Chou: OKU: Foot and Ankle 7

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Chapter 23: Disorders of the Achilles Tendon

FIGURE 5 Intraoperative photograph showing the use of a harvested flexor hallucis longus tendon to augment the Achilles tendon after extensive débridement.

degenerative changes of the tendon may require extensive débridement and augmentation with FHL tendon transfer ( Figure 5 ). A randomized prospective study compared patients with insertional Achilles tendinopathy treated with débridement alone with those who were augmented with an FHL transfer. 46 At 1-year follow-up, no signif icant difference in American Orthopaedic Foot and Ankle Society and visual analog scale scores was noted between the two groups. The FHL group was noted to have greater plantar flexion strength in the ankle. No assessment of the severity of tendinosis was provided for either group. The lack of a standardized method for assessing the severity of the condition makes it difficult to compare studies and provide firm recommendations. SUMMARY Acute and chronic injuries of the Achilles tendon can cause significant pain and disability. Physical examination usu ally allows an accurate diagnosis in cases of acute Achilles tendon rupture, but MRI may be helpful if the diagnosis is questionable or in the case of chronic pathology. Both surgical and nonsurgical management of acute Achilles tendon ruptures have been advocated, with recent evidence supporting early functional rehabilitation regardless of the approach taken. Most chronic Achilles tendon ruptures are managed surgically; however, nonsurgical management may be indicated in patients unfit for surgery or with low physical demands. A trial of nonsurgical management is indicated in the initial management of insertional and non insertional Achilles tendinopathy. If surgical treatment is required, an open or minimally invasive procedure can be chosen, depending on the type and severity of the pathol ogy. A return to occupational and recreational activities is possible for most patients; however, recovery may take 6 to 12 months.

level of competition and 22 of the 29 recreational athletes returned to the same level of competition. Consistent with recent trends, newer minimally invasive approaches to surgical management of chronic insertional tendinopathy have been described. A 2021 retrospective case series of 27 patients reported the outcomes of percutaneous calcaneo plasty in patients who presented with evidence of distal Achilles tendon inflammation and retrocalcaneal bursitis, without associated advanced tendinopathy or intratendi nous calcification. The study authors found improvement in patient-reported outcomes at an average of 26.5-month follow-up, with 22 patients (84.5%) reporting complete satisfaction and two additional patients (7.4%) reporting moderate satisfaction. 44 In regard to débridement, it is thought that as much as 50% of the Achilles tendon insertion can be detached without significantly increasing the risk of rupture. With additional detachment and exposure, suture anchors may be needed to secure the tendon. Although clinical data are lacking to determine the ideal number and configuration of anchors, a study suggested better outcomes with the use of two-suture anchors or double row fixation when compared with a single anchor. 45 Patients with significant FIGURE 4 A , Preoperative lateral foot radiograph from a patient with chronic insertional Achilles tendinopathy with associated Haglund deformity. B , Postoperative lateral foot radiograph after posterosuperior calcaneal ostectomy, débridement of retrocalcaneal bursitis, Achilles tendon inser tion débridement, and repair.

Section 7: Tendon Disorders and Sports Related Foot and Ankle Injuries

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Orthopaedic Knowledge Update ® : Foot and Ankle 7

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