Case Reports and Series
Achilles Tendon Reattachment after Surgical Treatment of Insertional Tendinosis Using the Suture Bridge Technique: A Case Series

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Abstract

Achilles tendinopathy is a clinical diagnosis characterized as a triad of symptoms including pain, swelling, and impaired performance of the diseased tendon. Achilles tendinopathy is divided into Achilles tendonitis and tendinosis based on histopathological examination. Achilles tendinosis is viewed microscopically as disorganized collagen, abnormal neovascularization, necrosis, and mucoid degeneration. Insertional Achilles tendinosis is a degenerative process of the tendon at the junction of the tendon and calcaneus. This disease is initially treated conservatively with activity modification, custom orthotic devices, heel lifts, and immobilization. After 3 to 6 months of conservative therapy has failed to alleviate symptoms, surgical management is indicated. Surgical management of insertional Achilles tendinosis includes Achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision. In this case series, we present 4 patients who underwent surgical management of insertional Achilles tendinosis with complete tendon detachment. All patients underwent reattachment of the Achilles tendon with the suture bridge technique. The Arthrex SutureBridge® (Arthrex, Inc., Naples, FL) device uses a series of 4 suture anchors and FiberWire® (Arthrex Inc.) to reattach the Achilles tendon to its calcaneal insertion. This hourglass pattern of FiberWire® provides a greater area of tendon compression, consequently allowing greater stability and possible earlier return to weightbearing activities. The patients were followed up for approximately 2 years’ duration. There were no intraoperative or postoperative complications. At final follow-up there was no evidence of Achilles tendon ruptures or device failures. All patients were able to return to their activities of daily living without the use of assistive devices. The patients’ average visual analog pain scale was 1 (range 0 to 4), and their average foot functional index score was 3.41 (range 0 to 10.71). The suture bridge technique is a viable option for Achilles tendon repair after surgical management of insertional Achilles tendinosis.

Section snippets

Patients and Methods

We retrospectively reviewed the charts of patients with insertional Achilles tendinopathy who underwent surgical correction of Achilles tendinosis with complete detachment of the Achilles tendon and subsequent reattachment with the Arthrex SutureBridge® device from August 2009 to May 2010. A total of 4 patients with 4 surgical procedures were identified. Before surgical treatment of insertional Achilles tendinosis, each patient underwent conservative therapy and had weightbearing

Case 1

A 59-year-old woman presented to the clinic with a chief complaint of worsening right posterior heel pain and deformity for 2 years’ duration. The patient had attempted a course of physical therapy and nonsteroidal antiinflammatory medications without alleviation of her posterior heel discomfort. On physical examination, the patient had tenderness to palpation over the insertion site of the Achilles tendon onto the calcaneus. Furthermore, on visual and palpatory examination the patient had an

Results

Upon chart review, all patients initially presented with a chief complaint of posterior heel pain that failed conservative treatment. Weightbearing anteroposterior and lateral radiographs of the affected foot were reviewed, which demonstrated a posterosuperior calcaneal exostosis in all patients. In addition, one patient had intratendonous calcifications on radiographic examination. An MRI was performed on all patients and showed insertional Achilles tendinopathy and retrocalcaneal bursitis.

Discussion

Evidence supports surgical treatment of insertional Achilles tendinosis for those patients failing 3 to 6 months of conservative therapy. Research demonstrates excision of the retrocalcaneal bursa, ostectomy of the calcaneal exostosis and debridement of the degenerative and/or calcific Achilles tendon results in improved patient symptoms and function. However, there is a disagreement amongst surgeons concerning the amount of Achilles tendon detachment necessary to adequately debride the tendon

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Financial Disclosure: None reported.

Conflict of Interest: None reported.

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