Surgical management of insertional tendinopathy of the Achilles tendon should allow debridement of calcific areas of the tendon and permit decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity [8]. This bony prominence on the superior aspect of the calcaneum, is associated with insertional Achilles tendinopathy [9]. Detachment and reconstruction of the Achilles tendon insertion including a V-Y lengthening of the proximal aponeurosis through a J shaped incision had 9% wound dehiscence, 4.6% infection rates, and 3% sural neuritis. Seventy four percent and 92% satisfaction rates were achieved in detached and non-detached tendon insertions respectively [10]. Complete excision of calcific deposits is recommended. This may require detaching the tendon from the calcaneum, and reattachment using suture anchors [3]. Complete detachment and reconstruction of the Achilles tendon does not decrease the working capacity of the gastrocsoleus muscle [11].
After the procedure, early mobilisation is safe in selected patients when less than 50% of the tendon has been resected [12], although using our technique we have had no patients who suffered detachment of the re-inserted Achilles tendon.
Previously described incisions include medial and J shaped incisions [13–15], lateral incision [7, 8, 16], and a combination of both medial and lateral incisions [1, 17]. Recently, a central tendon splitting approach has been described allowing access to the more commonly affected central portion of the tendon with the peripheral fibres being spared [18, 19]. Endoscopic procedures on the retrocalcaneal space have been described, but they cannot address the intratendinous pathology [20].
Iatrogenic sural nerve injury is a risk with all surgery to the hindfoot. The sural nerve lies 18.8 mm from the lateral border of the Achilles tendon at its insertion, then passes proximally towards the midline so that it passes the lateral border of the tendon 9.8 cm from the calcaneum [21, 22]. Iatrogenic nerve damage is relatively frequent, and surgical incisions may be made parallel to nerves to minimise the risk of this injury. The Cincinnati incision is used for soft tissue release around the hindfoot for paediatric club foot surgery [23]. Although this semi-circumferential incision is almost perpendicular to the course of the sural nerve, at this level the nerve has split into multiple small branches and we note that distal numbness has not been reported by our patients.
Transverse scars in the hind foot are difficult to identify once they have matured, and they are also not as prone to the problems of tethering and contracture which may occur with longitudinal scar tissue. Therefore, a transverse semi-circumferential scar may be cosmetically more pleasing, and, once healed, difficult to identify even at close inspection (Figure 9).
All our patients returned to their pre-injury activities, at an average of 9 months following surgery (range 6–15 months). Complications included one case of delayed wound healing with no growth from bacterial swabs and four cases of wound infection. Two of these cultured Staphylococcus Epidermidis and one cultured Enterococcus, all settling with oral antibiotics. A further case cultured Pasteurella. The patient confessed that her cat and dog had been licking her wound which required debridement and eventually the infection settled after 5 months. In no instance was a nerve injury reported.
