Severe insertional Achilles tendinopathy: Our experience with two different surgical techniques

K. Ahmad, R. Maheshwari, A. Munoruth, R. Kucharski, Z. Abiddin

Introduction: Severe insertional Achilles tendinopathy (IAT) is difficult to treat. This study reviews our experience of two surgical approaches undertaken at a single unit, open debridement of Achilles tendon insertion and dorsal closing wedge calcaneal osteotomy.

Methods: 35 patients with failed conservative management were considered for surgery. 25 patients were in the open debridement and 11 patients in the calcaneal osteotomy group. The open debridement, with excision of Haglund's when present, was performed by a single surgeon from 2010-2019. Standard technique used, with suture anchors for reinforcement of TA when required. The calcaneal osteotomies were performed by another surgeon during 2014-2019. Zadek's technique was utilized and plantar cortex was kept intact at the apex of the osteotomy. Fixation was achieved with screws, IOFIX device or calcaneal compression plates. The Manchester-Oxford foot questionnaire (MOXFQ) and followup assessment by the surgeon were used to assess outcomes.

Results: A total of 36 feet (35 patients) were assessed with a mean age of 52.6 years and followup of 20 weeks. The debridement group showed 76% (19 patients) with good to excellent outcome. Three patients required revision debridement with a fair outcome. Three patients had a poor outcome. One patient required revision with Zadek's osteotomy, two patients were referred to rheumatology for ongoing pain. The calcaneal osteotomy group showed 82% (9 patients) with good to excellent outcome. Two patients required removal of metal work with a fair outcome. One patient developed plantar fasciitis. Osteotomies were united in all patients. There were no major complications including venous thromboembolism in either group.

Conclusions: Both techniques are safe and satisfactory and correct patient selection is paramount for each. Calcaneal osteotomy also demonstrates encouraging results. The authors recommend a prospective comparative study with larger population and longer followup, as there is paucity of such studies in published literature.