Abstract
Background:
Haglund deformity and insertional Achilles tendinopathy involve a degenerative process demonstrating disorganized collagen and mucoid degenerative material causing pain and swelling.
Indications:
Operative management through a distally based midline incision should be explored if symptoms are refractory to nonoperative management (activity and shoewear modifications, heel lifts, physical therapy, and heel sleeves). Direct lateral approach with small longitudinal split and removal of lateral prominence “pump bump” is performed when a patient has pain isolated solely to the prominence. We feel that endoscopic removal does not allow for appropriate evaluative of degenerative tissue.
Techniques:
Through a distally based incision, we dissect to the level of the paratenon and make one smooth cut through paratenon and tendon. We then excise the mucoid, degenerative tissue. Removal of Haglund deformity and exostosis is carefully accomplished with a saw. We then utilize a rongeur to smooth Haglund deformity and any remaining medial/lateral calcaneal prominences. We then complete a dual-row speed bridge with 4 suture anchors (horizontal mattress) and a modified Mason-Allen technique. A Thompson test is then repeated and the longitudinal split is repaired. Postoperatively, we have patients weight bear as tolerated in a boot for with suture removal and transition to shoewear at the 2-week mark. We begin range of motion and activity once the wound has healed. We expect return to sport beginning at 3 months with full return by 6 months.
Results:
The current body of literature shows significant patient satisfaction and minimal risk of complication. Some authors have shown significant improvement in American Orthopaedic Foot and Ankle Score (AOFAS) scores, with only 1 patient requiring a flexor hallucis longus (FHL) transfer and no complications. Further studies identify early weight-bearing in Achilles suture bridge technique to have some promise with improvement in visual analog scale (VAS)/AOFAS scores, though there is risk of wound breakdown.
Discussion/Conclusion:
An Achilles suture bridge technique with early weight-bearing is a viable option for patients with Haglund deformity, and insertional Achilles tendinopathy who have failed conservative management.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
Today, we will be presenting on insertional Achilles tendinopathy: debridement and double-row suture bridge repair. My name is Albert Thomas Anastasio. Thank you to my co-authors Zoe Hinton, Rick Danilkowicz, and Annunziato Amendola.
First, our disclosure slide.
We will begin with a brief outline. We will start with a case presentation, talk about background, operative treatment, nonoperative treatment, our surgical technique, our postoperative protocol, and a brief discussion of outcomes.
We have a 59-year-old woman with chief complaint of ankle pain, insidious in onset, and worse with activity. She was seen in an outside clinic where Achilles tendinopathy was diagnosed. She was given a heel lift, a boot, and therapy, but has not improved with these modalities. Lateral radiographs do reveal Haglund deformity, as well as prominent exostosis distally, and when we zoom in we get a better view of that exostosis distally at the calcaneal insertion of the Achilles tendon.
Haglund deformity and insertional Achilles tendinopathy are characterized by being a degenerative process showing disorganized collagen and mucoid degeneration with a minimal inflammatory infiltrate. 7 On diagnosis, patients may complain of pain, swelling, and stiffness in the posterior heel. This involves progressive enlargement of the bony prominence of the heel, along with pain caused by direct pressure with shoewear. On radiographs, you may see a bone spur and intratendinous calcifications on the lateral foot. And magnetic resonance imaging and ultrasound can be helpful to determine the extent of the Achilles tendon degeneration.
Nonoperative treatment includes activity and shoewear modifications, heel lifts, stretching, physical therapy especially with eccentric training, and silicone heel sleeves and pads to decrease pain from direct pressure. Extra corporeal shockwave therapy has been used, but it does lack definitive data to support its use, and steroid injections should be avoided due to risk of rupture of the Achilles tendon.
Operative treatment includes excision of the retrocalcaneal bursa, resection of Haglund deformity, and debridement of the degenerative tendon including the calcification. If tendon detachment greater than 50% is required for thorough debridement, we do recommend reattachment with suture anchors. An FHL tendon transfer is indicated if more than 50% of the Achilles tendon itself requires excision.
We favor the use of a double-row repair.3,4,5,9 This was a biomechanical study published in the American Journal of Sports Medicine in 2013 comparing double-row repair for Haglund debridement with single-row repair. 2 Double row leads to significantly larger contact areas initially and 5 minutes after repair and this did lead to significantly higher peak load to failure on destructive testing. 2
We make our incision distally based to ensure that we can remove all the distal exostosis at the calcaneal insertion of the Achilles tendon distally. We then make an incision, dissect through the subcutaneous fat, to the level of the paratenon, and we make one clean cut through both paratenon and the tendon bulk as you can see here. 1 This allows for a nice closure of both the Achilles tendon and the paratenon.
After we have made our incision through the paratenon and the Achilles tendon, we see the significant mucoid degenerative tissue throughout the bulk of the Achilles tendon there distally. We then debride the mucoid degenerative tissue. This is referred to in the textbooks as having a crab-like or codfish-like appearance, and it is important to distinguish it from the healthy fibers of the Achilles tendon. And you can see here that after we have removed this portion of the mucoid degenerative tissue, a little bit remains there. And our senior author is pointing it out with his forceps there. We continue with our debridement until all the mucoid degenerative tissue is removed.
Once we have removed the mucoid degenerative tissue, we are left with relatively healthy-appearing tendon there. And here, our senior author is pointing out the prominent Haglund deformity, as well as an exostosis distally which is mobile in this case. There is the exostosis distally.
Thompson test confirms that even after detachment of the Achilles tendon distally, there are still some fibers remaining.
We then take the saw to remove both the exostosis and Haglund deformity. 6 And this part can be a little bit difficult as the saw has a tendency to skive posteriorly or superficially or anteriorly or deep so you constantly have to make micro-adjustments in the trajectory of your saw to make sure you resect the appropriate level of Haglund deformity. And I think we were able to achieve a nice resection here.
Once we have done this, we use a rongeur to smooth the edges of our cut. And then we use the saw to remove the medial and lateral bony ridges that have been left behind excision of Haglund deformity. And this part is very important as this can be a cause of failure as patients can have painful areas both medially and laterally if these ridges are not removed.
Once we have resected Haglund deformity, we see how the Achilles tendon will lay down at the anatomical site. And we see nice, tendinous appostion. We then also palpate the medial and lateral sides of the calcaneus to ensure that no bony prominences remain. Once we have done this, we then mark 4 sites for the double-row repair taking care to ensure that the Achilles tendon will be sitting at the anatomical site and that it is not either too proximal or too distal.
We then drill sequentially, followed by tapping in on forward and out on reverse. Once we have done this, we place our superior or proximal row and we then pass the suture through the proximal aspect of the tendon. What we do here is we take one limb of the suture and throw the suture in a modified Mason-Allen technique to lock that suture proximally. The other suture acts as a sliding stitch and we are able to achieve nice tendinous apposition even before doing the double-row repair. And you can see here that we have not placed our double row, but the tendon still opposes quite nicely to the calcaneal insertion of the Achilles tendon there and this is given our modified Mason-Allen technique.
Once we have done this bilaterally on both the medial and lateral anchors, we then throw our sutures in a cross configuration to see how this tendon will lay down once we place our distal row and we see nice tendinous apposition here. In cases where we have ample tissue to allow for placement of the distal row actually through the Achilles tendon, we will try to do so. This is not always possible, but here it was.
We are actually able to place that distal row through the distal aspect of the tendon and this further enhances tendinous apposition. You can see here that excellent tendinous apposition and Thompson test confirm excellent attachment of the Achilles tendon.
Here we have repaired the longitudinal split through the tendon using absorbable 0-vicryl. And we test the integrity of the repair and you can see here that there is excellent tendinous apposition and a strong repair. This informs our weight-bearing protocol which we will talk about at the end of the case.
We then proceed with closure. We favor a vertical mattress suture in which the first throw opposes the subcutaneous layers and the second throw opposes the dermal or subcuticular layers. We favor not using absorbable vicryl to oppose the subcutaneous layers as we feel that it adds suture bulk and it may act as a nidus for infection.
Our postoperative protocol is weight-bearing as tolerated in a boot for 2 weeks. The patient comes out of the boot and transitions to shoewear at 2 weeks and the sutures are out at that time. The patient begins range of motion and activity once the wound has healed.
Gradual return to sport begins at 3 months postoperatively with a full return at 6 months. So we favor an early weight-bearing protocol as we feel the repair is quite solid and there is a low risk of re-rupture.
The data support this as well. This is the intermediate and long-term outcomes of the suture bridge technique for the management of insertional Achilles tendinopathy. This was a study of 30 patients with a mean follow-up of 28 months. 3 American Orthopaedic Foot and Ankle Score (AOFAS) scores improved and 1 patient did require revisional surgery which was an FHL transfer. But, there were no wound complications for infections and a very high satisfaction rate.
This study looked at early weight-bearing using the Achilles suture bridge technique with a mean follow-up of 24 months. 8 Again, AOFAS scores improved and visual analog scale pain scores went down with a mean interval to weight-bearing of only 10 days. Now, there was one complication including postoperative wound dehiscence requiring surgical debridement and a soft tissue infection requiring antibiotics and a surgical debridement. But no postoperative ruptures occurred. So in summation, we feel that early weight-bearing may be associated with wound complications in patients that have compromised protoplasm, but it does not appear to be linked to postoperative rupture risk. So if we do not have concerns about a patient’s wound, we feel comfortable weight-bearing them quite early. If we do have concerns about the wound, we keep them non-weight-bearing for a couple of weeks while the wound heals.
Here are our references.
And a thank you to the Duke sports team including the Athletic trainers, Advanced Practice Providers, and surgical staff and video credit to Aribah Shah.
Footnotes
Submitted August 29, 2022; accepted September 23, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
