Clinical and Radiological Outcomes of Operative Therapy in Insertional Achilles Tendinopathy With Debridement and Double-Row Refixation

Abstract

Background: Insertional Achilles tendinopathy (IAT) is a painful pathology in which the strongest and thickest tendon of the human body is affected. Different conservative and operative treatments have been described to address this pathology. This study aimed to evaluate the medium-term clinical and radiological outcomes of patients who underwent a surgical therapy via a longitudinal tendon-splitting approach with debridement and double-row refixation. Methods: All patients were assessed pre- and postoperatively using a visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society (AOFAS) Hindfoot Score, the Foot and Ankle Outcome Score (FAOS), and the Foot Function Index (FFI). Additionally, a lateral radiograph of the foot was performed to assess the postoperative result. Forty-two patients with confirmed IAT who underwent surgery between 2013 and 2017 with a longitudinal tendon-splitting approach and tendon refixation using a double-row refixation system were evaluated. The average follow-up was 32.8 (range, 18-52) months. We included 26 female and 16 male patients with an average age of 56.8 (range, 27-73) years. Results: The mean VAS improved from 8.91 ± 1.0 preoperatively to 1.47 ± 2.5 postoperatively ( P < .01). AOFAS scores improved significantly from 51.0 ± 12.5 preoperatively to 91.3 ± 14.3 postoperatively ( P < .01). All total and subscores of the FFI and FAOS saw a significant improvement at follow-up ( P < .01). Lateral radiographs showed recurrent calcification in 30 patients (71.4%). Conclusion: We found that, at an average of 33 months posttreatment, insertional Achilles tendinopathy via a longitudinal tendon-splitting approach resulted in good outcomes for patients after failure of initial conservative therapy. Recurrent calcification seems to be very common but shows no association with inferior outcomes or the return of symptoms. Level of Clinical Evidence: Level IV, retrospective case series.

Double-Row Achilles Insertional Repair With Rip-Stop Increases Construct Strength Compared to Traditional Techniques: A Biomechanical Study

“…In fact, clinical evidence has presented that a conservative approach to tendon debridement may lead to recalcification of the anatomy. 9 To address this and to create a "worst-case" scenario for biomechanics, we performed a complete detachment of the tendon prior to repair as has been described in other cadaveric studies. 9 This allowed us to test the mechanism of failure of the anchors and tendon suture interface.…”

Management of Insertional Achilles Tendinopathy

“…Yontar et al 21 were able to follow their patients for five years on average and reported that 30 of 33 patients had excellent or good results with average preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores of 55.8 and 92, respectively. Greiner et al 22 showed significant improvements in outcome scores in their series of 42 patients, using a double-row construct, but did show that lateral radiographs at 33-month follow-up showed recurrent calcification in 71.4% of patients.…”

“…Rather than a limited approach, most surgeons use open surgical management involving calcaneoplasty, Achilles tendon débridement, bursal excision, and subsequent tendon reattachment. [17][18][19][20][21][22] This is most often performed with a central tendon-splitting approach described by McGarvey et al, 17 although paratendinous approaches exist. Ettinger et al treated 40 patients with this approach using a variety of different suture anchor techniques.…”

Reinforcement of the Achilles Tendon Double-Row Repair: Technique Tip

“…Patient-reported outcomes related to quality of life at 1 year posttreatment and beyond have also been documented as significantly improved over preoperative scores following the use of a double-row suture fixation system. 5 The weakness of this double-row arrangement is its reliance on very distal grasp of the tendon, leaving the possibility of the sutures pulling through the longitudinally oriented fibers of the Achilles. 4…”

“…Patient-reported outcomes related to quality of life at 1 year posttreatment and beyond have also been documented as significantly improved over preoperative scores following the use of a double-row suture fixation system. 5 The weakness of this double-row arrangement is its reliance on very distal grasp of the tendon, leaving the possibility of the sutures pulling through the longitudinally oriented fibers of the Achilles. 4 We present a novel modification to optimize the technique for performing a double-row repair at the Achilles insertion by employing a knotless intrasubstance suture construct with a Bunnell formation delivering a more substantial anchoring system.…”