#treatment - Foot & Ankle

Surgery for Insertional Achilles Tendinopathy

A whole host of problems can give rise to pain at the insertion of your achilles tendon. This maybe due to a prominence of the back of the heel bone (Haglund deformity) or due to degeneration and bone formation in the tendon attachment itself.  The bursa or fluid sac behind the heel bone can also become inflamed and cause pain.

What does surgery involve?

Surgery for insertional achilles tendinopathy is a last resort procedure when all other treatment modalities have failed.

This is normally performed as a day surgical procedure although on occasions you may need to stay overnight. The procedure is performed under general anaesthetic and with a tourniquet around your thigh to stop blood obscuring vision at the surgery site.

The surgical incision is normally in the midline at the back of your heel and the achilles tendon. Occasionally if only the Haglund process is being removed this can be done through an incision on the side or through keyhole (minimally invasive) techniques.

The aim of the operation is to partially detach the tendon and remove any diseased tendon or calcific deposits that are often found in this condition. The fluid sac in front of the bone (retrocalcaneal bursa) is also removed. Once a thorough “clean up” of the area is performed the bony bump on the back of the heel bone is removed with a saw. Finally the tendon is reattached back to the bone using a very strong synthetic material and small bone screws.  This is known as the Achilles SpeedBridge technique.

 

achilles_tendon_fixation_0-largeClick here to watch an animation of the surgery.

 

 

 

 

 

 

The tendon and the skin incision are then repaired with absorbable sutures to the skin and your foot is placed in a below knee plaster backslab.

What happens after the surgery?

After surgery you will be returned to the ward. You would have had a local anaesthetic block during your operation to help with pain control and may feel some numbness around the foot and the heel.

Occasionally your thigh may feel a little sore or red from the tourniquet. This is normal and will resolve in 24-48 hours.

What is the post operative rehab?

Week 0-2

During this time you will be in a plaster backslab (a half plaster that is put on in the operating theatre) the foot may be positioned with the toes pointing down if we feel extra protection of the repair is needed.

You will need to remain Non-Weight Bearing  with the aid of crutched and try and elevate your foot above your heart level for as much of possible. We recommend doing this for 40 min in every hour although it is important for you to spend the remaining 20 mins moving around to help with blood circulation.

We would have also prescribed heparin injections which you would need to continue taking everyday.

Weeks 2-8

Your first post op appointment with Mr Abbasian or Mr Amin will be at around 2 weeks. The backslab plaster is removed. At this point you may be given a walking boot.

Occasionally if there is concern about the tendon healing and repair strength you may be kept in a full plaster for longer.

The walker boot will remain in situ for the rest of this period.

Weeks 8-12

You will start graduating into your normal shoes although it is a good idea to use a pair of comfortable trainers at this stage. There would be swelling and discomfort which is normal. Sports or any high impact activity should be avoided.

Months 3-6

This is when a gradual return to day to day activity and then followed by low impact sports is started. You will be guided by your physiotherapist but we do not recommend sports that involve jumping or explosive push off to be done before the 6-month mark.

Months 6-12

Gradually improve to be able to do most sports and activities. Return to high level, high impact sports such as endurance running may not be possible after major surgery such as this for over one year although most of our patients are able to participate in sports on a social and non-competitive basis.

 

What are the risks of the procedure?

As with any surgical procedure there are a number of complications that you would need to be aware of.

  1. Wound breakdown or Infection  The blood supply to the skin around the incision can be compromised at the time of the surgery and very occasionally the skin incision may not heal well or breakdown. Sometimes this can be complication with a superimposed infection. The risks are higher if you are a smoker or a diabetic. Frequently we can manage this with a course of antibiotic and dressing changes but occasionally revision surgery to clear the infection and achieve skin cover may become necessary.
  2. Achilles tendon rupture It is possible for the reattached tendon to rupture and ‘come off’ the bone if the repair fails. With modern techniques this is less likely to happen.
  3. Nerve Injury Small nerves around the incision are commonly bruised and you may feel that the immediate area around the incision has unusual sensation. Larger nerves may rarely be injured. The Sural nerve is close to the surgery site and provides sensation to the outer aspect of the foot. A risk to this nerve exists and this can very rarely occur.
  4. Thrombosis A clot in the calf veins, ‘deep vein thrombosis or DVT’ may occur after this procedure as you are non-weight bearing and in a plaster. Occasionally the clot can break off and travel to the lungs (Pulmonary embolism). The risk of thrombosis varies from person to person. We assess your individual thrombosis risk pre-surgery and will usually provide you with blood thinning injections after this operation until your mobility returns to normal. You may still suffer from thrombosis even on blood thinning injections but the risk is reduced significantly.

How successful is the operation?

The published success rates reported are in the region of 70%. However because of concerns regarding the strength of repair of the Achilles insertion it was not possible to fully and safely detach the tendon to remove the diseased area. With newer techniques a more thorough removal of diseased tissue is possible and we have noticed a significant improvement in outcome in terms of pain relief.

It must be noted that this is a surgery that we consider only in patients who have failed all other treatment and are in significant pain. Surgery aims to improve the symptoms and although the symptoms are generally much improved some patients may have residual pain and swelling although a significant number will be pain free.

pre op haglund

Pre-op Haglund deformity and bone spur at the insertion of the Achilles tendon

post op haglund

Post op – removal of pain generating deformity confirmed.