SLR - November 2019 - Michael G. Kateman
Reference: Zhuang, Ze, Yang Yang, Kishor Chhantyal, Jianning Chen, Guohui Yuan, Yirong Ni, Dezhao Liu, and Dehai Shi. Central Tendon-Splitting Approach and Double Row Suturing for the Treatment of Insertional Achilles Tendinopathy. BioMed research international 2019 Aug 21;2019:4920647.Scientific Literature Review
Reviewed By: Michael G. Kateman, DPM
Residency Program: Ascension Wisconsin – Milwaukee, WI
Podiatric Relevance: Insertional Achilles tendinopathy is a troublesome and debilitating diagnosis for patients and often requires long periods of conservative treatments. There are several methods to surgically treat this problem if conservative methods fail. One such treatment option is endoscopic calcaneoplasty, however sufficient debridement of the retrocalcaneal exostosis and intratendinous calcifications may be nearly impossible with this method. To avoid under correction, several open methods of debridement have been proposed including the medial J-shaped, lateral, transverse, double and central split incisions. There has been no study to evaluate the superiority of open incision types. This study looked at the central split incision and double-row Achilles suture bridge technique for the treatment of Insertional Achilles tendinopathy.
Methods: Twenty-eight patients (28 feet) with insertional Achilles tendinopathy were included in this study. Inclusion criteria consisted of pain around the Achilles insertion, calcification or degeneration of the Achilles tendon on radiographs, and lack of improvement after conservative treatments greater than 6 months. All patients underwent surgical correction via the central tendon-splitting approach and double row Achilles tendon suturing technique. Patients were casted postoperatively for four weeks. As primary outcomes, The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue score (VAS) were assessed preoperatively and at two years postoperatively. At final follow-up, the Manchester-Oxford Foot Questionnaire (MOXFQ) as patient-reported outcome measures (PROMs) was also evaluated.
Results: Twenty-seven patients were present for at least two years. One patient was lost to follow-up. On average, patients followed up for 27.3 months. At 2 years post-operatively, the AOFAS score increased significantly, from 48.6 to 92.3. The postoperative VAS score decreased significantly from 6.7 to 0.1. At final follow-up, 24 patients had complete alleviation of pain, three patients complained of mild heel pain. The MOXFQ score at final follow up was 18.8 which showed relief of previous symptoms. Twenty-six patients could perform the heel-rise test at the final follow-up. Four patients had a loss of ankle dorsiflexion of at least 15 degrees . At study completion, no complications, including postoperative infection and tendon rupture, were found. All the patients resumed their daily activities.
Conclusions: There have been several described methods to surgically correct insertional Achilles tendinopathy. Considering the need for adequate exposure of the affected portions of the Achilles tendon as well as potential complications of wound dehiscence and decreased function post operatively, the central tendon-splitting approach and double row suture bridge tendon suture has been shown to be convenient for thorough debridement and firm fixation of Achilles tendon with low complication incidence. Therefore, it should be considered an effective alternative surgical option for insertional Achilles tendinopathy.