Surgical Treatment of Chronic Achilles Tendinopathy: Long-term Results of the Endoscopic Technique

doi:10.1053/j.jfas.2013.03.031

The Journal of Foot and Ankle Surgery

Volume 52, Issue 4, July–August 2013, Pages 451-455

https://doi.org/10.1053/j.jfas.2013.03.031 Get rights and content

Abstract

Surgery has long been established as a valid alternative for chronic Achilles tendinopathies that have failed conservative treatment. Endoscopic procedures have shown satisfactory preliminary results for managing such injuries. The aim of the present study was to evaluate the long-term clinical outcomes of endoscopic surgery in patients with chronic midportion Achilles tendinopathy. We evaluated 27 endoscopic procedures in 24 patients (mean age 45.5 ± 8.9 years; 12 males and 12 females) with chronic Achilles tendinopathy and at least 5 (mean 7.7, range 5 to 14) years of follow-up. All ambulatory procedures consisted of paratenon debridement and longitudinal tenotomies. The clinical evaluation included 2 specific functional rating systems (the Achilles Tendon Scoring System and the Victorian Institute Sport Assessment-Achilles questionnaire) and a pain visual analog scale. Patient satisfaction with the procedure was assessed using a patient global assessment response to therapy Likert scale score. All patients had an improved clinical outcome at the final follow-up visit. Both scoring systems showed significant improvement in all clinical outcomes at the last follow-up visit. The Victorian Institute Sport Assessment-Achilles questionnaire score had improved from 37.0 ± 4.9 points preoperatively to 97.5 ± 12.1 points postoperatively (p = .0006). The Achilles Tendon Scoring System score had improved from 32.6 ± 13.1 points preoperatively to 97.2 ± 12.3 points postoperatively (p = .000006). The pain visual analog scale score averaged 0.2 ± 1.1, and the patient global assessment response to therapy score was 0.25 ± 0.71. The percentage of patients with an excellent patient global assessment response to therapy score was 85.1%. Two postoperative problems were reported (7.4%): a delayed keloid lesion and a seroma with chronic fistula. The infection rate and systemic complication rate were 0%. In conclusion, endoscopic surgery provided a high rate of excellent long-term results in patients with chronic midportion Achilles tendinopathy. Debridement of the paratenon and crural fascia, along with longitudinal tenotomies, using a minimally invasive procedure provided completely resolution of symptoms at 7 years postoperatively in 96% of patients in the present consecutive series.

Section snippets

General

The study protocol and informed consent form were both approved by the appropriate ethical review committees and institutional review boards. The study was conducted in full accordance with the ethical standards for the treatment of patients.

Patients and Clinical Assessment

All patients with chronic midportion Achilles tendinopathy who had undergone endoscopy and had at least 5 years of clinical follow-up were eligible for the present study. Preoperatively, chronic midportion Achilles tendinopathy was diagnosed by the findings

Results

Both scoring systems showed significant improvement in all clinical outcomes at the last follow-up visit. The VISA-A score had improved from 37.06 ± 4.99 points preoperatively to 97.55 ± 12.11 points postoperatively (p = .0006). The ATSS score had improved from 32.66 ± 13.15 points preoperatively to 97.25 ± 12.31 points postoperatively (p = .000006; Fig. 2).

The pain visual analog scale score at the final examination averaged 0.22 ± 1.15 (range 0 to 6, 95% confidence interval −0.23 to 0.67). The

Discussion

The main finding of the present study was that endoscopic surgery provides a high rate of excellent long-term results in patients with chronic midportion Achilles tendinopathy. Endoscopic debridement of the paratenon and crural fascia and longitudinal tenotomies using a minimally invasive procedure provided complete symptom resolution at 7 years in 96% of patients in the present consecutive series. All patients had improved their preoperative clinical status and had reported a

Acknowledgment

We thank Vanesa Vinciunas for her language editing.

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Cited by (40)

Endoscopic debridement for non-insertional Achilles tendinopathy with and without platelet-rich plasma
2023, Journal of Sport and Health Science
When non-operative management fails to improve symptoms in patients with non-insertional Achilles tendinopathy, surgery may be required. Various open and endoscopic techniques have been proposed, and platelet-rich plasma (PRP) injections have been proposed as an adjunct to aid tendon healing.
Thirty-six patients with mid-portion Achilles tendinopathy were randomized to undergo endoscopic debridement alone (n = 19) or in combination with intraoperative PRP application (n = 17). Clinical outcome measures included the Visual Analogue Scale for pain, function, and satisfaction and the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire. Patients were followed-up at 6 weeks, 3 months, 6 months, and 12 months after surgery. An MRI examination at 3 and 12 months was used to assess signal alterations within the tendon.
Both groups showed significant clinical improvement (p < 0.05) after surgery, with no difference between the 2 groups. Tendon diameter increased at 3 months and decreased at 12 months. The tendinopathy area increased at 3 months and decreased at 12 months below baseline level in both groups. There was no significant difference between the groups regarding the MRI parameters. Nodular thickening and MRI-detected signal alteration persisted after surgery, with no association between imaging and clinical outcome. Five minor complications were reported: 2 in the PRP group and 3 in the control group.
Endoscopic debridement of the Achilles tendon improved clinical outcomes in patients with mid-portion tendinopathy. The addition of PRP did not improve outcomes compared to debridement alone. MRI parameters showed no association with clinical outcomes.
Tendoscopies in the foot and ankle
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Tendoscopy is an apparently safe and reliable procedure to manage some foot and ankle disorders. Most common foot and ankle tendoscopies are for the Achilles, peroneals, and posterior tibial tendon. Tendoscopy may be used as an adjacent procedure to other techniques, such as calcaneal osteotomies. The technique allows for an unrivalled view of the entire length of tendons while also providing a dynamic evaluation of their movement inside the sheath. Therefore, it is a useful tool both for the diagnosis and the minimally invasive treatment of different tendon disorders around the foot and ankle. In this paper we will review the techniques, indications, results, and existing evidence and outcomes and complications of foot and ankle tendoscopies. The original techniques will be presented together with tips and tricks to optimize the tendoscopic experience. We will also conducted a search of the biomedical literature to look for results and outcomes of posterior tibial tendoscopy, peroneal tendoscopy, and Achilles tendoscopy.
Die Tendoskopie ist eine augenscheinlich sichere und zuverlässige Maßnahme zur Behandlung von Problemen am Fuß und Sprunggelenk. Die häufigsten adressierten Sehnen sind die Achilles-, die Peroneal- und die Tibialis posterioer Sehne. Die Tendoskopie kann als alleinige Technik, oder zusammen mit anderen Techniken, wie der Calcaneus Osteotomie angewendet werden. Sie erlaubt die uneingeschränkte Sicht der gesamten Länge der Sehne und erlaubt eine dynamische Evaluation der Bewegung in der Sehnenscheide. Daher ist es eine sinnvolle diagnostische und minimalinvasive Behandlungstechnik für verschiedene Pathologien rund um den Fuß und das Sprunggelenk.
In dem Artikel werden die Technik, Indikationen und Ergebnisse, sowie die verfügbare Evidenz und das Outcome, sowie die Kompilationen der Tendoskopie vorgestellt. Die Original-Technik wird vorgestellt, sowie Tipps und Tricks um die Ergebnisse zu optimieren. Eine Übersicht über die verfügbare Literatur wird dargestellt.
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2020, Clinics in Sports Medicine
Posterior heel pain
2020, Orthopaedics and Trauma
Heel pain at or around the insertion of the Achilles tendon is a common presenting complaint affecting both young, active patients and those who are older and more sedentary. So-called posterior heel pain is often presumed to run a self-limiting course over a few months, resolving with rest, weight loss and stretching exercises. However, a small number of patients suffer with increasingly disabling symptoms that are refractory to this regimen. Posterior heel pain is classically split into insertional and non-insertional types, and in order to select an appropriate management plan the diagnosis must be precise. Further management without a clear understanding of the pathology is potentially detrimental to the patient. This review aims to provide a structured approach to careful clinical and radiological assessment and treatment of this condition.
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2020, Baxter’s The Foot And Ankle In Sport
Achilles endoscopic surgery is a minimally invasive option that has been described to manage different pathologies related to the Achilles tendon, including non-insertional Achilles tendinopathy, Haglund’s deformity, equinus contracture, even Achilles ruptures. Tendoscopic surgery minimizes the risk for some of the complications associated with open surgery, such as scarring, perioperative pain, and wound complications, and it may also provide a faster recovery. No clear guidelines have been established related to the efficacy of the endoscopic technique in Achilles tendinopathy. Only small series have been reported, and over different populations with varying degrees of tendinopathic compromise, which makes it even harder to give recommendations on its use. The indication for tendinoscopy in non-insertional Achilles tendinopathy is becoming more accepted, with good results and good outcomes consistently reported with few or no complications. As already said, these studies are limited by their low number of patients and retrospective nature, and therefore on a review of the literature performed in 2014 by Cychosz et al., a grade C recommendation (for intervention) to the Achilles tendoscopy was given. No evidence-based recommendation has been given to tendinoscopy for insertional Achilles tendinopathy, and more information and well-designed studies are needed to further elucidate the role of impingement against the calcaneus. The authors believe that this is a promising area for further research where limited surgical approaches will have an important role in the future.
Minimally Invasive and Endoscopic Approach for the Treatment of Noninsertional Achilles Tendinopathy
2019, Foot and Ankle Clinics

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: Financial Disclosure: This study was supported by the Nixus Foundation, Mosoteguy Foundation, and HLB Foundation.

: Conflict of Interest: None reported.

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Original ResearchSurgical Treatment of Chronic Achilles Tendinopathy: Long-term Results of the Endoscopic Technique

Abstract

Section snippets

General

Patients and Clinical Assessment

Results

Discussion

Acknowledgment

Arthroscopy

Arthroscopy

Foot Ankle Clin North Am

Foot Ankle Surg

J Foot Ankle Surg

J Foot Surg

Terminology for Achilles tendon related disorders

Knee Surg Sports Traumatol Arthrosc

Original Research
Surgical Treatment of Chronic Achilles Tendinopathy: Long-term Results of the Endoscopic Technique