Calci&icInsertionalAchillesTendinopathy:FunctionalOutcomeFollowingAchillesRepairwithFlexorHallucisLongusTendonTransfer

MichaelA.Howell,DPM;TimothyP.McConn,DPM;KarlR.Saltrick,DPM,FACFAS;AlanR.Catanzariti,DPM,FACFASDivisionofFootandAnkleSurgery|WestPennHospital|AlleghenyHealthNetwork|Pittsburgh,PA

StatementofPurposeThe purpose of this study is to provide a retrospectiveoutcomeofpatientswhohaveundergoneanAchillesrepairwitha Clexorhallucis longus(FHL) tendon transfer for themanagement of calciCic insertional Achilles tendinopathy(CIAT). The focus includes functional patient-reportedoutcomes and satisfaction post operatively, aswell as theincidence of revisional surgery and re-rupture rates.Secondaryobjectives includeassessing complications suchas infection, wound dehiscence, incidence of DVT, andprolongedpost-operativepainfollowingtheprocedure.

References

Analysis&DiscussionResults

Methodology&Hypothesis

Procedure

LiteratureReview

Surgerywasperformedunder general anesthesiawith thepatient in aproneposition. A gastrocnemius recession was considered when equinus waspresent.Aserpentineincisionwasmadeovertheposterioraspectoftheheel,allowing for access to the distal Achilles tendon for debridement and repair,ostectomyofthecalcaneus,andtransferoftheFHLtendon.Theparatenonwasincised and retracted.A full-thickness linear incisionwas thenmade into thedistalAchillestendon,extendingdistallyontothecalcaneustothelevelofbone.Allsofttissuesweredebridedfromtheposteriorcalcaneus,includingmediallyand laterally. A sagittal saw was then used to resect a portion of bone toadequatelydecompressthedistalaspectoftheAchillestendon.Aself–retainingretractor,placedproximallywithin the incisedportionof theAchilles tendon,allowed for harvesting of the FHL tendon. The foot and hallux were thenmaximallyplantar-Clexed,andtheFHLtendonwasincisedjustbeforeitenteredthe tarsal tunnel. The tendon end was sutured in a whipstitch fashion topreparefortransfer.OurtechniqueforFHLtendontransferincludeddeliveringabiotenodesisscrewintotheposteriorcalcaneus.TheAchillestendonwasthenreattachedtothecalcaneuswithanchorsandre-approximatedsidetosidewithabsorbablesuture.Skinclosurewasperformedinstandardfashion.(Figure1)

Table1.PatientDemographics(n=31)

Age(mean;range) 52.55;30-67

Sex(n) 21F;10M

BMI(mean;range) 36.69;25.1-55.7

Laterality(n) 19R;14L

Comorbidities(n;%)

HTN 16;52%

DM 10;32%

HLD 7;23%

OA 7;23%

GERD 5;16%

Hypothyroid 3;10%

Tobaccouse(n;%) 11;35%

Table2.PatientOutcomes(n=31)

A retrospective review was conducted on 31 consecutivepatients(33feet)whounderwentanAchillesrepairwithanFHLtendontransferprocedureforthemanagementofCIATbetweentheyears2011and2015.IdentiCicationofpatientswas performed via searchable computerized hospitaldatabase, including the appropriate ICD-9 and CPT codes.Before surgical treatment, each patient underwentconservative therapy and hadweight-bearing radiographstaken of their affected foot. Additionally, all patientsunderwent magnetic resonance imaging (MRI) of theaffected foot. Exclusion criteria included patients withincomplete medical and/or surgical records and patientsundertheageof18.ThehypothesisweposeisthatpatientswhohadundergoneanAchilles repairwith an FHL tendon transfer procedureforthemanagementofCIATwillhavefavorableoutcomes,along with increased Achilles functionality and overallsatisfaction.

CalciCic insertional Achilles tendinopathy (CIAT) is a relatively commonmusculoskeletalentitythatresultsinsigniCicantpainanddisability.Eliasetal.studied40patientswithadiagnosisofCIATandfoundanaveragepreoperativeAOFAS-AHscoreof56.3,withanaveragepreoperativeVASscoreof7.5. Inaretrospective study of 29 procedures, Hartog found signiCicantly lowerfunctional scores prior to Clexor hallucis longus transfer for CIAT, with anaverage preoperative AOFAS hindfoot score of 41.7. CIAT often includesretrocalcaneal bursitis, Haglund’s deformity, insertional calciCication,insertional paratenonitis, insertional tendinosis, equinus deformity and,sometimes,systemicenthesopathies.Advancedimaging,especiallyMRI,canprovideprognosticinformationtoguidetreatment. Unfortunately, the success rate with non-surgical treatmentdecreasessigniCicantlyonceintra-substancechangesconsistentwithtendinosisare present on MRI. In 24-45.5% of patients with Achilles tendinopathy,conservative management is unsuccessful and surgery has to be considered.Surgery should be considered in those patients who experience refractorydisease, disability, weakness and MRI changes consistent with tendinosis.Furthermore, it is important to keep in mind that long–standing disease isassociated with poor surgical outcomes and a greater rate of reoperation.Therefore,implementingnon-operativecareforaspeciCicperiodoftimebeforeproceeding with surgery might adversely affect the surgical outcome. ThetimingofsurgeryshouldbebasedonobjectivefactorssuchasclinicalCindingsandMRIresults,aswellasthepatient'sresponsetonon-operativetreatment.

1.EliasI,RaikinSM,BesserMP,etal.OutcomesofchronicinsertionalAchillestendinosis using FHL autograft through single incision. Foot Ankle Int2009;30(3):197–204.2. Den Hartog BD: Flexor hallucis longus transfer for chronic Achillestendinosis.FootAnkleInt2003;24:233–237.3.NicholsonCW,BerletGC,LeeTH.Predictionofthesuccessofnon-operativetreatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int2007;28:472–477.4.MaffulliN,SharmaP,LuscombeKL.AchillesTendinopathy:aetiologyandmanagement.JRSocMed.2004;97(10):472–476.5.MaffulliN,BinCieldPM,MooreD,etal.SurgicaldecompressionofchroniccentralcorelesionsoftheAchillestendon.AmJSportsMed1999;27:747–7526. Johnson KW, Zalavaras C, Thordardson DB. Surgical management ofinsertional calciCic achilles tendinosis with a central tendon splittingapproach.FootAnkleInt2006;27(4):245–250.7. Maffulli N, Reaper J, Ewen SW, et al. Chondral metaplasia in calciCicinsertionaltendinopathyoftheAchillestendon.ClinJSportMed2006;16(4)8.JohanssonKKJ,SarimoJJ,LempainenLL,etal.CalciCicspursattheinsertionof the Achilles tendon: a clinical and histological study.Muscles LigamentsTendonsJ2012;2(4):273-277.9. Roche AJ, Calder JDF. Achilles tendinopathy: A review of the currentconceptsoftreatment.BoneJointJ2013;95-B:1299–1307.10. RyanM,Wong A, Taunton J. Favorable outcomes after sonographicallyguided intratendinous injection of hyperosmolar dextrose for chronicinsertional and midportion achilles tendinosis. Am J Roentgenol2010;194:1047–1053.11. Kearney R, Costa ML. Insertional achilles tendinopathymanagement: asystematicreview.FootAnkleInt2010;31:689–694.12. Khan KM, Forster BB, Robinson J, et al. Are ultrasound and magneticresonanceimagingofvalueinassessmentofachillestendondisorders?Atwoyearprospectivestudy.BrJSportsMed2003;37:149–153.

Postoperatively,17patientsincludedinthestudycompletedaVISA-A(Victorian Institute of Sports Assessment – Achilles) and patientsatisfaction questionnaire at Cinal followup. The average calculatedVISA-A scorewas92% (range73 to100)on a scale from0 to100.Furthermore, 16 of 17 patients (94%)were very satisCiedwith theoutcomeoftheprocedureandwouldhavetheoperationagain.Intermsofpatientoutcomes(Table2),forall31patientsincludedinthe study, zero experienced re-rupture, DVT, or revisional surgery.Three patients (9%) experienced a superCicial infection, while onepatient (3%) developed a deep infection. Of note, all four of thesepatientsweredocumenteddiabetics. Theoverall average of time toweight-bearingwas less than5weeks,while time to shoegearwaslessthan8weeks.Figure1.SurgicaltechniqueforthetreatmentofCIATwithFHLtendontransfer.

Figure 2. MRI sagittal T2-weighted image of the ankleshowsacalcanealexostosiswithincreased signal intensity at theinsertion of the Achilles tendonand within the retrocalcanealbursae.

Scan with QR reader app toviewsurgicaltechniquevideo

Previous studies have found those suffering fromCIAT experience signiCicantly lower function scoresprior to intervention. Once conservative treatmenthas been exhausted, operative treatment is requiredinwhichall pathological componentsofCIAT shouldbe addressed. There is no evidence–based data tosupport the timing of operative invention, choice ofprocedures,orwhetherequinusrequirestreatment.Oneprocedureinparticular,theAchillesdetachment/reattachment with FHL transfer, encompasses theprinciplesofsurgicalmanagementofCIATaddressingall necessary components of this pathological entity.Inourinstitutionandinthisstudy,utilizingtheVISA-A postoperative scoring system, this procedure hasshowntobeasuccessfultreatmentofCIAT.Knowingtheseoutcomesmighthelpguideprocedureselectionfor physicians and will provide information topatientstohelpthemunderstandwhattoexpect.

TimetoWeight-bearing(weeks)(median;range) 4.48;3-8

TimetoShoeGear(weeks)(median;range) 7.75;4-12

Complications(n;%)

Re-Rupture 0;0%

SuperCicialInfection 3;9%

DeepInfection 1;3%

DVT 0;0%

Revisionalsurgery 0;0%

Followup(months)(mean;range) 14.88;6-44

Post-opVISA-Ascore(%)(mean;range) 92;73-100