The gold standard intervention for insertional Achilles tendinopathy with or without Haglund's deformity has been the open midline Achilles tendon splitting approach for many years. While this is a successful and highly vetted technique, this open hindfoot procedure has been associated with several complications and an extensive post-operative recovery. In comparison, the percutaneous Zadek osteotomy (ZO) has demonstrated safe and effective healing in patients with insertional Achilles tendinopathy with or without Haglund's deformity, with very minimal complications. Additionally, patients who undergo ZO experience a relatively early return to function and activity.
This comprehensive article explores the role of animal models in understanding Achilles tendinopathy, detailing methodologies for inducing tendon injury, histologic progression per the continuum model, and applications in translational research. It highlights rodent and large animal models, mechanical and chemical injury methods, and advances in imaging and diagnostics. Emphasis is placed on the development of targeted therapies including interleukin-1β and interleukin-17A antagonists. The article concludes by advocating for refined models, improved imaging, and more stratified clinical trials to enhance translation of preclinical findings into patient-specific treatments.
Noninsertional Achilles tendinopathy is a degenerative condition caused by chronic mechanical overload, commonly affecting athletes and active individuals. While nonoperative treatment is preferred, approximately one-third of cases require surgery. Various surgical options exist, including debridement, tendon scraping, paratenon release, and flexor hallucis longus transfer, with open and minimally invasive techniques yielding comparable outcomes. The condition's pathophysiology remains unclear, complicating treatment standardization. Given the lack of high-quality comparative studies, surgical approaches should be individualized based on patient factors and surgeon expertise. Future research correlating histopathological findings with clinical outcomes may help refine management strategies.
Achilles tendon repair is traditionally performed in the prone position using a direct posterior approach. Wound complications and nerve injury are possible complications that can occur. Prone positioning is associated with various complications and may prolong operative time. A posteromedial incision in the supine position may mitigate wound and neurologic complications as well as complications inherent to prone positioning. An added benefit is reducing the time required to position prone. This article shares the senior author's preferred technique of supine Achilles tendon repair, outlines indications and contraindications, and offers an in-depth discussion in comparison with traditional prone repair.
Circular external fixators are powerful tools for correcting foot and ankle deformities. We summarize the most frequent indications for its use in an orderly fashion, as well as the basic configurations in the treatment of these conditions, including hexapod fixators. Following Ilizarov's principles and the latest experts' recommendations, most foot and ankle deformities can be properly managed, providing safe and accurate correction.
This article examines the evolution of Achilles tendon repair, focusing on minimally invasive and percutaneous techniques that reduce complications and improve recovery. These approaches emphasize preserving anatomic structures like the paratenon and sural nerve while optimizing biomechanical repair strength. Modern suture configurations enhance stability, enabling early mobilization and better functional outcomes. Clinical evidence shows minimally invasive methods offer comparable or superior results to open surgery, with fewer wound complications and faster return to activity, though sural nerve injury remains a potential risk. These advancements reflect a balance between reduced surgical morbidity and improved patient outcomes.
Endoscopic flexor hallucis longus (FHL) tendon transfer is a minimally invasive surgical technique that shows promise for treating chronic Achilles tendon ruptures and tendinopathies. The procedure involves transferring the FHL tendon to the plantar foot for the calcaneus. Studies have demonstrated positive outcomes with improved American Orthopedic Foot and Ankle Society scores and patient-reported results along with low complication rates. However, for optimal results in highly active individuals, simultaneous reconstruction of the gastrocnemius-soleus complex may be necessary, particularly if significant elongation is present. This study provides a detailed surgical technique for this procedure.
Operative repair of the Achilles tendon is associated with complications such as wound issues, infection, and rerupture, presenting significant challenges for orthopedic surgeons. With a range of salvage techniques available-but no clear consensus or algorithm on the optimal approach-treatment must be tailored to each patient and case. This article explores various salvage options, including tendon transfers, V-Y advancements, gastrocnemius turn-down procedures, and allograft techniques, illustrated through case examples to provide practical insights.
This article explores the integration of blood flow restriction (BFR) exercise into the rehabilitation continuum following Achilles tendon repair. In this article, we propose specific time points for BFR use, dosage, and target tissues, highlighting its safety profile and demonstrating how it might enhance recovery via the maintenance of preinjury/preoperative muscle quality and quantity.
Acute Achilles tendon ruptures are common injuries, which had traditionally been managed surgically due to reported high rerupture rates in historic articles. However, recent evidence supports nonoperative treatment with accelerated functional rehabilitation, demonstrating equivalent rerupture rates and functional outcomes while avoiding surgical risks. This review provides a comprehensive, guide to nonoperative management of acute Achilles tendon rupture, addressing patient selection, imaging considerations, immobilization strategies, and rehabilitation protocols. Challenges in standardization, patient compliance, and health care resource availability are also discussed.
Chronic Achilles tendon rupture is a difficult condition to treat due to tendon retraction and histologic changes. Traditional treatments include primary repair (for defects <2 cm), VY advancement (using gastrocnemius aponeurosis for larger gaps), Achilles tendon turndown (using gastrocnemius fascia, often with flexor hallucis longus transfer), allografts, and tendon transfers (using peroneus brevis or flexor hallucis longus tendons). New synthetic graft options, such as acellular collagen matrices and Artelon, may improve chronic Achilles tendon rupture healing without the morbidity associated with traditional techniques.
Insertional Achilles tendinopathy is a common overuse injury of the lower extremity classically treated with open debridement and tendon repair. However, wound complications and prolonged non-weightbearing are limiting factors for this treatment. Recently, a minimally invasive endoscopic debridement with double-row suture repair has emerged as an alternative, soft-tissue friendly option for operative management. The purpose of this study is to examine the benefits of and provide a technique for this procedure using the Arthrex MIS Achilles Speedbridge System (Naples, FL).
