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Achilles tendon minimally invasive debridement

    Overview

    Learn the Achilles tendon minimally invasive 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 minimally invasive 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 if a minimally disruptive approach is used.
    Full weight bearing is usually possible after 5 weeks and after a period of functional rehabilitation a return to full and painfree 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 are better treated with a tendon transfer. Extensive gouty deposits in the Achilles I also tend to excise as they are avascular and can very diffusely infiltrate the tendon, leaving little tissue with any obvious repairitive capacity.
    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%.
    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
    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

    A limited postero-medial incision is used, skirting the anterior border of the tendon and and limited to the area determined pre-operatively.
    By marking pre-operatively with the patient, the precise area of tenderness is defined. It should be ensured that this corresponds to the changes on imaging.
    It would be exceptionally unusual that the degenerative change does not effect the tendon confluently. In other words at any one time only one zone of the tendon will be effected. The exception to this relates to insertional tendinosis where on occasion the body of the tendon may also be discreetly effected.
    The skin incision should be postero-medial and not directly posterior. This reduces the issue of the scar rubbing on the heel counter of a boot or shoe and is the easiest incision to be re-used in the unlikely eventuality of secondary surgery being required such as A Flexor Hallucis Longus tendon transfer.

    Once the skin has been incised a pair of fine tenotomy scissors should be used to dissect down in the same line through the fact directly onto the Achilles tendon.Care should be taken not to undermine the skin edges.

    The skin flaps should be left with fat intact, not undermined (1).
    The anterior/deep aspect of the tendon should be carefully defined (2).

    The paratenon (2) is usually thickened and can be very adherent to the tendon. It is next identified and freed initially from the most posterior aspect of the tendon .
    The anterior/deep aspect of the Achilles (1) needs to be defined. This usually has copious adherent new vessel formation from within the fatty layer.
    It is important to frequently de-tension the self retaining retractors if used and to ensure that they are deeply placed.

    New vessels are seen firmly adherent to the deep aspect of the tendon (1). These should be carefully dissected off to expose the whole deep aspect of the area in question. This type of neo-vascularisation is recognised as a potent source of pain.

    The vessels are diathermised , just off the tendon surface , using bipolar diathermy (1), before being cut. Care should be taken not to breach the deep fascia which lies just a bit further anterior to this (2).
    Beneath the deep fascia directly anterior to the Achilles is the FHL muscle belly but just slightly more medial and anteriorly placed (but also beneath the deep fascia) is the neurovascular bundle. Care should be excercised in placement of self-retaining retractors in this area.

    The para-tenon (1) is more comprehensively scissors & sharp dissected (as required) off the underlying Achilles tendon in the zone of the tendinosis. This is easier to do from the anterior (” deep”) aspect of the Achilles following the initial removal of any new vessel formation.
    The skin incision may need to be extended to access all areas of degenerative change.

    With both the neo-vascularisation and thickened para-tenon cleared away the Achilles tendinosis (2) is more easily identified (as is the small Plantaris tendon in this case).
    This vestigial tendon can be of use in reconstructing or filling small defects of the Achilles. Its presence cannot be relied upon as it is present in fewer than 20% of people.

    The anterior aspect of the tendon needs to be fully revealed either with a Langenbeck retractor or careful use of a small Wests’ self retaining retractor. A few vessels still need to be removed (1) and care should be taken with retractor placement to avoid pressure on the deep fascia(2) , beneath which lies immediately the neuro-vascular bundle in this area. When approaching the neurovascular bundle from this posterior position the posterior Tibial nerve will be the structure first encountered.

    Longitudinal incisions are made in the line of the tendon fibres , through all areas of degenerative change. THe whole circumference of the tendon should be dealt with in this way (2). Again care should be taken to avoid the deep fascia (3).

    Further incisions to the posterior aspect of the tendon.
    If very extensive incisions are required (both in terms of tendon circumference as well as its length) then consider closing any large & slack gaps within the tendon using running 2.0 Vicryl suture(s).
    Degenerate tears and cysts within the tendon should also be excised and the defects also closed using running 2.0 Vicryl sutures.
    If more extensive defects result from the tendon debridement consider transposing the Plantaris tendon if present or good quality local fascial tissue.

    A subcuticular wound closure with 3.0 Vicryl is used. Time should be taken to ensure a sound skin closure.
    A few 3.0 Vicryl sutures are over-sewn in an interrupted fashion to provide a back-up.

    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 exercises.
    Static bike from 5 weeks may be possible.
    Cross-training from 7 weeks at soonest.
    Light full weight bearing jog on treadmill from 10 weeks (sooner on Alter-G treadmill or in pool)
    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.
    Subsequent 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 .
    Almost all 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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