Results of Surgical Treatment of Insertional Achilles Tendinosis

Surgical procedures recommended for recalcitrant IAT have included excision of the posterior calcaneal osteophyte, excision of the Haglund’s exostosis, limited Achilles debridement, complete debridement of the tendon insertion with bone anchor re-attachment, and isolated gastrocnemius fascia release without direct treatment of the posterior heel. Several incisions have been advocated for treatment of IAT, including posterior mid-line, medial and/or lateral, J-shaped, and transverse incisions.^2,4–9 Gould described an extensive procedure for IAT that included a proximal V–Y lengthening of the gastrocnemius, complete detachment of the Achilles insertion, removal of the abnormal distal portion of the tendon, and re-attachment of the insertion with anchors.³ The purpose of this study is to determine the effectiveness of a simple surgical procedure for the treatment of IAT that we believe addresses all of the pathology while avoiding the time, cost, and prominence of suture anchors.

Materials and Methods
Surgical Technique
The patient is placed in the prone position with utilization of a thigh tourniquet. The first portion of the procedure is to perform a gastrocnemius fascia release through a 4cm posterior mid-line incision at the level of the musculotendinous junction (see Figure 1 ). Care is taken to identify and avoid injury to the sural nerve, which is a mid-line structure at this level. After the nerve is retracted, the fascia of the superficial posterior compartment of the leg is opened longitudinally and a chevron-shaped incision, with the apex proximal, is made through the gastrocnemius fascia, avoiding incision into the muscle (see Figure 2A ). With the knee extended the ankle is dorsiflexed, and the fascial incision can be seen to open about 2cm (see Figure 2B). The foot should dorsiflex at least 10º above neutral following the gastrocnemius fascia release.

A second posterior mid-line incision is then made, beginning 3cm above the top of the calcaneal tuberosity and extending distally to the thickened skin at the upper edge of the posterior aspect of the heel pad (see Figure 1 ). Care is taken not to elevate the skin flaps off the Achilles tendon. The scalpel is placed directly through the mid-line of the Achilles tendon, at the proximal end of the incision, and the scalpel is then brought straight distally. When the scalpel comes to the superior edge of the tuberosity, the incision through the mid-line of the tendon is continued distally, past the distal end of the tendon insertion. Sharp dissection is then used from the mid-line to elevate the Achilles insertion off the calcaneus, leaving a small amount of intact tendon insertion on both the medial and lateral aspects of the tuberosity. With the tendon insertion elevated off the tuberosity, osteotomes and rongeurs are used to remove any posterior osteophyte from the calcaneus. The Achilles tendon is then everted and any degenerative or calcified areas of tendon are sharply excised (see Figures 3A and 3B). The abnormal tendon is almost always limited to the anterior aspect of the tendon, and therefore the length of tendon is preserved by leaving the posterior portion of the tendon intact.

After debridement of the abnormal tendon, the tendon halves are again retracted with the overlying skin flaps, and the retrocalcaneal bursa is removed. We believe that impingement by the posterior–superior prominence of the calcaneus on the anterior aspect of the tendon always contributes to IAT, and therefore, in all cases, an osteotome is utilized to remove the posterior–superior portion of the tuberosity (Haglund’s deformity). This is easily accomplished through the mid-line incision in the tendon. A lateral radiograph is obtained to make certain that the Haglund’s deformity, posterior insertional osteophytes, and all tendon calcifications have been adequately removed (see Figures 4A and 4B ). If the ankle can be plantarflexed by pulling on each Achilles tendon half proximally with an Allis clamp, there is enough insertion remaining intact that anchor fixation is not necessary. The mid-line incision through the Achilles tendon is repaired with 2–0 Vicryl suture, with the knots buried on the deep aspect of the tendon (see Figure 5 ). The skin is closed with nylon or absorbable subcuticular suture.

Sterile dressings are applied and the ankle is splinted in neutral. One week post-operatively a short leg cast is applied for an additional three weeks, with continued non-weight-bearing. At four weeks postoperatively, the patient is placed in a hinged boot that is adjusted to allow full plantarflexion but no dorsiflexion. The boot is removed for bathing, sleeping, and range of motion exercises, but weight-bearing is not allowed until eight weeks post-surgery. At eight weeks postoperatively, progressive weight-bearing as tolerated is allowed in the boot. At 12 weeks after surgery, the boot is discontinued, and progressive strengthening and shoe-wear are allowed. Full return to impact-loading sports activity or heavy lifting is not allowed until six months following surgery.