Intermediate and Long-Term Outcomes of the Suture Bridge Technique for the Management of Insertional Achilles Tendinopathy

Abstract

Introduction. Insertional Achilles tendinopathy is a problem frequently encountered by the foot and ankle surgeon. Conservative care yields mixed results, and this condition is often treated surgically. Our hypothesis is that the suture bridge technique through a central posterior incision allows adequate visualization for thorough debridement and exostectomy and provides a stable tendon-to-bone interface for healing. Material and Methods. The medical records of 35 patients who underwent surgical treatment for insertional Achilles tendinopathy with the suture bridge technique, by a single surgeon, between 2006 and 2012 were retrospectively reviewed. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot instruments as well as a subjective questionnaire were utilized. Results. In all, 30 individuals who met the inclusion criteria for the treatment of insertional Achilles tendinopathy were evaluated at a mean follow-up of 28.93 ± 16.99 months. We included 10 men and 20 women, with a mean age of 49.1 ± 9.2 years. The mean preoperative AOFAS score was 56.6 ± 14.0. The average postoperative AOFAS score significantly increased to 91.7 ± 10.4 (P < .0001). One participant required revisional surgery, consisting of a flexor hallucis longus transfer performed by another physician. There were no wound complications or infections. Overall, there was a 97% (28/29) satisfaction rate. Conclusion. The central incision with complete detachment of the Achilles tendon and reattachment with the suture bridge technique for the treatment of insertional Achilles tendinopathy provides an effective treatment with good to excellent clinical outcomes in 97% of patients, with a mean follow-up of 29 months.

Levels of Evidence: Therapeutic, Level IV, Retrospective case series

Keywords

Achilles tendonitis heel rearfoot ankle reconstructive foot and ankle surgery diagnostic and therapeutic techniques bone (heel,toe) spurs general disorders complex foot and ankle conditions foot surgery techniques

“The surgical principles are to debride areas of symptomatic tendinosis and intratendinous calcification, promote tendon healing, and correct exacerbating mechanical factors.”

Introduction

Insertional Achilles tendinopathy is a clinical diagnosis comprising the spectrum of acute and chronic pathology involving the Achilles tendon insertion and its surrounding tissues. This condition is a frequent source of pain and cause of presentation to foot and ankle surgeons. Waldecker et al¹ reported a 4% incidence rate of insertional Achilles tendinopathy within a nonathletic population. Kvist² retrospectively reviewed 3336 competitive and recreational athletes, with 14% of participants presenting with Achilles tendon issues. He reported that 66% had paratendonitis, and 23% had either retrocalcaneal bursitis or insertional tendinopathy. Surgery was performed in 24% of patients with paratendonitis and insertional disease.

Nonsurgical treatment has mixed results reported within the literature, and surgical intervention is frequently required.^3,4 The surgical principles are to debride areas of symptomatic tendinosis and intratendinous calcification, promote tendon healing, and correct exacerbating mechanical factors.⁵ Inflamed bursae and areas of prominent bone must also be removed. The surgical technique and extent of tendon detachment are areas of debate. The purpose of this article is to review the surgical outcomes of patients who underwent the use of the suture bridge technique as part of the overall management of insertional Achilles tendinopathy.

Materials and Methods

After institutional review board approval, medical records from 2006 to 2012 were reviewed. A total of 35 patients who underwent surgical management using the suture bridge technique for the treatment of insertional Achilles tendinopathy were identified. All patients in the study presented with posterior heel pain that had failed 3 to 6 months of nonoperative management. All patients had radiographic evidence of an enthesopathy at the Achilles insertion with a prominent posterior calcaneal tuberosity. Patients were included in the study if they were 18 years or older and underwent surgical correction of insertional Achilles tendinopathy and calcaneal exostectomy with the use of the Arthrex Achilles SutureBridge (Arthrex Inc, Naples, FL) to reattach the Achilles tendon with a minimum follow-up of 6 months. Exclusion criteria were incomplete medical records, use of an alternative surgical technique or implant for insertional Achilles tendinopathy, and failure to follow up with the senior author for greater than 6 months. Clinical outcomes were assessed by preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot outcome instruments as well as a subjective postoperative satisfaction questionnaire consisting of 3 questions obtained via a telephone interview. Patients included in this study were evaluated and treated preoperatively, intraoperatively, and postoperatively by the senior author (PRB). Additional information collected from the medical records included data on gender, age, surgical site, postoperative course, and complications. Statistical analysis was performed by the lead author using the Student t test for evaluation of statistical significance (P < .05).

Surgical Technique and Postoperative Course

Each patient was placed in a prone position and a thigh tourniquet was used to maintain hemostasis; all patients received preoperative antibiotics in accordance with Surgical Care Improvement Project guidelines. Following standard prepping and draping, a posterior midline incision was made. The incision was then carried down to the paratenon while maintaining full thickness skin flaps. The paratenon was then incised for later repair. The Achilles tendon was then detached transversely from its insertion, exposing the entire retrocalcaneal exostosis (Figure 1). The degenerative and calcified portions of the Achilles tendon were carefully excised. The exostosis was removed with an oscillating saw or osteotome, and all edges were smoothed with a hand rasp (Figure 2). All calcifications protruding off the calcaneus and within the Achilles tendon were removed, and this was confirmed with an intraoperative fluoroscopic image. The tendon was then tensioned appropriately and reattached to the newly created bleeding cancellous surface of the calcaneus using the Achilles Suture Bridge (Arthrex Inc, Naples, FL) anchor system (Figure 3). The paratenon was closed with 4-0 Monocryl using a locked running stitch, and the skin reapproximated with 3-0 nylon. The patients were immobilized in a non-weight-bearing Jones compressive dressing in gravity equinus for 1 week. At their first postoperative visit, reliable patients were placed in a CAM boot with an Achilles wedge system and those patients deemed unreliable were placed in a cast with the foot in a relaxed position, with all patients being instructed to remain non–weight bearing. All patients remained non–weight bearing until their 3-week follow-up visit, at which time sutures were removed, and they were then allowed to weight bear as tolerated with the use of a CAM boot and Achilles wedge system. Patients were instructed to remove one 5° wedge each week starting from 15° of plantarflexion, until they were able to ambulate at a neutral position in the boot. Patients were then transitioned back into regular shoe gear as tolerated. If necessary, physical therapy was initiated on a case-by-case basis.

Figure 1.

Complete Detachment of the Achilles Tendon Exposing Large Calcaneal Exostosis.

Figure 2.

Postresection and Debridement of Calcaneus.

Figure 3.

Suture Bridge Construct.

Results

A total of 30 patients met the inclusion criteria: 10 men and 20 women, with an average age of 49.1 ± 9.2 years. Follow-up ranged from 7 months to 65 months, with a mean follow-up of 28.9 ± 16.9 months (Table 1). Preoperative and postoperative AOFAS hindfoot scores were found to be 56.6 ± 14.0 and 91.7 ± 10.4, respectively. This increase was found to be statistically significant (P < .0001; Table 2).

Table 1.

Patient Demographics and Follow-up

	Gender	Age	Site	Follow-up (months)
1	Male	40	Left	65
2	Male	38	Right	63
3	Male	58	Left	64
4	Female	53	Right	49
5	Female	56	Right	47
6	Female	53	Right	46
7	Female	35	Right	45
8	Female	41	Left	43
9	Male	57	Left	41
10	Female	50	Right	35
11	Female	41	Right	29
12	Female	63	Right	27
13	Male	34	Left	26
14	Male	37	Left	25
15	Female	54	Right	25
16	Female	47	Right	22
17	Female	44	Right	22
18	Female	62	Left	22
19	Male	36	Left	21
20	Female	60	Right	21
21	Female	54	Right	20
22	Male	49	Left	19
23	Male	36	Right	16
24	Female	45	Right	14
25	Female	57	Left	13
26	Female	56	Left	11
27	Female	50	Right	11
28	Female	65	Right	10
29	Female	55	Left	10
30^a	Male	48	Right	7
Totals	10 Male, 20 female	49.13 (±9.19)	18 Right, 12 left	28.93 (±16.99)

Patient also underwent open gastrocnemius recession.

Table 2.

Preoperative and Postoperative AOFAS Hindfoot Scores

	Preoperative AOFAS Score	Postoperative AOFAS Score	Complications
1	41	53	Continued pain requiring revisional surgery (FHL transfer)
2	55	91
3	61	100
4	68	100
5	61	92
6	30	97
7	43	80
8	27	97
9	66	100
10	51	90
11	55	98
12	38	98
13	62	93
14	50	97
15	29	100
16	75	100
17	66	98
18	71	98
19	75	100
20	66	94
21	51	90
22	75	84
23	62	90
24	67	73
25	69	97
26	68	79
27	63	95
28	59	90
29	39	79
30	54	97
Average	Preoperative, 56.57 (±14.02)	Postoperative, 91.67 (±10.35)	P value <.0001

Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; FHL, flexor hallucis longus.

Of 30 patients, 29 were able to be reached by telephone to complete a subjective questionnaire used to assess satisfaction (Table 3). This questionnaire revealed that 19 patients had an excellent outcome, 9 patients had a good outcome, and 1 patient had a poor outcome. This same patient who was unsatisfied with the surgical procedure was having continued pain that required a second surgical procedure, a flexor hallucis longus tendon transfer, performed by a different surgeon. This patient reported ongoing pain with an inability to return to work, dependence on walking aids and bracing, continued need for pain medications, and a generalized decrease in activity level. No patient developed postoperative wound complications, including wound dehiscence or hypertrophic scarring. One patient required an open gastrocnemius recession at the time of his index procedure. Postdebridement, his Achilles tendon was found to be short, and intraoperatively, it was deemed necessary to maintain adequate ankle joint range of motion.

Table 3.

Subjective Questionnaire

Overall Outcome	Participants (n = 29)
Excellent	19
Good	9
Fair	0
Poor	1

Would You Recommend This Surgery to Friend/Family?	Participants (n = 29)

Yes	27
No	2

Would You Have This Surgery Again?	Participants (n = 29)

Yes	26
No	3

Discussion

The true pathogenesis of Achilles tendinopathy remains unknown. Lyman et al⁶ investigated the distribution of tensile strain at the insertion of the Achilles tendon during functional range of motion. They hypothesized that the location of highest strain would be anterior, but their cadaveric biomechanical study showed increasing strain in the posterior portion of the tendon. The authors described a stress-shielding effect within the tendon anteriorly. Other biomechanical literature supports the finding that the site affected with tendinopathy is generally located at the site of “stress shielding.”⁷ Rufai et al reported the tendency for cartilage-like changes to develop within the tendon on the stress-shielded side of the enthesis, leading to intratendinous bone formation through endochondral ossification.⁸ Benjamin et al⁹ found that calcification and spur formation at the insertion are not dependent on inflammation or preceding micro tears of the Achilles. They felt that the spur formation was an adaptive process, which increases the surface area at the bone-tendon junction to protect this attachment in the face of increased mechanical loads.⁹

Unfortunately, nonoperative treatment of Achilles tendinopathy has mixed results within the literature. The success rates vary from 53% in one study³ to 89% in another.⁴ Overall, the success of nonoperative treatment is most likely dependent on the severity of the tendinopathy,³ and often times, success is limited because of the multifactorial nature of the pathology. Both the disease process and mechanical irritation from shoe gear can lead to recurrence and failure of conservative treatment. Nonoperative treatment modalities include activity and shoe gear modification, nonsteroidal anti-inflammatory medications, heel lifts, orthotics, cast or boot immobilization, extracorporeal shockwave therapy, and physical therapy. If symptoms persist after 3 to 6 months of conservative therapy, surgical treatment is advised.¹⁰

Many surgical procedures exist for the treatment of insertional Achilles tendinopathy; however, all have common goals: excision of the inflamed retrocalcaneal bursa, thorough debridement of the degenerative and calcified tendon, and removal of the calcaneal exostosis. Kolodziej et al¹¹ performed a biomechanical study in which cadaveric Achilles tendons were loaded to failure after detaching sequential amounts of the Achilles tendon. They found that one could detach up to 50% of the Achilles without fear of rupture. Calder and Saxby¹² evaluated the clinical outcomes of insertional Achilles tendon surgery and concluded that early weight bearing is safe if less than 50% of the tendon is detached. These findings have led some authors to not recommend completely detaching the tendon.¹³ However, McGarvey et al¹⁴ found that 95% of their surgical patients had central calcifications requiring a more extensive debridement. They concluded that limiting resection of the diseased tissue to 50%, for fear of rupture, leads to inadequate debridement and thus failure of surgical treatment. They were also the first to describe the central longitudinal approach to debride the calcified tendon.¹⁴ This technique was further investigated by Nunley and colleagues¹⁵ in 2011. In their study, they utilized a central incision and detached up to 70% of the tendon while maintaining the medial and lateral insertion sites of the Achilles tendon. They concluded that this technique affords the surgeon the ability to treat all areas of the pathology with good long-term success in regard to motion, strength, and overall function while preventing nerve and vascular injury and minimizing wound complications.

Complete detachment of the Achilles tendon has been advocated by several authors.^16,17 Wagner compared no or partial detachment (removing less than 50% of the tendon) with complete detachment of the Achilles tendon and concluded that complete detachment allowed for a more adequate debridement and easier removal of the calcaneal exostosis. It should be noted that in their study, they had 2 revisions in the partial detachment group—1 for continued pain secondary to incomplete debridement and the other for an Achilles rupture—whereas the complete detachment group did not require any revisional surgery.¹⁷

It is the opinion of the authors that in order to adequately treat the entirety of the pathology associated with Achilles tendinopathy, the Achilles tendon must be completely detached, leaving the surgeon with the dilemma of reattachment. To our knowledge, our study of 30 patients and 30 surgeries presents the largest patient population in the literature with the longest follow-up to date for the suture bridge technique. The postoperative AOFAS scores as well as the subjective questionnaire support the suture bridge technique as a reproducible surgical procedure, which provides good to excellent patient satisfaction. Our average preoperative and postoperative AOFAS scores of 57 and 92, respectively, showed a statistically significant increase and are similar to the results of other authors.¹⁵ Furthermore, our series demonstrates that removing the entire Achilles tendon and reattaching it with a Suture Bridge construct did not lead to any postoperative Achilles tendon ruptures.

Our study also illustrates the safety of the central posterior incision for Achilles tendon pathology because no wound healing complications developed in our series. This incision placement takes advantage of the fact that it lies centrally along the peroneal angiosome and the posterior tibial angiosome while being medial to the sural nerve.^18,19 Highlander and Greenhagen²⁰ performed a systematic review of the use of posterior leg incisions and found no greater incidence of wound healing complications compared with posterior-medial incisions.²⁰ The advantage of the posterior incision is the excellent visualization for resection and reattachment of the tendon.

Currently, only case reports regarding the suture bridge technique have been published in the medical literature.^21,22 Witt and Hyer²² reported on 4 cases with successful treatment of Achilles tendinosis where the Arthrex suture bridge was used. The advantages of this technique are that it provides adequate visualization and debridement without the loss of early mobility²¹ while providing a large “footprint” or contact area between tendon and bone, thus increasing friction and overall strength of the surgical construct.²³ The large footprint also increases the total surface area of tendon-to-bone contact, theoretically increasing the speed of incorporation. The strength of the suture bridge construct for Achilles pathology has been reported in the treatment of bone affected by Charcot neuroarthropathy,²¹ a condition with known poor bone mineral density.²⁴

Although limited data exist on the use of double row anchor or transosseous fixation techniques for the treatment of insertional Achilles tendinopathy, there are multiple studies investigating its use in shoulder surgery. In their systematic review of double-row versus single- row rotator cuff repairs, Trappey and Gartsman²⁵ found that the majority of basic science data suggest that double-row repairs have a greater footprint, improved contact area and pressure, better initial fixation strength, and a higher load to failure when compared with single-row repairs. Although many studies have shown the biomechanical superiority of the double-row construct, this has not always been the case in terms of clinical superiority. Franceschi et al²⁶ enrolled 60 participants who were randomized into double-row versus single-row repair and found no statistical difference in the postoperative functional assessment at a 2-year follow-up. However, this is in contrast to Gartsman et al,²⁷ who, in their prospective randomized trial comparing a single-row repair to a transosseous equivalent technique (Suture Bridge technique), found a statistically significant difference when rerupture rates were evaluated with ultrasound.

Conclusion

The central incision with complete detachment and reattachment of the Achilles tendon with the suture bridge technique for the treatment of insertional Achilles tendinopathy allows the surgeon adequate visualization to treat all areas of the pathology with minimal risk of nerve injury or wound complications. The suture bridge technique provides an excellent bone-to-tendon healing interface with adequate fixation as demonstrated by the fact that there were no postoperative Achilles tendon ruptures. The technique also provides good to excellent clinical results in 97% of cases at intermediate and long-term follow-ups.

References

Waldecker

Hofmann

Drewitz

. Epidemiologic investigation of 1394 feet: coincidence of hindfoot malalignment and Achilles tendon disorders. Foot Ankle Surg. 2012;18:119-123.

Kvist

. Achilles tendon injuries in athletes. Ann Chir Gynaecol. 1991;80:188-201.

Nicholson

Berlet

Lee

. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int. 2007;28:472-477.

Kearney

Costa

. Insertional Achilles tendinopathy management: a systematic review. Foot Ankle Int. 2010;31:689-694.

Aronow

. Posterior heel pain (retrocalcaneal bursitis, insertional and noninsertional Achilles tendinopathy). Clin Podiatr Med Surg. 2005;22:19-43.

Lyman

Weinhold

Almekinders

. Strain behavior of the distal Achilles tendon: implications for insertional Achilles tendinopathy. Am J Sports Med. 2004;32:457-461.

Maganaris

Narici

Maffulli

. Biomechanics of the Achilles tendon. Disabil Rehabil. 2008;30:1542-1547.

Rufai

Ralphs

Benjamin

. Structure and histopathology of the insertional region of the human Achilles tendon. J Orthop Res. 1995;13:585-593.

Benjamin

Rufai

Ralphs

. The mechanism of formation of bony spurs (enthesophytes) in the Achilles tendon. Arthritis Rheum. 2000;43:576-583.

10.

Irwin

. Current concepts review: insertional Achilles tendinopathy. Foot Ankle Int. 2010;31:933-939.

11.

Kolodziej

Glisson

Nunley

. Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendonitis and Haglund’s deformity: a biomechanical study. Foot Ankle Int. 1999;20:433-437.

12.

Calder

Saxby

. Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int. 2003;24:119-121.

13.

Schepsis

Jones

Haas

. Achilles tendon disorders in athletes. Am J Sports Med. 2002;30:287-305.

14.

McGarvey

Palumbo

Baxter

Leibman

. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int. 2002;23:19-25.

15.

Nunley

Ruskin

Horst

. Long-term clinical outcomes following the central incision technique for insertional Achilles tendinopathy. Foot Ankle Int. 2011;32:850-855.

16.

Wagner

Gould

Kneidel

Fleisig

Fowler

. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int. 2006;27:677-684.

17.

DeVries

Summerhays

Guehlstorf

. Surgical correction of Haglund’s triad using complete detachment and reattachment of the Achilles tendon. J Foot Ankle Surg. 2009;48:447-451.

18.

Attinger

Evans

Bulan

Blume

Cooper

. Angiosomes of the foot and ankle and clinical implications for limb salvage: Reconstruction, incisions, and revascularization. Plast Reconstr Surg. 2006;117:261S-293S.

19.

Leduc

Walling

. Posterior midline approach for treatment of Achilles calcific insertional tendonopathy. Tech Foot Ankle Surg. 2010;9:217-220.

20.

Highlander

Greenhagen

. Wound complications with posterior midline and posterior medial leg incisions: a systematic review. Foot Ankle Spec. 2011;4:361-369.

21.

Greenhagen

Highlander

Burns

. Double row anchor fixation: a novel technique for a diabetic calcaneal insufficiency avulsion fracture. J Foot Ankle Surg. 2012;51:123-127.

22.

Witt

Hyer

. Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series. J Foot Ankle Surg. 2012;51:487-493.

23.

Amendola

Boyle

Mazzocca

Obopilwe

Rincon

McWilliam

Dhar

. Biomechanical testing of distal Achilles fixation using suture anchors: single row vs. SutureBridge. Arthrex, Inc. Company Literature, 2007. Available at: www.arthrex.com. Accessed 8/26/2012.

24.

Greenhagen

Wukich

Jung

Vardaxis

Yoho

. Peripheral and central bone mineral density in Charcot neuroarthropathy compared to diabetic and nondiabetic population. J Am Podiatr Med Assoc. 2012;102:213-222.

25.

Trappey

IV Gartsman

. A systematic review of the clinical outcomes of single row versus double row rotator cuff repairs. J Shoulder Elbow Surg. 2011;20:S14-S19.

26.

Franceschi

Ruzzini

Longo

. Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: a randomized controlled trial. Am J Sports Med. 2007;35:1254-1260.

27.

Gartsman

Drake

Edwards

Elkousy

Hammerman

O’Connor

. Ultrasound evaluation of arthroscopic full-thickness rotator cuff repair: single-row versus double-row versus suture bridge (transosseous equivalent) fixation. Results of randomized, prospective study. Paper presented at: 26th Annual Open Meeting of American Society of Shoulder and Elbow Surgeons; March 13, 2010; New Orleans, LA.