Calcific Insertional Achilles Tendinopathy-Achilles Repair With Flexor Hallucis Longus Tendon Transfer: Case Series and Surgical Technique.

Calcific insertional Achilles tendinopathy (CIAT) is a relatively common musculoskeletal entity that results in significant pain and disability, as well as posterior muscle group weakness. There is a lack of evidence criteria to support the timing of operative intervention, choice of procedures, or whether equinus requires treatment. The purpose of this study was to retrospectively review 45 patients (48 feet) who have undergone surgical management of CIAT with concomitant posterior muscle group weakness with the single heel rise testing. All patients underwent debridement and repair of the Achilles tendon with reattachment of the Achilles tendon to the calcaneus, ostectomy of the calcaneus, and flexor hallucis longus tendon transfer. Those patients with equinus also underwent gastrocnemius recession. The focus includes patient-reported satisfaction, time to return to normal shoe gear, and the incidence of revision surgery. The overall average of time to weightbearing was 4.3 weeks. After surgery, 73.3% (n = 33) of the 45 patients responded to the following question: "Would you have this surgery done again?" Of these patients, 93.9% (n = 31) responded "Yes" and 6.1% (n = 2) responded "Unsure." Of the same 33 patients, 84.8% (n = 28) responded that they were "Very Satisfied" with the procedure and 15.2% (n = 5) responded that they were "Satisfied." Twelve patients (26.7%) did not respond to either question. One of the 12 patients (8.3%) who did not respond had bilateral procedures. None of the patients experienced tendon rupture, deep vein thrombosis, or the need for revision surgery. Four patients (8%) experienced a superficial infection, whereas 1 patient (2%) had development of a deep infection. No correlations were found when looking at the relationship between body mass index and return to weightbearing/normal shoe gear with Spearman analysis.

Spondylodiscitis and Achilles tendonitis due to gout.

The patient, a 62-year-old man with a 3-year history of hyperuricemia, presented with severe neck pain, Achilles enthesopathy and polyarthralgia. He consumed alcohol heavily. The biochemical profile was normal except for elevated levels of CRP (3.6 mg/dl; normal < 0.3), uric acid (UA) (10.9 mg/dl; normal 2.5-7.5) and creatinine (1.7 mg/dl; normal 0.5-1.0). Bone scintigraphy showed polyarthritis at the right elbow, wrist and bilateral first MTP joints. Notably, bone scintigraphy with computed tomography also revealed spondylodiscitis of C5-C6, which was confirmed by MRI, and left Achilles tendonitis. Moreover, left Achilles tendonitis was also confirmed by ultrasonography, indicating enthesitis with low-echoic lesion and calcification. Needle aspiration yielded a white viscous liquid, with numerous urate crystals identified on polarized light microscopy. He was diagnosed with gouty arthritis associated with spondylodiscitis and Achilles tendonitis. After the treatment with allopurinol, colchicine and predonisolone, his symptoms were improved, and serum CRP and UA levels were normalized. The cervical spine and Achilles tendon are rare and notable sites of involvements in gout, and differential diagnosis of gouty arthritis from spondyloarthritis, rheumatoid arthritis, tumor, pseudogout, and infection is necessary. When the patient was noted to have neck pain and Achilles enthesopathy, we should always recognize gouty arthritis.

Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis.

INTRODUCTION: While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT. METHODS: A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups. RESULTS: No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012). DISCUSSION: Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients. LEVEL OF EVIDENCE: Level III.

Inadequate Purchase in the Proximal Tendon Stump Using the Percutaneous Achilles Repair System: A Technical Tip.

Minimally invasive approaches for the Achilles tendon have emerged as viable alternatives for acute Achilles ruptures, with several potential benefits in comparison to the open approach. Occasionally, proper purchase in the proximal tendon stump is not achieved due to severe degenerative disease of the tendon. In this article, we present a technique in which a small accessory incision is used during percutaneous Achilles repair in order to pass the sutures in a more proximal and healthy area of the tendon. This technique is useful for situations in which adequate tendon grasp is not obtained, avoiding the need of conversion to an open approach.Level of Evidence: Level V: Expert opinion.

The Role of Epigenomics in Mapping Potential Precursors for Foot and Ankle Tendinopathy: A Systematic Review.

Tendinopathy of the foot and ankle is a common clinical problem for which the exact etiology is poorly understood. The field of epigenetics has been a recent focus of this investigation. The purpose of this article was to review the genomic advances in foot and ankle tendinopathy that could potentially be used to stratify disease risk and create preventative or therapeutic agents. A multi-database search of PubMed, Cochrane, Google Scholar, and clinicaltrials.gov from January 1, 2000 to July 1, 2022 was performed. A total of 18 articles met inclusion and exclusion criteria for this review. The majority of such research utilized case-control candidate gene association to identify different genetic risk factors associated with chronic tendinopathy. Polymorphisms in collagen genes COL5A1, COL27A1, and COL1A1 were noted at a significantly higher frequency in Achilles tendinopathy versus control groups. Other allelic variations that were observed at an increased incidence in Achilles tendinopathy were TNC and CASP8. The extracellular matrix (ECM) demonstrated macroscopic changes in Achilles tendinopathy, including an increase in aggrecan and biglycan mRNA expression, and increased expression of multiple matrix metalloproteinases. Cytokine expression was also influenced in pathology and aberrantly demonstrated dynamic response to mechanical load. The pathologic accumulation of ECM proteins and cytokine expression alters the adaptive response normal tendon has to physiologic stress, further propagating the risk for tendinopathy. By identifying and understanding the epigenetic mediators that lead to tendinopathy, therapeutic agents can be developed to target the exact underlying etiology and minimize side effects.Level of Evidence: Level IV: Systematic Review of Level II-IV Studies.

Changes in Muscle Morphology Following Gastrocnemius Recession for Achilles Tendinopathy: A Prospective Cohort Imaging Study.

Background. The purpose of this study was to evaluate changes in posterior compartment muscle volume and intramuscular fat content following gastrocnemius recession in people with Achilles tendinopathy (AT). Methods. Eight patients diagnosed with unilateral recalcitrant AT and an isolated gastrocnemius contracture participated in this prospective cohort study. Magnetic resonance imaging was performed on both limbs of each participant before and 6 months following an isolated gastrocnemius recession. Involved limb muscle volumes and fat fractions (FFs) of the medial gastrocnemius, lateral gastrocnemius, and soleus muscle were normalized to the uninvolved limb. Preoperative to postoperative comparisons were made with Wilcoxon signed-rank tests. Results. Soleus or lateral gastrocnemius muscle volumes or FFs were not significantly different between study time points. A significant difference was found in medial gastrocnemius muscle volume (decrease; P = .012) and FF (increase; P = .017). Conclusion. A major goal of the Strayer gastrocnemius recession, selective lengthening of the posterior compartment while preserving soleus muscle morphology, was supported. The observed changes isolated to the medial gastrocnemius muscle may reduce ankle plantarflexion torque capacity. Study findings may help inform selection of surgical candidates, refine anticipated outcomes, and better direct postoperative rehabilitation following gastrocnemius recession for AT.Levels of Evidence: Level IV: Prospective cohort study.

Normal Ultrasonographic Parameters of the Posterior Tibial, Peroneal, and Achilles Tendons.

Tendinopathy of the foot and ankle is common and can lead to pain or functional limitations. The most frequently affected tendons in the foot and ankle are the posterior tibial, peroneal, and Achilles. We used ultrasound to determine normal values for these tendons. From 2015 to 2016, a prospective, standardized bilateral lower extremity ultrasound examination protocol was performed by a musculoskeletal ultrasonographer of the 4 tendons and above and below the malleoli as appropriate. A total of 199 patients with 398 extremities were identified, consented, and participated in the study. Most tendons were normally distributed. The average size of the tendons was as follows: Achilles 5.0 mm (range 2.8-11.2 mm); peroneus long above the malleolus 2.1 mm (range 0.7-3.6 mm), below the malleolus 2.9 mm (range 0.8-6.3 mm); peroneus brevis above the malleolus 1.2 cm (range 0.3-4.0 mm), below the malleolus 1.3 mm (range 0.5-4.8 mm); posterior tibial tendon above the malleoli 3.7 mm (range 1.9-8.1 mm), below the malleolus 4.6 cm (range 1.8-11.8 mm). Standard deviations and distribution curves were similarly calculated for each tendon. This baseline data can assist clinicians in their diagnostic ability with ultrasound. Given its low cost, lack of ionizing radiation and dynamic ability along with an improved understanding of normative data it may become an increasingly used diagnostic modality. Levels of Evidence: Level II: Diagnostic.

Nonsurgical Treatment Options for Insertional Achilles Tendinopathy.

Most nonoperative treatments for insertional Achilles tendinopathy (IAT) have insufficient evidence to support treatment recommendations. Exercise has the highest level of evidence supporting the ability of this treatment option to reduce IAT pain. The effects of exercise may be enhanced by a wide variety of other treatments, including soft tissue treatment, nutritional supplements, iontophoresis, education, stretching, and heel lifts. When exercise is unsuccessful, extracorporeal shock wave therapy seems to be the next best nonoperative treatment option to reduce IAT pain. After other nonoperative treatment options have been exhausted, injections may be considered, particularly to facilitate participation in an exercise program.

Obesity-Related Foot Pain: Diagnosis and Surgical Planning.

Obese patients are at higher risk for surgical complications and consist of a large portion of podiatric patients. Obese patients are additionally at increased risk of developing specific podiatric conditions, and it is important to be able to identify and appropriately treat these conditions accordingly. Initially, conservative treatment is adequate for a variety of pathologic conditions related to obesity. Occasionally surgical intervention is warranted depending on the severity and lack of response to conservative measures. Arthrodesis-type procedures are often preferable and may be necessary, as opposed to periarticular osteotomy, in obese patients even if the deformity is flexible.

Liquifying PLDLLA Anchor Fixation in Achilles Reconstruction for Insertional Tendinopathy.

Insertional Achilles tendinopathy (IAT) is a frequent cause of posterior heel pain and is often associated with Haglund's deformity. Surgical correction for refractory cases of IAT has been well studied; however, the method of tendon fixation to bone in these procedures remains controversial, and to date, no standard technique has been identified for tendon fixation in these surgeries. Often, after Haglund's resection, there is large exposed cancellous surface for Achilles reattachment, which may require unique fixation to optimize outcomes. Previous studies have consistently demonstrated improved patient outcomes after Achilles tendon reconstruction with early rehabilitation with protected weight bearing, evidencing the need for a strong and stable anchoring of the Achilles tendon that allows early weight bearing without tendon morbidity. In this report, we highlight the design, biomechanics, and surgical technique of Achilles tendon reconstruction with Haglund's deformity using a novel technique that utilizes ultrasonic energy to liquefy the suture anchor, allowing it to incorporate into surrounding bone. Biomechanical studies have demonstrated superior strength of the suture anchor utilizing this novel technique as compared with prior techniques. However, future research is needed to ensure that outcomes of this technique are favorable when compared with outcomes using traditional suture anchoring methods. LEVELS OF EVIDENCE: Level V: Operative technique.

Content Relevance of the Foot and Ankle Ability Measure in Patients With Achilles Tendon Diseases.

BACKGROUND: The Foot and Ankle Ability Measure (FAAM) is among the most widely utilized and best psychometrically supported lower extremity-specific patient-reported outcome measures. However, its content relevance has never been directly subjected to patient assessment. METHODS: This was an institutional review board-approved, prospective, cross-sectional study of 75 patients with Achilles tendon diseases who ranked the relevance of the FAAM's items and subscales as 1 = Not relevant, 2 = Somewhat relevant, or 3 = Very relevant. Substantial content relevance was indicated by a minimum mean item or subscale score of 2.0. Nonsurgical and surgical subgroups were compared. RESULTS: At the whole group level, the mean score was above 2.0 for each individual item and subscale. Subgroup analysis revealed that the mean relevance was above 2.0 for each of the items and subscales with the exception of the "Personal Care" item, which nonsurgical patients ranked significantly lower than did surgical patients (mean = 1.74 vs 2.23, P = .02). Additionally, this was part of a general trend across items with more 95% confidence intervals crossing below 2.0 in the nonsurgical data set (15 items, 52%) than the surgical data set (1 item, 3%). CONCLUSION: These data confirm that the FAAM has substantial content relevance to patients with Achilles tendon diseases. However, it is unclear why the surgical subgroup consistently ranked items higher than did the nonsurgical subgroup. Future work should address how a patient's content relevance perception is influenced by the relative effects of their Achilles disease type and their perceived level of disease-related functional impairment. LEVELS OF EVIDENCE: Diagnostic, Level III.

Proximal to Distal Exostectomy for the Treatment of Insertional Achilles Tendinopathy.

When insertional Achilles tendinopathy is addressed surgically via a central-Achilles splitting approach, the calcaneal osteotomy has classically been performed from distal to proximal. We describe a simple proximal to distal technique that allows optimal resection of both the calcaneal exostosis and Achilles enthesophyte, minimizes risk to the soft tissues and skin, provides a bony attachment surface parallel to the axis of the Achilles tendon, and avoids the risk of osteotomy extension into the subtalar joint. LEVELS OF EVIDENCE: Level V: Technique tip.

Predicting Failure of Nonoperative Treatment for Insertional Achilles Tendinosis.

Nonoperative treatment for midportion Achilles tendinosis is well defined by the literature. Multiple modalities are described for the management of insertional Achilles pathology, but no consensus exists regarding efficacy. Surgical intervention for insertional Achilles tendinosis (IAT) is successful greater than 80% of the time. Our objective was to risk stratify patients who would fail nonsurgical management of IAT and thus benefit progressing to surgery. We reviewed the records of 664 patients with IAT. The cohort was 53% male and 80% obese. Mean age was 53.7 years (standard deviation 14.7 years). Average duration of symptoms was 10.4 months (standard deviation 28 months). Of the parameters collected, 4 were found to correlate with failing nonoperative treatment: visual analog scale, limited ankle range of motion, previous corticosteroid injection, and presence of Achilles tendon enthesophyte. We found that as the number of risk factors increased so did the chance of failing nonoperative treatment. With all 4 parameters, chance of failing conservative treatment was only 55%. Thus, nonoperative management should be exhausted until surgery is the only remaining option. However, the presence of one of the aforementioned risk factors can aid a surgeon in the decision to pursue surgery in the appropriate clinical scenario. LEVELS OF EVIDENCE: Level IV: Retrospective Case series.

Use of a Non-Crosslinked Porcine Dermal Matrix in Repair of the Achilles and Other Tendons of the Foot.

BACKGROUND: Ankle tendon augmentation with biological matrixes has been shown to be beneficial, especially for Achilles tendon rupture as it adds to the integrity of the repair. Biologic matrix augmentation has been used increasingly in chronic and complex injuries where reinforcement is required. The objective of this study was to present outcomes of a series of patients who underwent tendon repair augmented with a new biologic matrix. METHODS: Sixteen patients underwent ankle tendon repair, augmented with Proformix biologic tissue matrix. Patients were evaluated pre- and postoperatively for function and pain, and were followed for up to 3 years for complications. RESULTS: This study included 10 females and 6 males, with a mean age of 44.6 years (range, 23-71 years). Patients were evaluated at 2 months postoperatively, and then further followed for a mean 19.0 months (range 7-38 months) to assess complications and reinjuries. Foot and Ankle Disability Index scores significantly increased from preoperatively (38.3) to 2 months postoperatively (85.2) ( P < .001). Furthermore, there were no reports of reruptures or significant complications. CONCLUSIONS: Weakness or rupture in tendons of the foot, especially the Achilles tendon, can be treated surgically and the repair augmented with Proformix, a new, biological matrix. Our study presented a series of 16 patients whose surgical repairs had been augmented with the new biological matrix, all of whom have achieved excellent results. LEVELS OF EVIDENCE: Level IV: Case series.

Endoscopic Transfer of Flexor Hallucis Longus Tendon for Chronic Achilles Tendon Rupture: Technical Aspects and Short-Time Experiences.

BACKGROUND: Chronic Achilles tendon ruptures can lead to reduced power of plantar flexion in the ankle with impaired gait ability. The open 1- or 2-incision technique for flexor hallucis longus transfer has proven good functional outcome but has the disadvantage of relatively extensive surgery performed at a vulnerable location. To reduce the risk of soft tissue problems, the flexor hallucis longus transfer can be performed endoscopically. MATERIAL AND METHOD: An endoscopic technique for flexor hallucis longus transfer is presented together with the experiences from the first six patients operated with this method. RESULTS: No wound healing problems or infections. Five of 6 patients managed single leg heel raise on the affected side 12 months after surgery. CONCLUSION: The functional results are promising. The soft tissue dissection is minor, and no patients had postoperative wound healing problems or infection. Endoscopic flexor hallucis longus transfer may be an operative procedure that can be considered also in patients with potential wound healing problems. LEVELS OF EVIDENCE: Level IV: Technical note/case series without controls.

Insertional achilles tendinopathy associated with altered transverse compressive and axial tensile strain during ankle dorsiflexion.

The purposes of this case-control study (N = 20) were to examine the effects of insertional Achilles tendinopathy (IAT) and tendon region on tendon strain in patients with IAT compared to a control group without tendinopathy. An ultrasound transducer was positioned over the Achilles tendon insertion during dorsiflexion tasks, which included standing and partial squat. A non-rigid image registration-based algorithm was used to estimate transverse compressive and axial tensile strains of the tendon from radiofrequency ultrasound images, which was segmented into two regions (superficial tendon and deep). For transverse compressive strain, two-way mixed effects ANOVAs demonstrated that there were interaction effects between group and tendon region for both dorsiflexion tasks (Heel lowering, p = 0.004; Partial squat, p = 0.008). For axial tensile strain, the IAT group demonstrated a main effect of lower tensile strain than the control group (Standing, p = 0.001; Partial squat, p = 0.033). There was also a main effect of greater tensile strain in the superficial region of the tendon compared to the deep during standing (p = 0.002), but not during partial squat (p = 0.603). Reduced transverse compressive and axial tensile strains in the IAT group indicate altered mechanical properties specific to the region of IAT pathology. Additionally, patterns of compressive strain are consistent with the theory of calcaneal impingement contributing to IAT pathology. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:910-915, 2017.

Repair of Chronic Achilles Ruptures Has a High Incidence of Venous Thromboembolism.

BACKGROUND: Despite the low incidence of deep vein thrombosis (DVT) in foot and ankle surgery, some authors report a high incidence of symptomatic DVT following Achilles tendon rupture. The purpose of this study was to identify DVT risk factors inherent to Achilles tendon repair to determine which patients may benefit from prophylaxis. METHODS: One hundred and thirteen patient charts were reviewed following elective and nonelective Achilles tendon repair. For elective repair of insertional or noninsertional Achilles tendinopathy, parameters examined included lateral versus prone positioning and the presence versus absence of a flexor hallucis longus transfer. For nonelective repair, acute Achilles tendon ruptures were compared to chronic Achilles tendon ruptures. RESULTS: Of 113 Achilles tendon repairs, 3 venous thromboembolism (VTE) events (2.65%) occurred including 2 pulmonary emboli (1.77%). Seventeen of these repairs were chronic Achilles tendon ruptures, and all 3 VTE events (17.6%) occurred within this subgroup. Elevated body mass index was associated with VTE in patients with chronic Achilles ruptures although this did not reach significance ( P = .064). No VTE events were reported after repair of 28 acute tendon ruptures or after 68 elective repairs of tendinopathy. Two patients with misdiagnosed partial Achilles tendon tears were excluded because they experienced a VTE event 3 weeks and 5 weeks after injury, prior to surgery. CONCLUSION: In our retrospective review, chronic Achilles ruptures had a statistically significant higher incidence of VTE compared with acute Achilles ruptures ( P = .048) or elective repair ( P = .0069). Pharmaceutical anticoagulation may be considered for repair of chronic ruptures. Repair of acute ruptures and elective repair may not warrant routine prophylaxis due to a lower incidence of VTE. LEVELS OF EVIDENCE: Prognostic, Level III: Case Control Study.

The Effect of Suture Anchor Insertion Angle on Calcaneus Pullout Strength: Challenging the Deadman's Angle.

BACKGROUND: Refractory cases of Achilles tendinopathy amenable to surgery may include reattachment of the tendon using suture anchors. However, there is paucity of information describing the optimal insertion angle to maximize the tendon footprint and anchor stability in the calcaneus. The purpose of this investigation is to compare the fixation strength of suture anchors inserted at 90° and 45° (the Deadman's angle) relative to the primary compressive trabeculae of the calcaneus. METHODS: A total of 12 matched pairs of adult cadaveric calcanei were excised and potted to approximate their alignment in vivo. Each pair was implanted with 5.5-mm bioabsorbable suture anchors placed either perpendicular (90°) or oblique (45°) to the primary compressive trabeculae. A tensile load was applied until failure of anchor fixation. Differences in failure load and stiffness between anchor fixation angles were determined by paired t-tests. RESULTS: No significant differences were detected between perpendicular and oblique suture anchor insertion relative to primary compressive trabeculae in terms of load to failure or stiffness. CONCLUSION: This investigation suggests that the fixation strength of suture anchors inserted perpendicular to the primary compression trabeculae and at the Deadman's angle are possibly comparable. LEVELS OF EVIDENCE: Biomechanical comparison study.

Division Tenorrhaphy: A Novel Technique for Chronic or Failed Nonoperatively Treated Achilles Tendon Rupture.

Here we describe a modified open technique for the repair of a ruptured Achilles tendon using multiple looped sutures with the creation of interdigitating tendon stumps maximizing surface area for suture application as well as allowing for significant tissue overlay. This technique produces a high strength repair that is useful in cases of extensive degeneration or poor-quality tissue. Degenerative tissue may be encountered with chronic ruptures or failed nonoperative treatment, as well as those ruptures that occur at the proximal myotendinous junction. We present 2 cases in which the technique was utilized: one of a failed nonoperatively treated rupture and another of a chronic rupture. The technique was found to be successful for both patients with improvement in visual analogue scale, Achilles tendon total rupture score, American Orthopaedic Foot and Ankle Score, and Foot and Ankle Disability Index. LEVELS OF EVIDENCE: Level IV.

Flexor Hallucis Longus Tendon Transfer for Calcific Insertional Achilles Tendinopathy.

Calcific insertional Achilles tendinopathy can result in significant pain and disability. Although some patients respond to nonoperative therapy, many patients are at risk for long-term morbidity and unpredictable clinical outcomes. There is no evidence-based data to support the timing of operative invention, choice of procedures, or whether equinus requires treatment. This article suggests the need for a classification system based on physical examination and imaging to help guide treatment. There is an obvious need for evidence-based studies evaluating outcomes and for properly conducted scientific research to establish appropriate treatment protocols.