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SURGICAL TREATMENT FOR ACHILLES TENDINOPATHY IN ATHLETES
E. Rolland, G. Lorton, G. Saillant
Article Summary

INTRODUCTION
GENERAL CONSIDERATIONS
1 - Anatomy of the Achilles tendon
2 - Anatomopathology
3 - Surgical treatment
IN PRACTICE
SURGICAL TECHNIQUES FOR TENDINOPATHY OF THE MAIN BODY
1 - Tender nodule or Tendon cyst
2 - Partial tear
3 - "Cold nodule"
SURGICAL TECHNIQUES FOR INSERTIONAL TENDINOPATHY
1 - Bursitis without tendon lesion on MRI (Haglund disease)
2 - Partial tear of distal Achilles tendon and Secondary anterior bursitis
3 - Partial avulsion of the Achilles tendon insertion and Increased dorsiflexion
POSTOPERATIVE MANAGEMENT
CONCLUSION
Service de chirurgie Orthopédique ­ Hôpital de la PITIE ­ 75013 PARIS

 

 

INTRODUCTION

Operative management of Achilles tendinopathy is still considered in the orthopaedic world as minor and poorly coded surgery, due to the wide variety of anatomopathological forms and lack of accuracy of the techniques available. However, as any surgical repair, it requires careful assessment of the lesions and the use of an appropriate surgical technique to ensure a successful outcome.

Surgical treatment for Achilles tendinopathy began to develop in the 1980s, after Jenkins' experiments in sheep using carbon fiber and the experimental work done on horses by the veterinary team from Chantilly.

The early techniques advocated by Kvist involved isolated synovectomy. After that, other techniques were introduced which included longitudinal tenotomy and use of carbon fibres (Lemaire), and variants using autografts.

Kouvalchouk, in 1987 (Cahiers d'Enseignement de la SOFCOT), and then in 1993 (Techniques Chirurgicales, EMC), provided an accurate and complete synthesis of all existing techniques and indications for each anatomopathological form of Achilles tendinopathy.

Analysis of the various surgical series (complications associated with carbon fibres), technical improvements (transosseous reattachment of the tendon), progress in imaging techniques (echography, MRI), have contributed to simplify the surgical strategy, taking into account both the anatomopathological type and extent of the injury.

 

GENERAL CONSIDERATIONS

1 - Anatomy of the Achilles tendon

The Achilles tendon joins three muscles, the two heads of the gastrocnemius and the soleus (triceps surae). It is the largest and strongest tendon in the human body (approx. 15 cm long, 12-15 mm wide, and 5-6 mm thick). It is characterized by :

  • Fibre arrangement : wavy-spiral conformation ; the orientation of the tendon fibres rotates 90 degrees internally as it courses toward its insertion, so that the posterior fibres run inferolaterally, whereas the anterior fibres run inferomedially.
  • Sheath : unlike many other tendons, the Achilles tendon does not have a true tendon sheath. Instead, it is enveloped by a paratenon, a membrane consisting of two layers : a deeper layer (visceral layer) surrounding and in direct contact with the epitenon, and a superficial layer (parietal layer), the peritenon, which is connected with the underlying layer through the mesotenon. The paratenon originates from the deep fascia of the leg (crural fascia), covering the tendon posteriorly. The paratenon enhances tendon gliding by reducing friction between tendon and surrounding tissue ; it also plays a trophic role.
  • This calcaneal area can be divided into three parts :
    • tendo calcaneus bursa : it has a smooth surface, and separates the Achilles tendon from the upper part of the posterior surface of the calcaneum.
    • middle part : rough surface that provides insertion for the tendon.
    • inferior part : it is oblique distally and anteriorly, and receives superficial fibres that course distally to the middle plantar fascia.

 

2 - Anatomopathology

At the early stage of tendinopathy, microscopic examination of the lesions shows altered collagen fibre structure and signs of healing which may progress toward a normal scar or a pathological scar (depending on whether the athletic activity is stopped/cut back or not).

In chronic Achilles tendinopathy, there is a pathological scar, and possibly a nodule, cyst, fissure, partial tear, or intratendinous, peritendinous or insertional calcification.

A nodule is the result of disordered healing of a microtear in a collagen bundle. It may be "cold" or tender with chronic scar tissue. A pseudocyst is also the result of a microtear or partial avulsion, but that leaves place for a synovialized fluid cavity.

A fissure is a longitudinal lesion that involves the entire length of the tendon. In a partial tear, several collagen bundles are disrupted and cannot possibly heal. It generally occurs in the peritendinous or insertional area.

A neighboring synovial pathology may occasionally occur, with thickening and synovial adhesions, in cases of peritendinous injury or pre-Achilles bursitis if the injury is close to the insertion site.

So, several conditions may coexist at the tendon enthesis : normal ageing signs, intratendinous ossifications, partial tear (predominantly anterior with secondary bursitis), and partial avulsion with subchondral bone reactions. This makes diagnosis very difficult as treatments vary a great deal, depending on which type of lesion is predominant : tendon injury, bone lesion, or peritendinous tissue lesion.
 

3 - Surgical treatment

The terms "synovectomy" and "longitudinal tenotomy" need to be clarified.

Localization of the injury : it may be a central core lesion or a peritendinous injury.

A peritendinous injury will be associated with a synovial or bursal pathology that will cause adhesion formation, exudative synovitis, or bursitis which require special treatment.

A peritendinous injury is most often located posteriorly, and requires a synovectomy with excision of the peritenon and retention of the crural fascia (Fig. 1).

An insertional lesion is most often located anteriorly, and requires not only a bursectomy, but also excision of the posterior superior angle of the calcaneum to allow exploration of tendon enthesis and check for absence of an inferior partial tear or partial avulsion of the tendon insertion.

A central core lesion can only be assessed through open tenotomy. Incision of the tendon is the initial step of longitudinal tenotomy. This technique has two advantages : firstly, it facilitates diagnosis (i.e. identification of the cysts and nodules to be excised) ; secondly, it creates a neovascularization in the tissue that results in secondary thickening of the tendon. Multiple longitudinal incisions are made in the tendon in line with its fibres (Fig. 2). Longitudinal tenotomy is performed after synovectomy, using Halsted forceps, from an incision made in the inferior one-third of the tendon. It progresses slowly towards the myotendinous junction, and then towards the calcaneal insertion of the tendon. Creating even-size strips is essential to achieve proper distribution of mechanical loads. The number of strips (3-5 max.) depends on the width of the tendon and also on whether or not an excision procedure is required.

Thus, performing synovectomy and longitudinal tenotomy in tendinopathy of the main body, and bursectomy and excision of the posterior superior angle of the calcaneum in insertional tendinopathy, not only have a therapeutic role but are also the necessary steps prior to exploration of the tendon which allows to determine whether an additional procedure is required.

 

IN PRACTICE

As far as surgical treatment and prognosis are concerned, one must distinguish between tendinopathy of the main body and insertional tendinopathy.

Diagnosis of Achilles tendinopathy at clinical examination is generally not difficult : focal tenderness to palpation, pain on active stretching in the standing position, and pain with resisted contraction (single leg raise). Furthermore, pain topography must be sufficiently accurate to allow determination of the type of tendinopathy.
Conservative treatment is generally the rule : physical therapy and relative rest to get rid of pain and allow healing, and once healed, to allow the scar to withstand the mechanical loads induced by the athletic activity.

However, should functional impairment persist, recur or worsen, due to unstable scar or extensive tendon lesion, operative treatment may be necessary to allow the athlete to carry on.

Prior to performing surgery, additional investigations including MRI are necessary. Analysis of cross-sectional images (sagittal, coronal, horizontal) and sequences (T1, T2, fat sat, Gadolinium-enhanced) should be performed to confirm the presence of tendon damage, determine the anatomopathological type of the lesion and its extent, and the presence of chronic scar tissue. This helps define the appropriate operative strategy, since different techniques are used for tendinopathy of the main body and insertional tendinopathy.

 

SURGICAL TECHNIQUES FOR TENDINOPATHY OF THE MAIN BODY

Whereas clinical examination allows correct diagnosis of tendinopathy of the main body, location of painful swelling, and detection of pathological increase in dorsiflexion, only imaging and a methodical analysis of the findings can allow evaluation of the tendon structure and inflammation of adjacent tissues.

Three situations can be encountered :

  • tender nodule (with chronic scar tissue as evidenced by MRI), or tendon cyst, 
  • partial tear (with or without increased dorsiflexion), 
  • "cold nodule" with no signal alterations on MRI (T2 with Gadolinium enhancement). 

 

1 - Tender nodule or Tendon cyst

The operation is performed under general or regional anesthesia, with the patient in the prone position and feet hanging over the end of the table. A tourniquet is placed at the root of the limb (Plate 1).

Plate 1

A medial approach is used, with the incision extending from the calcaneum to the musculotendinous junction. This approach offers the advantages of avoiding later painful impingement upon the back of the shoe, and avoiding the risk of damage to the sural nerve that is associated with the lateral approach.

The crural fascia is incised (without subcutaneous dissection). Synovectomy consists in excising both layers of the paratenon to remove any adhesions, and eliminate any localized or diffuse areas of thickened, fibrotic paratenon. Thus, the tendon is completely freed and can be carefully inspected.

Visual inspection and finger palpation allow detection of a pearly white or indurated area that confirms the presence of a tendon nodule or cyst as evidenced on preoperative MRI.

A 1 cm incision is made with a scalpel over the abnormal part of the tendon : it is the initial step of longitudinal tenotomy that is performed with the tip of Halsted forceps to preserve the wavy-spiral conformation of the bundles and avoid damage to healthy fibres.

The forceps is slowly advanced to the myotendinous junction and then to the calcaneal insertion of the tendon. Gently pulling the two strips apart allows exploration of the affected intratendinous area (a) and excision with a scalpel through proper saucerisation (b) of nodular scarring or cyst walls down to healthy tissue (fibrillar appearance). A further one or two incisions are made to complete the longitudinal tenotomy, and blunt dissection with the forceps (as described above) is repeated.

Care must be taken to maintain the same distance between the longitudinal incisions so that all the strips have the same width, mechanical loads are evenly distributed, and no disruption can occur at any weak point.

Then, the strips are reapproximated and sutured longitudinally using absorbable interrupted sutures.

The tourniquet is deflated and hemostasis is obtained. Lastly, a Redon drain is placed and the crural fascia is closed.

The wound is closed in two layers. Skin closure is performed with over-and-over sutures or intradermal running sutures. Finally, a compressive dressing is applied with the ankle in physiological equinus.

 

2 - Partial tear

Patient positioning and approach are the same as above (Plate 2).

Plate 2

However, tenolysis and synovectomy are often more extensive, and include freeing of adhesions and excision of synovial thickenings both on the tendon side and the fascial side. The margins of the partial tear are sharply debrided to normal fibrillar appearance so as to allow evaluation of the extent of the tear.

In cases of a minor tear that does not exceed one-fourth of the tendon diameter, a simple longitudinal tenotomy is sufficient ; otherwise, Achilles tendon reconstruction is necessary. In this case, rather than using a graft harvested from a remote donor site (e.g. tensor fasciae latae) or a local tendon graft (e.g. peroneal or flexor tendon), it is much preferable to use a local Achilles tendon flap (mini Bosworth technique). This flap is raised from the posterosuperior portion of the Achilles tendon and its size depends on the width and thickness of the tear. The flap is reflected anteriorly or posteriorly, maintaining an inferior hinge proximal to the torn area. The donor site is closed with edge-to-edge sutures, and the flap is sutured without undue tension to the lateral and inferior margins of the tear.

Longitudinal tenotomy of the healthy tendon area should only be performed if required by the topography and extent of the reconstruction.

The wound is closed in three layers : fascia, subcutaneous tissue, and skin over a Redon drain to minimize the potential risk of complications (i.e. necrosis, wound dehiscence, infection).

An anterior or posterior splint is applied with the ankle in physiological equinus.


3 - "Cold nodule"

As preoperatively assessed, there is no need for synovectomy, excision, or reconstruction of the damaged tendon ; a simple longitudinal tenotomy is sufficient.

If open longitudinal tenotomy cannot be performed, percutaneous (or endoscopic as recently described) longitudinal tenotomy can be used to minimize the risk of skin complications and above all, to simplify the immediate postoperative course (Plate 3).

Plate 3

A 1 cm vertical, posteromedial skin incision is centred over the painful area and carried deep to the tendon, and the crural fascia is opened. As the posterior aspect of the tendon can be visualized through this window, a 1 cm incision is made parallel to the lateral margin of the tendon. Two or three incisions may be necessary, depending on the width of the tendon. Then, Smilie scissors are used for the subcutaneous tenotomy.

The use of blunt tip scissors is highly recommended to avoid damage to the tendon fibres.

The tip of the scissors is inserted into the incision and slowly advanced in line with the tendon fibres under digital guidance, first proximally as far as the myotendinous junction, and then distally until it makes contact with the calcaneum. If the trajectory is too lateral near the insertion site, progression of the scissors should be stopped to avoid partial disinsertion of the tendon. Alternate dorsiflexion and plantarflexion movements greatly facilitate this step as they make the tendon glide smoothly past the window. The procedure is repeated for each incision to create 3 or 4 full-length strips. The wound is closed in 3 layers (without drainage) after suturing of the fascia.

 

SURGICAL TECHNIQUES FOR INSERTIONAL TENDINOPATHY

Treatment and prognosis of insertional tendinopathy are much more difficult than for tendinopathy of the main body.

However, accurate assessment of the lesions will assist in planning the appropriate operative strategy and improving the prognosis.

Whereas clinical examination allows correct diagnosis of insertional tendinopathy, determination of the topography of pain (medial, lateral, midplane, global), and detection of pathological increase in dorsiflexion, only imaging and a methodical analysis of the findings can allow evaluation of the structure of the distal portion of the tendon, inflammation of adjacent tissues, and calcaneal insertion site.

As for tendinopathy of the main body, three situations can be encountered :

  • bursitis without tendon lesion (Haglund disease)
  • partial tear of distal Achilles tendon and secondary bursitis
  • partial avulsion of the Achilles tendon insertion and increased dorsiflexion

 

1 - Bursitis without tendon lesion on MRI (Haglund disease)
(Plate 4)

Plate 4
 

The operation is performed under general or regional anesthesia, with the patient in the prone position and feet hanging over the end of the table. A tourniquet is placed at the root of the limb. A medial or most often lateral approach is used, depending on the topography of pain, with the incision extending from the inferior aspect of the calcaneum, in the painful area, to the middle one-third of the tendon.

The crural fascia is incised (without subcutaneous dissection), and bursectomy is performed. It consists in excising, either with a scalpel or an electrocautery, the tissues that fill the space between the anterior surface of the tendon end and the posterior superior angle of the calcaneum.

A Hohmann retractor (a) is placed flush to the insertion site, opposite the skin incision, and inclined to properly expose the posterior superior angle of the calcaneum. A large bone chisel (b) is positioned immediately adjacent to the tendon insertion and tilted so that it lies flush with the posterior aspect of the subtalar joint. The posterior superior angle of the calcaneum is osteotomized. Forced plantarflexion is applied to assess the quality of the resection by palpation. Any residual bone spicules or prominences at the insertion site (often present opposite to the incision) must be removed using a narrow rongeur to avoid impingement.

The insertion site is carefully examined : inspection of the anterior aspect of the insertion for macroscopic tendon lesion is performed to confirm imaging findings ; finger palpation helps confirm the absence of induration or dehiscence within the thickness of the tendon end. If inspection is satisfactory, no associated tendon procedure is required.

The tourniquet is deflated and hemostasis is obtained. Application of wax on the resected surface is not systematic. A Redon drain is placed and the crural fascia is closed. The wound is closed in two layers. Skin closure is performed with over-and-over sutures or intradermal running sutures. Finally, a compressive dressing is applied with the ankle in physiological equinus.

 

2 - Partial tear of distal Achilles tendon and Secondary anterior bursitis
(Plate 5)

Plate 5

The procedure is the same as previously described, up to osteotomy of the posterior superior angle of the calcaneum that reveals partial tears of the anterior aspect of the tendon and palpable indurated areas, without avulsion of the tendon insertion (a). In this situation, longitudinal tenotomy of the distal portion of the tendon is necessary. Four strips are created - with sometimes minimal periosteal stripping of the calcaneus for middle strips - to check for integrity of the insertion, excise the degenerated areas on the anterior surface of the tendon through minimal (but necessary) saucerisation (strips are folded over to uncover these areas), and promote healing through secondary thickening of the tendon.

The wound is closed in 3 layers over a Redon drain, after suturing of the fascia.

 

3 - Partial avulsion of the Achilles tendon insertion and Increased dorsiflexion
(Plate 6)

Plate 6

Longitudinal tenotomy is not necessary and even iatrogenic (major risk of complete avulsion occurring secondarily). Extent of the avulsion is visualized and evaluated by finger palpation of the tendon end, after the posterior superior angle of the calcaneum has been resected. Then, degenerated scar tissue must be removed down to healthy tissue (fibrillar appearance), which results in a more or less severe (thickness and width) tissue defect that requires Achilles insertion reconstruction.

In this case, rather than using a graft harvested from a remote donor site (e.g. tensor fasciae latae, patellar tendon) or a local tendon graft (e.g. peroneal or flexor tendon), it is much preferable to use a local Achilles tendon flap (mini Bosworth technique).

This flap is raised from the anterior middle one-third of the Achilles tendon and its size depends on the width and thickness of the lesion. The flap is reflected anteriorly, maintaining an inferior hinge located within 3-4 cm of the insertion.

Then, a groove is created (using a narrow rongeur) in the posterior osteotomy area, immediately anterior to the anatomic insertion site.

The tendon flap can be reattached using transosseous sutures, according to the inverted double "U" technique described by Walch for reattachment of the rotator cuff. This has been shown to provide a strong reliable construct provided that heavy nonabsorbable sutures are used (Mersuture 3/0).

Placement of protective tendon-to-bone sutures may be considered, depending on the extent of the reattachment.


In cases of major avulsion involving more than the two-thirds of the tendon insertion, it is preferable to completely release the tendon from its attachment and then reattach it using this technique, after minimal debridement of the tendon end. Protection with tendon-to-bone sutures is mandatory.

Wound closure in three layers over a Redon drain requires utmost care ; all the knots must be buried far from the scar to avoid any risk of secondary skin complications.

Postoperative immobilization in an anterior or posterior plaster splint with the ankle in physiological equinus is mandatory.

 

POSTOPERATIVE MANAGEMENT

Postoperative management is now well coded. Apart from reconstruction of the tendon or tendon insertion that requires strict immobilization with the ankle in physiological equinus and non-weight bearing for 45 days, in all other cases, walking is allowed on Day 4 after removal of the drain, using a 2.5 cm (approx.) cork heel-lift inside the shoe.

During 3 weeks, this heel lift is regularly thinned. At the end of this period, the patient is able to wear normal footwear.

Also, during this period, the patient is encouraged to perform active exercises, but no rehabilitation program is initiated.

Sutures are removed the third postoperative week and gentle physical therapy is started to recover dorsiflexion of the tibiotarsal joint.

The patient is allowed to resume jogging after two months, and training to jumping and push-off impulses after three months only.

 

CONCLUSION

The results of surgical treatment of Achilles tendinopathy in athletes are as difficult to analyse as those of nonoperative management, due to the variety of anatomopathological forms of Achilles tendinopathy and the number of techniques available. However, results can be improved if surgeons distinguish between tendinopathy of the main body and insertional tendinopathy, and determine the anatomopathological type and extent of the lesion in order to select the appropriate technique.

Thus, surgical treatment of lesions/degenerative conditions such as nodules, cysts, partial tears, can yield up to 80% satisfactory results which allow return to sports within 3-6 months. In contrast, in cases of reconstruction of the tendon or tendon insertion, the outcome of surgery varies from an individual to the other, and return to sports can only be decided on a case-to-case basis. Decision criteria are based on : type of lesion, clinical examination, tests during eccentric muscle training exercises, and progress monitored with periodic echodoppler examinations rather than MRIs, as MRI interpretation in an operated tendon is always difficult.

Maîtrise Orthopédique n° 138 - November 2004
 
 
 
 
 
 
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