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Achilles tendon debridement

    Overview

    Learn the Achilles tendon debridement surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Achilles tendon debridement surgical procedure.
    The indication for an Achilles tendon debridement is painful Achilles tendinosis which has failed to respond to conservative managements.
    These conservative managements including tried and tested physiotherapy regimens, orthotic off loading and injection therapies can be expected to work in 70% of patients , irrespective of the extent (and often nature) of the Achilles involvement. Shockwave therapy also may have a role in conservative management though its effectiveness is lower.
    A debridement can be expected to work in 90% of patients with a return to limited weight-bearing possible in most after 2 weeks if using a post-operative boot.
    Full weight bearing is usually possible after 5 weeks and after a period of functional rehabilitation a return to full activity is the norm.

    Indications

    INDICATIONS.
    –Painful Achilles tendinosis which has failed to respond to conservative managements
    There is some argument about how severe & extensive tendinosis needs to be before a radical excision of the degenerate tendon sections is required rather than the debridement described in this technique. A radical debridement then may on occasion necessitate an intercurrent tendon transfer for reconstruction (See Flexor Hallucis Tendon transfer).
    There would be little argument that if in excess of 50% of the tendon bulk is excised then debridement should probably be supplemented by a transfer. The question is what type of tendinotic tissue needs this sort of radical excision or how extensive tendinosis needs to be for it to be excised ?.
    There is little good evidence at all on this point. My own practice is to primarily incise/repair most degrees of severity of tendinosis if conservative management has been exhausted. The exceptions to this in my own practice is the poor tendon tissue seen in cysts and associated with tears, which I excise and close deeply. This will rarely amount to 50% of the tendon. Large areas of intra-tendinous calcification should also be excised and may leave defects that may require a transfer. Extensive gouty deposits in the Achilles I also tend to excise as they are exceptionally avascular and abnormal.
    SYMPTOMS & EXAMINATION.
    Symptoms are those of pain and swelling well localised to the tendon. Often the onset is acute and after a minor injury though the pathology may be extensive and likely chronic though asymptomatic. It may produce pain only on start up of activity or during running or sport and rarely will progress to give pain at rest also.
    In most patients the area of tendinosis will be discreetly tender and swollen compared to the normal tendon. It can often be as well seen as palpated. If this is not the case ,and pain is from a locally tender tendon ,it may simply be paratenon inflammation overlying a healthy tendon. There will be argument on this point as the disorder may be a continuum starting with paratenon inflammation only . For selection of interventional options it is still a distinction worth making.
    It is very unusual for non-contiguous areas of the Achilles to be effected by degenerate change at the same time and also fairly rare to get sequential change in different parts of the tendon over a period of time. Also unusual is for both the “body” of the tendon and its insertion to be effected at the same time (though this is not as unusual as non-contiguous areas being effected) .
    Once the tendon has settled (whatever the means required) it tends to remain asymptomatic in the longer term(though structurally altered). This is of course very unlike the course often seen with degenerate change in joints.
    INVESTIGATION.
    MRI: An MRI is the most user (surgeon) friendly way to image the tendon. The extent, location and nature of degenerative change is most objectively demonstrated by MRI. Smaller degrees of change may not be so well identified as with ultrasound and isolated inflammation of the paratenon also is usually best seen using ultrasound. MRI is in no way discriminative as to whether a tendon will respond to conservative treatment nor what type of operative treatment is likely to be required.
    Ultrasound: I tend to use this if clinically the problem appears to be either paratenon inflammation (which may be treatable at the same sitting with a steroid and local paratenon injection) or a very localised and small area of tendinosis which may be treatable with dry needling or a fractionated plasma injection.
    NON-OPERATIVE TREATMENT.
    Physiotherapy: Tried and tested program of passive & active modalities which works all told in 70 % of patients.
    Shockwave therapy: Of use in some, perhaps a success rate of over 50%. Does have a small risk of rupture associated with the intervention.
    Orthotic /Shoewear: Most patients should try using a slightly higher heel to detension the tendon during gait. A custom made functional foot orthotic to minimise pes planus and raise the heel slightly may have a similar effect. Formal immobilisation using a weight bearing cast or post-operative boot for 4-6 weeks might be considered in some as an alternative to operation though with far lower rates of success (perhaps at best 50% at a guess).
    Injection therapies: Including paratenon stripping , dry needling and fractionated plasma injections into the tendon. These interventions tend to work best for small and localised areas of tendinosis.
    Steroid should not be used in cases of tendinosis due to the risk of precipitating tendon rupture.
    ALTERNATIVE OPERATIVE TREATMENT
    Radical excision of all tendinotic tissue (with or without tendon transfer): A multitude of options including Flexor Hallucis Longus , Peroneals , Flexor Digitorum Longus and allograft.
    Gastrocnemius Lengthening: (see results section).
    CONTRAINDICATIONS.
    The usual relative contraindications (or factors that need optimising) including poor vascularity , poor soft tissue quality , active smoking and poor patient compliance.
    The extent and nature of tendon change is regarded by some as a reason not to debride and repair the Achilles as previously mentioned.



    Setup

    Almost all Achilles repairs can be carried out with the patient supine (though a prone position has been used in this technique).
    GA or Regional Anaesthetic and Popliteal block for post operative pain relief.
    The incision used most sensibly is not a direct posterior one onto the tendon but postero-medial & just anterior to the tendon
    One or two side supports should be placed on the operated side at thigh and trunk level whilst several sandbags are placed under the opposite buttock , thus turning the operated leg into 90 degrees of external rotation
    The further addition of rolled up sterile towels allow an extra element of helpful rotation and access to the back and lateral aspects of the tendon
    Thigh tourniquet to be used and Flowtron on non-operated calf.
    Prophylactic antibiotics and LMWHeparin peri-operatively & post-operatively
    Bipolar diathermy

    Operation

    With mild tendonosis(left side)of the achilles tendon the swelling can be fairly subtle. It is classically described as fusiform and can be got above and below. In mild cases no abnormality may be felt.

    The skin incision used is medial and skirts the anterior margin of the Tendo-Achilles. Length is determined by the amount of tendon involved which is determined (and usually marked) pre-operatively.
    Placing the incision medially and away from the direct posterior aspect of the tendon has two distinct advantages with no detrimental effect upon the extent of exposure afforded.
    The first is that a scar placed medially avoids the issue of skin tethering onto the achilles and having a scar sitting in direct contact with the heel counter of a shoe.
    The second is that if further /revision surgery is needed it is likely that the Flexor Hallucis Longus tendon will be required. This is more safely accessed from a postero-medial approach than a direct posterior approach.

    Once through the skin use fine tenotomy scissors to blunt dissect direct onto the Achilles tendon. Full thickness skin flaps should be raised. The skin healing here is slow and can be poor so avoid undermining the skin edges. Self retainers should be placed deeply ,not directly beneath the skin edges, and frequently detensioned.

    The Achilles tendon (1) being progressively defined from its surrounding tissues. Immediately anterior and deep to it is fat and then a deep fascial layer. Beneath this lies the Flexor Hallucis Longus muscle belly. Also beneath this defined layer but lying just anterior to the front edge of the tendon is the neurovascular bundle. Placing deep retractors here should be avoided.

    Full thickness skin flaps have been raised(1) . The tendon sheath around the Achilles (paratenon) is now visible(2). It is considerably thickened and also a recognised source of pain.
    Compare with the next slide in the surgical series the appearance of the tendon with its paratenon intact & once it has been removed (next slide).

    The inflammed paratenon(3) is dissected off the Achilles tendon and removed. The underlying area of tendonosis(1) is very obvious. The tendon fibres are far less well defined and the tendon is swollen compared to normal(2).

    The posterior aspect of the Achilles tendon is clearly affected by the degenerative change. The deep(anterior) aspect of the Achilles should also be inspected.
    The anterior aspect of the tendon may have “leashes” of vessels adherent (which sit within the fat layer, and are known as neo-vascular tissue) and these should be carefully dissected off the tendon and the vessels cauterised using careful and light bipolar diathermy away from the Achilles tendon .The bipolar forceps should not placed in any way deeply within this anterior fatty layer as deep/anterior to lies the neurovascular bundle beneath the deep fascial layer.
    It is most important that the whole circumference of the tendon once adequately exposed is inspected . and all areas of neo-vascularisation are removed. These are also recognised as sources of pain.

    Longitudinal incisions into the centre of the
    Achilles tendon are made (1). These should be made at various points across the width of the tendon, exact spacing dependant upon where the degenerative change lies.
    If as a result of the number and length of incisions made the tendon is tending towards “buckling open” then I would use running 2.0 vicryl sutures to close any such defects. I would also recommend any defects produced by excising deep placed cysts or tears are first of all excised and then repaired in the same way.
    There is no clear agreement or evidence on what level of degenerate tendon tissue should be excised and what is likely to heal if incised and left. Intra-tendinous tears though are usually particularly poor tissue and require complete excision .The same can be said of cysts. The more usual amorphous tendinotic tissue which comprises most of the diseased Achilles that will be encountered can be usually simply be deeply incised. It is rare to need to remove much Achilles tendon tissue.
    An exception which can be particularly unforgiving is the tendon afflicted by extensive gouty disease. This is better treated by more radical excision of the degenerate tissue. If a defect of any note results (some sources would quote 50% loss of the tendon tissue) be prepared to supplement with an FHL tendon transfer.

    The wound closed with a subcuticular stitch after the fat has been closed with a 2.0 Vicryl suture. Marcain being infiltrated around the Achilles for additional post-operative pain relief.

    Post Operative

    The first two weeks are spent in a lightweight cast , limited weight bearing
    After two weeks into long post-operative boot and commence weight bearing using crutches.
    Usually by the end of 4 weeks post op it is comfortable to weight-bear just in the boot without the need for crutches.
    From 5 weeks commence weight-bearing rehab (strength & balance) and non-weight bear strengthening and range of motion excercises.
    The most rapid progression likely would be:
    Static bike from 5 weeks
    Cross-training from 7 weeks
    Light Full weight bearing jog on treadmill from 10 weeks
    (sooner on Alter-G treadmill or in pool)
    If at any stage during rehabilitation pain starts to become an issue then mobilisation & activity should be reduced to a level that is pain-free. This may require going back into the boot or readopting the use of crutches.
    Of upmost importance through-out the post-operative period is that the wound is looked after . Wound infection and small areas of breakdown occur easily in a freshly healed wound that is allowed to rub on socks/shoewear.
    Any exudate from the wound which is allowed prolonged contact with the wound will further exacerbate any skin breakdown . Dressing changes may therefore need to be frequent if such a complication ensues.
    Once out of cast I advise another month of daytime dressings when in shoes and also nocturnal dressings whilst any of the wound remains unhealed
    Showering & bathing is from when out of cast

    Recommended Reading

    In this areas the understanding of the nature of the pathology and how to treat it has changed considerably in the last few decades and the results reported in older papers in particular should be read with this in mind
    Surgical decompression of chronic central core lesions of the Achilles tendon. Amercican Journal of sports medicine.1999. 27:747-52
    Maffuli et al
    14 athletes with chronically painful Achilles tendinosis were operated upon. Only one third excellent results and of the remainder the level of symptoms was such that just under half of the original cases underwent re-operation.
    It is easy to see how this could be sited against more conservative debridement type surgery for Achilles tendinosis. However the technique described specifically encourages the anterior fat with neo-vascularisation to be left attached to the tendon as well as the paratenon. Knowledge that both of these structures cause pain has meant that surgical technique has moved on significantly from that described in this paper.
    Noninsertional Achilles Tendinopathy Treated with Gastrocnemius Lengthening .Foot & Ankle International . 2011 :375-379
    Victoria B. Duthon, Anne Lubbeke, Sylvain R. Duc, Richard Stern, Mathieu Assal,
    14 patients with 17 tendons with failed conservative management of Achilles tendinopathy. Within 12 months of operation the AOFAS scores were significantly improved and within 24 months the majority were back to sport.
    Surgical treatment of chronic Achilles tendonitis.American journal of sports medicine 1989.17 (6):754-9
    G Nelens M Martens A Burssens
    93 tendons with tendonitis and 50 with tendinosis treated operatively after a mean of 18 months conservative management .
    With the tendinosis resection of all diseased tissue was undertaken resulting in 19 patients with excellent or good outcome. In 24 patients an additional turndown of the gastrosoleus was indicated following debridement resulting in excellent or good in 21 cases .
    90% of outcomes were excellent or good .
    Flexor Hallucis longus transfer in treatment of Achilles tendinosis. J Bone Joint Surg (Am) 2013. 95(1):54-60.
    L C Schon et al
    An older surgical population , average age in the mid 50s, in whom the FHL transfer was used to supplement Achilles debridement (which itself has a good outcome). 24 month follow up revealed significant improvement in function and pain (within 3 to 6 months of operation though continuing to improve). Single heel raise was the slowest aspect to improve. 2/3 rds of patients observed no alteration in balance due to loss of FHL function (but 1/3 rd did).
    The use of ultrasound in the assessment of Achilles tendinosis . J Bone Joint Surg.2009.91-B;1405-1409.
    A.W.M.Mitchell, J.C.Lee, J.C.Healy.
    A good review article

    Reference

    • orthoracle.com

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