Issue: August 2007
August 01, 2007
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Pain relief seen with combined surgical options for insertional Achilles tendinosis

All patients reported that they would have the surgery again and recommend it to others.

Issue: August 2007
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SAN DIEGO — A surgical treatment for insertional Achilles tendinosis that combines various procedures used for this condition demonstrated efficacy and significant pain relief at a mean of 2 years postoperatively.

For 5 years, Thom A. Tarquinio, MD, has used the procedure that combines excision of the postero-superior calcaneal prominence or Haglund’s deformity, excision of the insertional calcaneal osteophyte, Achilles debridement and a gastrocnemius fascia release.

 

Achilles tendinosis patient
As is typical with insertional Achilles tendinosis patients, surgeons were unable to bring this patient past neutral with the knee extended or flexed.

Images: Ferguson CA

Tarquinio, Christopher A. Ferguson, MD, and their colleagues evaluated 25 patients who underwent this procedure between May 2002 and October 2005. All patients previously failed conservative treatment.

“This is a technically simple procedure, it gives reliable, consistent results [and] it provides excellent pain relief,” Ferguson said at the American Orthopaedic Foot and Ankle Society Specialty Day Meeting, held here.

Investigators lost three patients to follow-up and one patient declined to participate, leaving 21 patients with 22 treated feet, Ferguson said. This patient group included 18 women and 3 men. Patients were a mean age of 57 years and had a mean body mass index of 34.74.

Investigators performed chart reviews on all patients, conducted telephone interviews with five patients, and administered American Academy of Orthopaedic Surgeons Foot and Ankle questionnaires to 16 patients. Physical therapists also evaluated those 16 patients for postoperative range of motion, Ferguson said.

Surgical technique

The surgical technique involved two posterior midline incisions with the patients in the prone position.

Ferguson said they performed a gastrocnemius fascia release (Vulpius technique) to protect the insertion during the healing phase, to avoid avulsion, and to decrease pain.

Surgeons then made a distal incision down through the Achilles tendon and debrided the medial half of the tendon.

“We don’t actually detach the entire tendon, so this avoids the use of bone anchors,” Ferguson said. “We are able to remove the posterior calcaneal osteophytes and resect the retrocalcaneal bursa, and excise the Haglund’s exostosis.”

Ferguson said that surgeons then debrided the lateral half of the Achilles tendon, and finally closed the wound with buried Vicryl sutures (Ethicon). At an average 21.8-month follow-up, patients rated their pain an average 1.5 on a 10-point scale – significant relief compared to the preoperative 8.95, Ferguson said, with 52% of patients having reported complete pain relief.

A midline incision through the Achilles tendon
Surgeons began the procedure with the patient in the prone position and with two posterior midline incisions. Shown here: a midline incision through the Achilles tendon.

Retrocalcaneal bursa
The surgeons then exposed the retrocalcaneal bursa.

Medial half of Achilles tendon
Shown here, the surgeons next debrided the medial half of the Achilles tendon.

Patient results

Physical therapy evaluation found an insignificant difference in postoperative range of motion between the operative and nonoperative sides, with the operative side at a mean 4.07° less than the nonoperative, Ferguson said.

Investigators found a significant difference in postoperative strength between the two sides, however. Measured by standing single-leg heel lifts, patients were able to perform a mean 4.67 out of 5 on the nonoperative side compared to 1.8 on the operative side.

“These are heavy, low-demand patients and all but one patient did not even know they were weak until the time of the evaluation,” Ferguson said. “The patients were essentially unable to bear weight on their affected foot prior to surgery because of pain and all were able to resume their precondition level of activity after surgery.”

All patients reported that they would have the surgery again and would recommend it to family and friends, Ferguson said.

“Thirteen of the patients were very satisfied, five were somewhat satisfied, two were neutral and only one patient, our sole workers’ compensation patient, was very dissatisfied.”

Removal of Haglund’s deformity
Next, they removed Haglund’s deformity, as seen here.

Lateral half of the Achilles tendon
After removing Haglund’s deformity, the surgeons debrided the lateral half of the Achilles tendon.

Surgeons closed the wound
Finally, surgeons closed the wound with buried Vicryl sutures in the Achilles tendon.

For more information:
  • Christopher A. Ferguson, MD, can be reached at the University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216; 601-984-6525; e-mail: chrisfergusonmd@gmail.com. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
Reference:
  • Ferguson CA, Tarquinio TA, Wingerter S, Ware N. Results of surgical treatment of insertional Achilles tendinosis. Presented at the American Orthopaedic Foot and Ankle Society Specialty Day Meeting. Feb. 17, 2007. San Diego.