Patients who have persistent pain and disability at the Achilles insertion after adequate non-surgical treatment may be offered surgical debridement of the tendon and excision of the calcaneal prominence. We would not normally offer surgery for persistent swelling of the tendon as this is not usually a problem in itself. However, some patients with insertional tendonopathy have a lot of swelling and difficulty getting shoes on and we would consider debulking for this.
The main options are:
- excision of the calcaneal prominence and retro-calcaneal bursa, with minimal if any debridement of the tendon. This is appropriate only in patients with minimal tendonopathy and no large posterior spurs, including younger patients who have only a prominence. There is increasing published experience with endoscopic "calcaneoplasty".
- excision of the calcaneal prominence and retro-calcaneal bursa and debridement of the Achilles insertion, with reattachment of the Achilles or reconstruction with FHL or other tendon transfer.
There are a number of small series of open treatment, mostly quoting success in relieving pain in about 90% of patients. Chen et al (2001) found that 25 of their 30 patients took up to 2.5 years to achieve a final result. Brunner et al (2005) also found delayed improvement, such that 6/36 patients in their study would not recomment the procedure.
van Dijk described endoscopic calcaneoplasty in 2001, with excellent/good results in 19/20 patients.
Leitze et al (2003) described the results of endoscopic calcaneoplasty in 30 patients and compared them with 17 historical controls who had open procedures. Follow-up was 22 months. There were no significant differences in AOFAS or Maryland foot scores. Three patients had continued pain in both groups. There were one wound healing problem and two sensitive scars in the endoscopic group and three healing problems and three sensitive scars in the open group. There were two sensory disturbances and one regional pain syndrome in the endoscopic group and three sensory disturbances in the open group.
Lohrer (2006) performed endoscopic calcaneoplasty on 6 cadaver limbs and open calcaneoplasty on 9. Medial and lateral approaches were used in the open specimens. Endoscopic resection left more posterior height on the calcaneum and a flatter resection angle. Some bursal tissue was left in two endoscopic cases and loose bony fragments in three open procedures. There were minor injuries to the medial Achilles tendon in both groups, and one sural nerve injury in each group.
Ortmann and McBryde (2007) reported 28 patients who had endoscopic calcaneoplasty and were reviewed an average of 3 years post-operatively. Post-operatively patients wer protected in a splint for 2 weeks and a walker boot for 2-3 weeks. One patient who removed the boot suffered a tendon rupture. The mean AOFAS ankle-hindfoot score improved from 62 to 97 (some pre-op scores were collected retrospectively), and median pain scores from 7-8 to 1-2/10. Full weightbearing was attained at a mean of 4 weeks and sports by 12 weeks. One patient did not get pain relief and had an open debridement. There were no wound problems or nerve injuries.
Kaynak (2013) reproted 5yr follow-up on 28 patients. Most were young patients with Haglund's deformity and retrocalcaneal bursitis but no tendinopathy. Mean AOFAS score increased from 52/100 to 99.
Endoscopic calcaneoplasty is a promising technique which really needs one or more RCTs to compare with the open procedure.
The original series to report the treatment of purely insertional tendonopathy is that of McGarvey et al (2002), who reported 22 procedures. Surgery was performed through a posterior longitudinal tendon-splitting incision with resection of the Haglund's deformity and retrocalcaneal bursa where appropriate. Four patients had over 50% of the width of the tendon resected - three were reinserted with bone anchors and one reinforced with plantaris. At review 2-3y post-op about 70% were pain-free and unrestricted in their activities and 15% had some improvement, but some were no better and two worse than before surgery. Forty percent had wound problems, all minor.
Calder and Saxby (2003) debrided the Achilles insertion with detachment of 50% or less in 49 heels (three other patients had >50% detachment and reattachment with suture anchors). Partial weightbearing mobilisation was allowed immediately. There were two ruptures - one who had both heel operated on at the same sitting, one with psoriatic arthropathy.
den Hartog (2003) described 26 patients who underwent debridement of the Achilles, apparently including the insertion, and augmentation with the FHL tendon. FHL was harvested through the posterior incision. A cast was worn for 6 weeks, followed by a walker boot. At an average follow-up of 3y, mean AOFAS score improved from 42 to 90/100. Results were at least as good in patients over 50y. There were 2 medial calcaneal nerve injuries, no wound problems and no significant FHL donor site deficits.
Wagner and Gould (2006) reported two groups of patients who had debridement procedures. Twenty-six patients (31 heels) had debridement of the Achilles insertion without reattachment. Thirty-nine heels in 39 patients had some degree of detachment and reattachment with suture anchors. The exact criteria for detatachment are not very clear. Outcomes are reported in summary - functional outcomes were similar in the two groups but there were somewhat more wound problems in the detached group.
Johnson (2006) reported 22 patients who had 50-70% of the insertion released and all bone spurs and Haglund deformities removed. All patients had reattachement with suture anchors. At a mean follow-up of 3 years, the mean AOFAS ankle-hinfoot score increased from 53 to 89/100, with the majority of the improvement being in pain scores. However, eleven patients had some scar tenderness, five had some difficulty with shoewear and two (both Workers' Compensation patients) were unable to work after surgery. There were two minor wound infections and one DVT.
Most series report FHL transfer in conjunction with Achilles tendon debridement and posterior calcaneoplasty for Achilles tendonopathy. In these patients the main issue is whether the transfer improved outcome over debridement alone. There are no direct comparative studies, but reported outcome measures are similar in series of bothe techniques. Hertog (2003) transferred the FHL into the Achilles insertion with a suture anchor in 26 patients. The mean AOFAS score improved from 42 to 90/100. More improvement was obtained in patients over 50 and it took 8 months to reach maximal improvement. Martin (2005) in serted the graft through a bone tunnel and wove it into the Achilles. In 44 patients followed up a mean 4.9y, the mean VAS pain score was 1.5/10 and SF-36 scores were comparable to matched normals. Cottam (2008) reported 62 patients using a single incision and interference screw fixation. A modified AOFAS outcome score improved from a mean 20 to 51/63; there were 9 infections and 5 wound problems.
Although there are no studies directly comparing single or double incision techniques or different methods of graft attachment, the reported results appear similar. Recruitment of enough patients for RCTs would probably require several centres.
Donor site morbidity
Although FHL contributes to push-off in the late stance phase of gait, donor morbidity when it is used as a transfer in both these situations is minimal. SAmmarco (2002) noted clinical weakness of hallux flexion in all of 19 patients who had FHL transfer to the navicular fo adult acquired flatfoot, but none had perceived disability or problems walking. The remaining series are transfers for Achilles rupture or tendonopathy. Coull (2003) found some clinical weakness of hallux interphalangeal flexion and minor reduction of total pressure loading on the distal phalanx but no increased loading elsewhere. Hahn (2008) noted weakness of the hallux in 6/16 patients but this was noticeable by only 2 patients. Will (2009) noted slight weakness of the hallux but no disability in 1/19 patients, and Richardson (2009) obtained similar findings in 48 patients who had a single-incision harvest.
Mulier (2007) studied nerve lesions caused by open harvest of FHL in cadavers. 8/24 specimens had injuries to the medial or lateral plantar nerve, including two lateral nerve transections. All specimens required release of tendon interconnections before FHL could be retrieved into a posterior hindfoot incision.