93
10
les tendon insertion on the calcaneus is indicative of insertional tendinopathy. Pain 2–5 centimeters proximal to the Achilles tendon insertion is con- sistent with midsubstance tendinopathy and/or paratendinopathy. Since management and out- come are different for these two conditions, it is important to determine which is present and responsible for the pain. Paratendinopathy can be associated with a more diffuse swelling of the tendon sheath and occasionally some crepitus.
Midsubstance tendinopathy frequently creates a more focal, fi rm swelling of the tendon that is tender on direct palpation (Fig. 10.1). Occasion- ally it can be diffi cult to determine the presence of both conditions on physical examination. In addition, both conditions can at times coexist.8
Imaging studies can help to diagnose midsub- stance tendinopathy. Both MRI and ultrasound can show the intratendinous lesions.9,10 However, intratendinous lesions on imaging studies may not necessarily correlate with clinical symptoms, as such tendon lesions can exist in nonsymp- tomatic tendons.11 Therefore, one should correlate imaging fi ndings with history and physical exami- nation in each patient. Based on this, it could be argued that imaging studies are not required to make the diagnosis of midsubstance tendinopa- thy. However, if surgical management is contem- plated, these studies can be helpful. The goal of surgery is to identify and, in most instances, excise the pathologic tissue to elicit an acute healing response. In midsubstance Achilles tendinopathy, the pathologic tissue is generally surrounded by normal tendon. Preoperative localization of the lesion through imaging studies will allow the
Introduction
Tendinopathy can affect the Achilles tendon in several regions of the tendon. One particularly common site is the main body of the tendon. Mid- substance or intratendinous lesions were fi rst rec- ognized in the 1970s.1 Both surgical and nonsurgical management of Achilles tendinopathy have been emphasized. Cohort studies in the past 30 years have indicated that the etiology and response to various management modalities varies depending on the type of Achilles tendinopathy.2–5 Therefore, outcome studies have generally reported the results of management for intratendinous tendi- nopathic lesion separately from paratendinous and insertional problems. Finally, intratendinous lesions and partial tears may represent similar problems on different ends of the tendinopathy spectrum.6,7 There is no uniform agreement on the defi nition of a partial tear. However, descriptions of partial tears often suggest that they may result from intratendinous lesions that progressed to the surface of the tendon.
Evaluation and Indications for Management
The initial evaluation of Achilles tendon pain should include a careful history and physical examination of the character and location of the pain. Frequently, this will allow determination of the type of Achilles tendinopathy responsible for the pain. Pain and tenderness directly at the Achil-
Open Surgery for Achilles Tendinopathy
Murali K. Sayana, Louis C. Almekinders, and Nicola Maffulli
94 M.K. Sayana et al.
surgeon to minimize surgical dissection, and ensure that all pathologic tissue is addressed.
Most patients with confi rmed midsubstance tendinopathy should have a trial of nonsurgical management as described previously. The results of nonsurgical management have traditionally been somewhat unpredictable. Angermann12 re- ported a 35% failure rate at longer-term follow-up with nonsurgical management. Paavola4 found that 29% of patients eventually had surgical man- agement in a cohort of patients with 8-year follow- up. More recently, new concepts in the nonsurgical management of Achilles tendinopathy have been introduced.13,14 These methods may be more effective, and it is possible that the failure rate will be reduced. However, failure of nonsurgical management remains a possibility. The defi nition of failure is not universally agreed upon. Most authors suggest at least 3 to 6 months of nonsurgi- cal management should be attempted. Even if symptoms are still present at that point, surgical management may not be indicated. Frequently, pain is at least reduced.15 Some patients may have developed strategies to manage their symp- toms by activity-level modifi cations. Athletes fre- quently have adapted their training schedules to minimize symptoms. If the patients are willing to accept these changes, there appears to be no medical risk in allowing them to continue to train and compete with their current symptoms. In par-
ticular, the risk of complete rupture is low, as most patients with ruptures have no prodromal symptoms.
Patients will also need to understand the risks, length of recovery, and success rate following sur- gical management to make an informed decision about further surgical management for their midsubstance Achilles tendinopathy. Saxena16 reported that return to activity in patients under- going surgery for tendinopathy of the main body of the Achilles tendon was longer than in those who required isolated excision of the paratenon, with mean return-to-activity in patients with surgery for tendinopathy of the main body of the Achilles tendon of 13.2 weeks. Schepsis17 indicated that return to full activities usually takes 5 to 6 months postoperatively.
Outcome and success rates have been reported in several cohort studies. However, the scientifi c quality of these studies is frequently low, making a true assessment of the value of surgical manage- ment for this problem more diffi cult.18 Failures of surgery are not uncommon. Schepsis19 reported a success rate of 67% in the surgical management of midsubstance tendinopathy. The same report includes success rates of 87% for paratendinopa- thy and 86% for insertional problems. Nelen20 reported overall 80% good and excellent results with surgical management of midsubstance problems.
FIGURE 10.1. Swelling of the Achilles tendon 4 cm proximal to the insertion.
10. Open Surgery for Achilles Tendinopathy 95
Surgical Technique
The prone position allows excellent access to the affected area. Alternatively, the patient can be positioned supine with a sandbag under the oppo- site hip and the affected leg positioned in a fi gure- of-four position. Open surgery for tendinopathy of the main body of the Achilles tendon involves a longitudinal incision. Generally the incision is made on the medial side of the tendon to avoid
injury to the sural nerve and short saphenous vein (Fig. 10.2). A straight posterior incision may also be more bothersome with the edge of the heel counter pressing directly on the incision. Preop- erative imaging studies can guide the surgeon in the placement of the incision. The skin edge of the incision should be handled with extreme care throughout the procedure, as wound healing problems are possible and potentially disastrous.
The paratenon is identifi ed and incised (Fig. 10.3).
FIGURE 10.2. Incision for open surgery: 1 cm medial to the midline. Avoids sural nerve, short saphenous vein, and the scar is away from the shoe counter.
FIGURE 10.3. Paratenon and the Achilles tendon exposed.
96 M.K. Sayana et al.
In patients with evidence of coexisting paratendi- nopathy, the scarred and thickened tissue is gen- erally excised. Care should be taken to minimize dissection and excision on the anterior side of the tendon. The fatty tissue anteriorly is thought to contain much of the vascular supply to the tendon.
Based on preoperative imaging studies, the tendon is incised sharply in line with the tendon fi ber bundles (Fig. 10.4). The tendinopathic tissue can be identifi ed as it generally has lost its shiny
appearance, and frequently contains disorganized fi ber bundles that have more of a “crabmeat”
appearance. This tissue is sharply excised (Fig.
10.5). The remaining gap can be repaired using a side-to-side repair. If signifi cant loss of tendon tissue occurs during the debridement, consider- ation could be given to a tendon augmentation or transfer. A tendon turn-down fl ap has been described for this purpose.20 With a turn-down procedure, one or two strips of tendon tissue from FIGURE 10.4. Incision in the tendon along the lines of tendon fibers.
FIGURE 10.5. Tendinopathic tissue being sharply excised.
10. Open Surgery for Achilles Tendinopathy 97
the gastrocnemius tendon is dissected out proxi- mally while leaving the strip attached to the main tendon distally. It is then fl ipped 180° and sewn in to cover and bridge the weakened defect in the distal tendon. A plantaris weave has also been reported for this purpose.19 The plantaris tendon can be found on the medial edge of the Achilles tendon. It can be traced proximally as far as pos- sible and detached as close as possible to the muscle tendon junction to gain as much length as possible. It can be left attached distally to the cal- caneus, looped and woven through the proximal Achilles tendon, and sewn back onto the distal part to the tendon. Alternatively, the plantaris can be detached distally as well and used as a free graft. Finally, transfer and augmentation with the fl exor hallucis longus tendon has been reported.21
Postoperative Regimen
The rehabilitation program following open sur- gery for midsubstance tendinosis has not been studied in a controlled manner. Therefore, the regimen mainly depends on the experience and preference of the surgeon. Most reported pro- grams emphasize early motion and avoidance of prolonged immobilization. A period of initial splinting and crutch walking is generally used to allow pain and swelling to subside. In addition, wound healing complications are diffi cult to manage and an initial period of immobilization may promote skin healing. After 14 days, the wound is inspected and motion exercises are initi- ated. Alfredson22 studied the effect of more pro- longed immobilization on the calf muscle strength after Achilles tendon surgery. No signifi cant effects were found when comparing 2 weeks versus 6 weeks of immobilization. However, he did not report on the overall outcome with regard to the tendinopathic pain. Many basic science studies have shown the benefi cial effects of motion on soft tissue healing. Therefore, the patient is encour- aged to start daily active and passive ankle range- of-motion exercises. The use of a removable walker boot can be helpful during this phase. We do not limit weight bearing according to the degree of debridement needed at surgery, and
encourage early weight bearing. However, exten- sive debridements and tendon transfers may require protected weight bearing for 4 to 6 weeks postoperatively. Ultrasound and scar massage are frequently used, although the exact value of these modalities is unclear. After 6 to 8 weeks of mostly range-of-motion and light resistive exercises, initial tendon healing will have been completed.
More intensive strengthening exercises are started, gradually progressing to plyometrics and eventu- ally running and jumping. However, most patients do not tolerate sports-specifi c exercises until 4 to 6 months postoperatively. It can take as much as 6 to 12 months before athletes feel fully recovered from this procedure.
Summary
Open surgery for midsubstance tendinopathy of the Achilles tendon can be considered if prolonged nonoperative management fails. However, patients should be informed of the potential failure of the procedure, risks of wound complications, and sometimes prolonged recovery period. The sur- gical procedure is relatively straightforward, but on occasion may require concomitant transfer of tendon tissue to reinforce the weakened tendon.
Rehabilitation is focused on early motion and avoidance of overloading the tendon in the initial healing phase.
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