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Insertional Achilles tendinosis benefits from early weight-bearing and surgery
Only two patients developed minor wound complications during the 2-year follow-up.
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Early weight bearing following Achilles detachment and repair may provide good subjective function and few wound complications for patients with calcific insertional Achilles tendinosis.
In a prospective study of 26 patients with calcific insertional Achilles tendinosis who failed conservative treatment, James R. McWilliam, MD, found that patients' AOFAS scores increased 18 points after receiving an Achilles detachment and repair with an immediate weight-bearing regimen. During an average 2-year follow-up, he also discovered that 92% of the patients reported good or excellent results with the procedure. The same percentage of the cohort also said that they reached to their desired activity level.
The study also revealed two minor wound complications, which surgeons resolved with topical antibiotics and dressing changes. "I think with appropriate strength of repair, individuals can begin immediate weight bearing and rehabilitation," McWilliam, an orthopedist with New York Medical College, told Orthopedics Today. He presented his findings at the American Orthopaedic Foot and Ankle Society 22nd Annual Summer Meeting.
Active and passive PT
The research included 17 women and 11 men with an average age of 66 years. Physicians diagnosed patients by physical exam and confirmed calcification with lateral X-rays.
The patients initially received a minimum 3 months of conservative treatment. The active and passive physical therapy included gait training, stretching, strengthening and proprioception exercises. Prior to physical therapy, 20% of the patients were symptomatic and wore removable casts for 2 weeks. All patients wore either a 0.25 or 0.5-inch heel lift and many wore open-heeled shoes.
Surgical treatment, rehab
When the conservative treatment failed, surgeons performed a full Achilles detachment and debridement and calcaneal osteotomy. They also repaired the Achilles using the suture bridge technique. Surgeons immediately cast patients in a neutral position. "With the tendon fixed in such a way as to allow neutral casting, there's much less postoperative tension," McWilliam said. "It also allows patients to be weight bearing early." The surgeons allowed patients limited weight bearing to perform activities of daily living.
At 2 weeks postop, they removed the sutures and replaced the casts with removable versions. The patients also used bands for resistance and began passive strengthening exercises. Depending on comfort, patients discarded their casts at 6 to 8 weeks postop. In the next 2 weeks, they began a physical therapy regimen that included proprioception, range of motion and strengthening exercises.
During follow-up, McWilliam found that patients' average AOFAS scores improved from 69 points preoperatively to 87 points postoperatively (P<.05). In addition, all but one patient in the group reported that they would undergo the operation again, and only 8% of the cohort judged their surgical outcome as fair.
McWilliam attributes the good results to putting stress on the tendons. "If you place tension on the tendon, or if you expose them to tension, then they'll heal in a more organized fashion," he said. " ... They have less postoperative atrophy because they've been able to bear weight almost immediately, so they have a faster and more complete recovery."
For more information:
- McWilliam JR. Immediate weight bearing after complete Achilles detachment and repair for calcific insertional Achilles tendinosis. Presented at the American Orthopaedic Foot and Ankle Society 22nd Annual Summer Meeting. July 14-16. La Jolla, Calif.