SLR - November 2013 - Jennifer L. Buchanan
Reference: Maffulli N, Oliva F, Testa V, Capasso G, Del Buono A. Multiple Percutaneous Longitudinal Tenotomies for Chronic Achilles Tendinopathy in Runners. Am J Sports Med. 2013 41(9): 2151-2157.
Scientific Literature Review
Reviewed by: Jennifer L. Buchanan, DPM
Residency Program: Cambridge Health Alliance
Podiatric Relevance: Chronic midsubstance Achilles tendinopathy that is nonresponsive to conservative treatment may be treated surgically via multiple longitudinal incisions within the tendon. Short term successful treatment with this method has had similar outcomes as observed in more invasive procedures. This study reports on the long term outcomes (average 17 years) of middle and long distance runners and the impact that concurrent paratendinopathy has on the effectiveness of the procedure.
Methods: Surgery was performed on 52 patients at an average of 13 months from the onset of symptoms. These patients were diagnosed with tendinopathy clinically and with ultrasound. They were also assessed for symptoms of paratendinopathy. During the procedure, the patients were placed in the prone position. Under local anesthesia, a No. 11 surgical blade was inserted into the marked areas of pathology. The foot was passively dorsiflexed and plantarflexed with the blade in the tendon. This was performed in five locations within the area of pathology, and steristrips were applied. Postoperative early active dorsiflexion and plantarflexion were encouraged. On post-op day two, the patients were placed in a walking boot and were transitioned to weight-bearing, as tolerated, with crutch assistance, and were transitioned to full weight-bearing in two to three days. Activity was gradually increased under physical therapy guidance to gentle running at four to six weeks. Thirty-nine patients were seen at an average follow-up of 17 years. The patients filled out the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. Maximum calf circumference was measured and the four-point Boyden Assessment was used to assess function. Isometric plantarflexion strength of the gastroc-soleus complex was determined using a custom device. Finally, an independent radiologist performed follow-up ultrasound assessments on all patients.
Results: At final follow-up, 39 of the original 52 patients were available. Twenty-nine could perform at least 60 single heel lifts and eight could perform 30-50 lifts. Seven patients had contralateral pain. Mean VISA-A score was 78.5 with no difference between those with and without paratendinopathy; However, no preoperative values were available for comparison. Thirty patients reported good or excellent outcomes with the Boyden assessment. Average maximum calf circumference did not change from pre-op to post-op but was significantly lower than contralateral circumference (p = .02). Isometric strength testing demonstrated significantly lower peak torque in the operated limb versus the contralateral limb (228.6 +/- 119.3 N vs 274.2+/- 130 N; p = .01). Twenty patients were still active in middle and long distance running, though average function compared to baseline was 60 +/- 13 percent. None of the patients still involved in middle and long distance running at final follow-up had paratendinopathy on pre-op and final ultrasound assessments. Paratendinopathy was found on the remaining 19 patients who were less active at final follow-up. There were no neurovascular damage or wound healing complications utilizing this technique.
Conclusions: Following multiple percutaneous tenotomies for chronic Achilles tendinosis, 77 percent of patients achieved stable outcomes and 51.3 percent were actively involved in running 17 years later. The remaining patients had signs of paratendinopathy and were less active later in life. Therefore, the authors suggest that this procedure is indicated in patients with isolated midportion Achilles tendinopathy and not where signs of paratendinopathy are present. However, it cannot be determined whether these findings reflect normal aging to the tendon or are due to the effect of surgery on the tendon.