bisbinas I. 2017; Treatment of insertional Achilles pathology with dorsal wedge calcaneal osteotomy in athletes. Foot Ankle Int. 38:381–7. doi: 10.1177/1071100716681139. DOI: 10.1177/1071100716681139. PMID: 27920330.

11. Chimenti RL, Cychosz CC, Hall MM, Phisitkul P. 2017; Current concepts review update: insertional Achilles tendinopathy. Foot Ankle Int. 38:1160–9. doi: 10.1177/1071100717723127. DOI: 10.1177/1071100717723127. PMID: 28789557. PMCID: PMC5956523.

12. Carmont MR, Maffulli N. 2007; Management of insertional Achilles tendinopathy through a Cincinnati incision. BMC Musculoskelet Disord. 8:82. doi: 10.1186/1471-2474-8-82. DOI: 10.1186/1471-2474-8-82. PMID: 17697370. PMCID: PMC1976314.

13. Jarin I, Bäcker HC, Vosseller JT. 2020; Meta-analysis of noninsertional Achilles tendinopathy. Foot Ankle Int. 41:744–54. doi: 10.1177/1071100720914605. DOI: 10.1177/1071100720914605. PMID: 32349544.

14. Lohrer H, David S, Nauck T. 2016; Surgical treatment for Achilles tendinopathy - a systematic review. BMC Musculoskelet Disord. 17:207. doi: 10.1186/s12891-016-1061-4. DOI: 10.1186/s12891-016-1061-4. PMID: 27165287. PMCID: PMC4862213.

15. Duthon VB, Lübbeke A, Duc SR, Stern R, Assal M. 2011; Noninsertional Achilles tendinopathy treated with gastrocnemius lengthening. Foot Ankle Int. 32:375–9. doi: 10.3113/FAI.2011.0375. DOI: 10.3113/FAI.2011.0375. PMID: 21733439.

16. Bedi HS, Jowett C, Ristanis S, Docking S, Cook J. 2016; Plantaris excision and ventral paratendinous scraping for Achilles tendinopathy in an athletic population. Foot Ankle Int. 37:386–93. doi: 10.1177/1071100715619989. DOI: 10.1177/1071100715619989. PMID: 26637273.

17. Nicholson CW, Berlet GC, Lee TH. 2007; Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int. 28:472–7. doi: 10.3113/FAI.2007.0472. DOI: 10.3113/FAI.2007.0472. PMID: 17475142.