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Endoscopic Achilles Tenolysis for Management of Heel Cord Pain after Repair of Acute Rupture of Achilles Tendon
The Journal of Foot & Ankle Surgery 52 (2013) 125–127
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Endoscopic Achilles Tenolysis for Management of Heel Cord Pain after Repair of Acute Rupture of Achilles Tendon Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, Northern Territory, Hong Kong SAR, China
a r t i c l e i n f o
a b s t r a c t
Keywords: calcaneus endoscopy injury pain rupture tendoscopy
Tendon pain after repair of an acute Achilles tendon rupture can result from suture granuloma formation, modification of the threshold of the pain receptors inside the tendon by scar tissue, expansion of the paratenon by tendon enlargement with secondary stimulation of mechanoreceptors, or underlying tendon degeneration. In the present technique report, an endoscopic technique of Achilles tenolysis for denervation and debulking is described that might be applicable in cases in which conservative treatment fails to alleviate the pain. Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.
Rupture of the Achilles tendon is a relatively common injury, and recent reports have described favorable results with operative treatment, using either open or percutaneous approaches, of acute ruptures in physically active patients. Operative repair appears to provide superior functional results and a lower rate of repeat rupture compared with conservative management (1). The incidence of pain at the tendon repair site is variable and depends in part on the method of repair (2). The incidence of postrepair pain has been reported to be as high as 67% (2), and the pain might affect the patient’s ability to perform sporting and other activities. In the present report, an endoscopic technique of Achilles tenolysis is described. The method is applicable for denervation and debulking of the Achilles tendon should nonoperative treatment methods fail to adequately alleviate the patient’s pain. Surgical Technique With the patient in the prone position on the operating table and a tourniquet applied to the ipsilateral thigh, posteromedial and posterolateral portals are made along the margins of the Achilles tendon near its insertion into the calcaneus. The cleavage plane between the tendon and the deep scar tissue (Fig. 1) is then bluntly
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail address: [email protected]
Fig. 1. Magnetic resonance images showing thickened tendon after repair of acute Achilles tendon rupture (arrow designates cleavage plane between tendon and ventral scar tissue).
1067-2516/$ - see front matter Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2012.09.007
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T.H. Lui / The Journal of Foot & Ankle Surgery 52 (2013) 125–127
Fig. 2. (A) Endoscopic debridement of Achilles tendon through dorsomedial and dorsolateral portals. (B) Arthroscopic shaver was inserted into plane between Achilles tendon (a) and ventral scar tissue (b). (C) Plantaris tendon (c) at medial side of Achilles tendon.
Fig. 3. (A) Scar tissue (b) at edge of tendon (a) pushed toward shaver (c) and freed from tendon edge (B and C). (D) Debridement extended to flexor hallucis longus muscle (d) to ensure complete resection of deep scar tissue.
dissected using a hemostat, a 30 , 4.0-mm arthroscope and an arthroscopic shaver are inserted into this plane, and the deep scar tissue is dissected and resected from the ventral (deep, anterior) surface of the tendon. The plantaris tendon is then identified along the medial aspect of the tendon and resected to eliminate additional fibrosis and restriction of ankle motion (Fig. 2). The scar tissue at the edge of the tendon can be pushed into the shaver and freed from the surfaces of the Achilles tendon. Debridement should extend to the flexor hallucis longus muscle and tendon to ensure complete resection of the deep scar tissue (Fig. 3), and care should be taken to avoid injury to the adjacent neurovascular structures at the level of the ankle. The tenolysis can be extended to the dorsal side of the Achilles tendon to complete the release of scar tissue.
Discussion The etiology of tendon pain after repair of an acute Achilles tendon rupture is not fully understood. Nonabsorbable suture granuloma formation, alteration of the threshold at which pain receptors in the tendon are stimulated by new scar tissue, and distension of the paratenon owing to tendon enlargement with secondary stimulation of the abundant mechanical receptors of the paratenon have been proposed as causes of postrepair Achilles tendon pain (2). Postrepair neovascularization and fibrous degeneration secondary to collagenation could also contribute to tendinopathy (3–7), because neovascularization is known to be associated with concomitant ingrowth of nerve endings, which is thought to lead to postoperative Achilles tendon pain. The treatment options for this type of Achilles tendinopathy include conservative and percutaneous measures, such as eccentric exercises, extracorporeal shockwave therapy, and intratendinous injections of corticosteroids, aprotinin, polidocanol, platelet-rich plasma, autologous blood, and high-volume saline, as well as open
surgical tenolysis and debridement. Open surgery aims to excise the fibrotic adhesions and remove areas of failed healing, using multiple longitudinal incisions in the tendon to detect and remove intratendinous adhesion and to restore vascularity and possibly stimulate latent viable cells to initiate cell matrix response and healing (8). Endoscopic denervation and debulking, as described in the present report, focuses on disruption of abnormal neoinnervation, thereby interrupting pain impulse transmission from the repaired tendon. Similar to other minimally invasive surgical methods, the endoscopic technique of Achilles tendon denervation and debulking is thought to be associated with less exposure of deep structures, fewer wound complications, less scar formation, and better cosmesis. A thickened plantaris tendon located in close proximity to the medial margin of the repaired Achilles tendon commonly exists in patients with chronic, painful, midsubstance tendinosis and can contribute to pain and a sense of stiffness in the leg (9). These symptoms might warrant sectioning and partial excision by endoscopic methods (10). The endoscopic method of Achilles tenolysis has also been shown to effectively debulk the tendon and relieve adhesion (11–14). Also, some patients with tendon pain after repair of a ruptured Achilles tendon complain of a sense of tightness deep in the leg and discomfort with walking or exercise, without an objective limitation of ankle dorsiflexion. It is this group of patients that might be best suited to endoscopic Achilles tenolysis. The release of scar tissue around the tendon has been, in our experience, associated with relief of the sense of deep leg tightness. References 1. Strauss EJ, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 38:832–838, 2007. 2. Rebeccato A, Santini S, Salmaso G, Nogarin L. Repair of the Achilles tendon rupture: a functional comparison of three surgical techniques. J Foot Ankle Surg 40:188–194, 2001.
T.H. Lui / The Journal of Foot & Ankle Surgery 52 (2013) 125–127
3. Osadnik R, Joern Redeker J, Kraemer R, Vogt PM, Knobloch K. Microcirculatory effects of topical glyceryl trinitrate on the Achilles tendon microcirculation in patients with previous Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 18:977–981, 2010. 4. Ohberg L, Lorentzon R, Alfredson H. Neovascularization in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 9:233–238, 2001. 5. Andersson G, Danielson P, Alfredson H, Forsgren S. Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 15:1272–1279, 2007. 6. Bjur D, Alfredson H, Forsgren S. The innervation pattern of the human Achilles tendon: studies of the normal and tendinosis tendon with markers for general and sensory innervations. Cell Tissue Res 320:201–206, 2005. 7. Schubert TE, Weidler C, Lerch K, Hofstadter F, Straub RH. Achilles tendinosis is associated with sprouting of substance P positive nerve fibers. Ann Rheum Dis 64:1083–1086, 2005.
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8. Maffulli N, Longo UG, Loppini M, Spiezia F, Denaro V. New options in the management of tendinopathy. Open Access J Sports Med 1:29–37, 2010. 9. Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med 45:1023–1025, 2011. 10. van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc 19:1367–1375, 2011. 11. Maquirriain J, Ayerza M, Costa-Paz M, Muscolo DL. Endoscopic surgery in chronic Achilles tendinopathies: a preliminary report. Arthroscopy 18:298–303, 2002. 12. Phisitkul P. Endoscopic surgery of the Achilles tendon. Curr Rev Musculoskelet Med 5:156–163, 2012. 13. Steenstra F, van Dijk CN. Achilles tendoscopy. Foot Ankle Clin 11:429–438, 2006. viii. 14. Thermann H, Benetos IS, Panelli C, Gavriilidis I, Feil S. Endoscopic treatment of chronic mid-portion Achilles tendinopathy: novel technique with short-term results. Knee Surg Sports Traumatol Arthrosc 17:1264–1269, 2009.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Endoscopic Achilles Tenolysis for Management of Heel Cord Pain after Repair of Acute Rupture of Achilles Tendon Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, Northern Territory, Hong Kong SAR, China
a r t i c l e i n f o
a b s t r a c t
Keywords: calcaneus endoscopy injury pain rupture tendoscopy
Tendon pain after repair of an acute Achilles tendon rupture can result from suture granuloma formation, modification of the threshold of the pain receptors inside the tendon by scar tissue, expansion of the paratenon by tendon enlargement with secondary stimulation of mechanoreceptors, or underlying tendon degeneration. In the present technique report, an endoscopic technique of Achilles tenolysis for denervation and debulking is described that might be applicable in cases in which conservative treatment fails to alleviate the pain. Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.
Rupture of the Achilles tendon is a relatively common injury, and recent reports have described favorable results with operative treatment, using either open or percutaneous approaches, of acute ruptures in physically active patients. Operative repair appears to provide superior functional results and a lower rate of repeat rupture compared with conservative management (1). The incidence of pain at the tendon repair site is variable and depends in part on the method of repair (2). The incidence of postrepair pain has been reported to be as high as 67% (2), and the pain might affect the patient’s ability to perform sporting and other activities. In the present report, an endoscopic technique of Achilles tenolysis is described. The method is applicable for denervation and debulking of the Achilles tendon should nonoperative treatment methods fail to adequately alleviate the patient’s pain. Surgical Technique With the patient in the prone position on the operating table and a tourniquet applied to the ipsilateral thigh, posteromedial and posterolateral portals are made along the margins of the Achilles tendon near its insertion into the calcaneus. The cleavage plane between the tendon and the deep scar tissue (Fig. 1) is then bluntly
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail address: [email protected]
Fig. 1. Magnetic resonance images showing thickened tendon after repair of acute Achilles tendon rupture (arrow designates cleavage plane between tendon and ventral scar tissue).
1067-2516/$ - see front matter Ó 2013 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2012.09.007
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T.H. Lui / The Journal of Foot & Ankle Surgery 52 (2013) 125–127
Fig. 2. (A) Endoscopic debridement of Achilles tendon through dorsomedial and dorsolateral portals. (B) Arthroscopic shaver was inserted into plane between Achilles tendon (a) and ventral scar tissue (b). (C) Plantaris tendon (c) at medial side of Achilles tendon.
Fig. 3. (A) Scar tissue (b) at edge of tendon (a) pushed toward shaver (c) and freed from tendon edge (B and C). (D) Debridement extended to flexor hallucis longus muscle (d) to ensure complete resection of deep scar tissue.
dissected using a hemostat, a 30 , 4.0-mm arthroscope and an arthroscopic shaver are inserted into this plane, and the deep scar tissue is dissected and resected from the ventral (deep, anterior) surface of the tendon. The plantaris tendon is then identified along the medial aspect of the tendon and resected to eliminate additional fibrosis and restriction of ankle motion (Fig. 2). The scar tissue at the edge of the tendon can be pushed into the shaver and freed from the surfaces of the Achilles tendon. Debridement should extend to the flexor hallucis longus muscle and tendon to ensure complete resection of the deep scar tissue (Fig. 3), and care should be taken to avoid injury to the adjacent neurovascular structures at the level of the ankle. The tenolysis can be extended to the dorsal side of the Achilles tendon to complete the release of scar tissue.
Discussion The etiology of tendon pain after repair of an acute Achilles tendon rupture is not fully understood. Nonabsorbable suture granuloma formation, alteration of the threshold at which pain receptors in the tendon are stimulated by new scar tissue, and distension of the paratenon owing to tendon enlargement with secondary stimulation of the abundant mechanical receptors of the paratenon have been proposed as causes of postrepair Achilles tendon pain (2). Postrepair neovascularization and fibrous degeneration secondary to collagenation could also contribute to tendinopathy (3–7), because neovascularization is known to be associated with concomitant ingrowth of nerve endings, which is thought to lead to postoperative Achilles tendon pain. The treatment options for this type of Achilles tendinopathy include conservative and percutaneous measures, such as eccentric exercises, extracorporeal shockwave therapy, and intratendinous injections of corticosteroids, aprotinin, polidocanol, platelet-rich plasma, autologous blood, and high-volume saline, as well as open
surgical tenolysis and debridement. Open surgery aims to excise the fibrotic adhesions and remove areas of failed healing, using multiple longitudinal incisions in the tendon to detect and remove intratendinous adhesion and to restore vascularity and possibly stimulate latent viable cells to initiate cell matrix response and healing (8). Endoscopic denervation and debulking, as described in the present report, focuses on disruption of abnormal neoinnervation, thereby interrupting pain impulse transmission from the repaired tendon. Similar to other minimally invasive surgical methods, the endoscopic technique of Achilles tendon denervation and debulking is thought to be associated with less exposure of deep structures, fewer wound complications, less scar formation, and better cosmesis. A thickened plantaris tendon located in close proximity to the medial margin of the repaired Achilles tendon commonly exists in patients with chronic, painful, midsubstance tendinosis and can contribute to pain and a sense of stiffness in the leg (9). These symptoms might warrant sectioning and partial excision by endoscopic methods (10). The endoscopic method of Achilles tenolysis has also been shown to effectively debulk the tendon and relieve adhesion (11–14). Also, some patients with tendon pain after repair of a ruptured Achilles tendon complain of a sense of tightness deep in the leg and discomfort with walking or exercise, without an objective limitation of ankle dorsiflexion. It is this group of patients that might be best suited to endoscopic Achilles tenolysis. The release of scar tissue around the tendon has been, in our experience, associated with relief of the sense of deep leg tightness. References 1. Strauss EJ, Ishak C, Jazrawi L, Sherman O, Rosen J. Operative treatment of acute Achilles tendon ruptures: an institutional review of clinical outcomes. Injury 38:832–838, 2007. 2. Rebeccato A, Santini S, Salmaso G, Nogarin L. Repair of the Achilles tendon rupture: a functional comparison of three surgical techniques. J Foot Ankle Surg 40:188–194, 2001.
T.H. Lui / The Journal of Foot & Ankle Surgery 52 (2013) 125–127
3. Osadnik R, Joern Redeker J, Kraemer R, Vogt PM, Knobloch K. Microcirculatory effects of topical glyceryl trinitrate on the Achilles tendon microcirculation in patients with previous Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc 18:977–981, 2010. 4. Ohberg L, Lorentzon R, Alfredson H. Neovascularization in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 9:233–238, 2001. 5. Andersson G, Danielson P, Alfredson H, Forsgren S. Nerve-related characteristics of ventral paratendinous tissue in chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc 15:1272–1279, 2007. 6. Bjur D, Alfredson H, Forsgren S. The innervation pattern of the human Achilles tendon: studies of the normal and tendinosis tendon with markers for general and sensory innervations. Cell Tissue Res 320:201–206, 2005. 7. Schubert TE, Weidler C, Lerch K, Hofstadter F, Straub RH. Achilles tendinosis is associated with sprouting of substance P positive nerve fibers. Ann Rheum Dis 64:1083–1086, 2005.
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8. Maffulli N, Longo UG, Loppini M, Spiezia F, Denaro V. New options in the management of tendinopathy. Open Access J Sports Med 1:29–37, 2010. 9. Alfredson H. Midportion Achilles tendinosis and the plantaris tendon. Br J Sports Med 45:1023–1025, 2011. 10. van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc 19:1367–1375, 2011. 11. Maquirriain J, Ayerza M, Costa-Paz M, Muscolo DL. Endoscopic surgery in chronic Achilles tendinopathies: a preliminary report. Arthroscopy 18:298–303, 2002. 12. Phisitkul P. Endoscopic surgery of the Achilles tendon. Curr Rev Musculoskelet Med 5:156–163, 2012. 13. Steenstra F, van Dijk CN. Achilles tendoscopy. Foot Ankle Clin 11:429–438, 2006. viii. 14. Thermann H, Benetos IS, Panelli C, Gavriilidis I, Feil S. Endoscopic treatment of chronic mid-portion Achilles tendinopathy: novel technique with short-term results. Knee Surg Sports Traumatol Arthrosc 17:1264–1269, 2009.