The AOFAS Orthopod-Cast
Episode: How I Treat This: Insertional Achilles Tendinosis
Release Date: October 30, 2024
Host: Nick Strasser (AOFAS Podcast Committee)
Guests: Dr. Oliver Schipper & Dr. Ben Jackson

Episode Overview

This episode continues the Orthopod-Cast’s “How I Treat This” series, with an in-depth, candid discussion between Drs. Nick Strasser, Oliver Schipper, and Ben Jackson on contemporary approaches to treating insertional Achilles tendinosis. Each surgeon brings a unique practice background and evolving viewpoint, resulting in a practical exploration of terminology, diagnosis nuances, operative choices (open vs. minimally invasive), the Zadek osteotomy, pearls and complications, technical evolution, and the future of surgical treatment for this challenging problem.

Key Discussion Points and Insights

1. Definitions & Diagnostic Nuances

[01:25–04:26]

• Dr. Oliver Schipper:

  • Differentiates between non-insertional (mid-substance) and insertional Achilles pathology.
  • Describes insertional Achilles tendinosis as “tenderness across that broad Achilles insertional sleeve, often associated with edema” ([01:51]).
  • Recognizes overlapping presentations, including Haglund’s deformity, retrocalcaneal bursitis, bony edema, and calcific metaplasia at the insertion.
  • “It’s really that tenderness across the Achilles insertional sleeve. That’s what I’m really referring to as Achilles insertional tendinosis.” ([02:44])

• Dr. Ben Jackson:

  • Prefers the term "insertional Achilles enthesopathy" when there is calcified enthesis.
  • Pragmatic approach: for patients, uses terms like “insertional Achilles tendonitis,” “retrocachaneal bursitis,” acknowledging that these are often the “same thing” in practice ([03:44]).

2. Patient Profile & Non-operative vs. Operative Decision Point

[04:26–05:12]

• These conditions are common in middle-aged to older adults (40s–60s), often women.
• Discussion centers around patients who have failed non-operative management and are now candidates for surgery.

3. Operative Management: Evolving Approaches

A. Dr. Schipper’s Evolution: From Open to Minimally Invasive Zadek Osteotomy

[05:12–13:44]

• Started with open Achilles insertional reconstructions, sometimes with gastrocnemius recession; FHL transfer reserved for revisions.

• Challenges with open procedures:

  1. Wound complications: “That area at the Achilles insertion is a very slow healing area.” ([05:39])
  2. Technical difficulties: Uncertainty about “how much” bone and tendon to remove.
  3. Unpredictable outcomes: “Sometimes, people [have] residual pain at the insertion.” ([06:06])
  4. Slow recovery: “Often can be 6 to 12 months to recover, especially if you include a gastroc recession.” ([06:13])

• Transitioned to the minimally invasive Zadek osteotomy after exploring MIS techniques with colleagues.

• Zadek Osteotomy Defined: “A dorsal closing wedge calcaneal osteotomy...removes the posterior superior corner (Haglund’s area) and detensions the Achilles—about 8 degrees of dorsiflexion gained without a gastroc recession.” ([07:14])

• Key findings:

  • “These patients, oftentimes, their pain was gone at like their two-week appointment, their six-week appointment… just kind of wild.” ([08:18])
  • Recovery has “cut in half: three to five months” compared to open procedure.
  • Perceived as a “first line option” for most patients now; open reserved mostly for revision or extensive disease.

• Literature: A newly accepted two-year study showing “98% satisfaction, 4% complication rate, significant improvement” ([10:44]).

• Technical critique: The challenge is “how do you generalize this to everyone?” to reduce variable outcomes across surgeons ([12:58]).

B. Dr. Jackson’s Experience: Mixed Outcomes with Zadek, Leaning Toward Open

[13:44–19:55]

• Initial experience with traditional open split Achilles approach (taking off a large portion of calcaneus, suture anchors).
  • Wound complications are “real”; longer, less predictable recovery (6-12 months).
• Tried Zadek osteotomies: Mixed results—complications such as technical errors, thermal necrosis, plantar heel pain, hardware issues.
  • “I would say I’ve had very mixed results. I think some of it’s probably technical. So to me, I wish there was a little bit more … definition about exactly where you do your V cut.” ([14:48])
  • “I feel like my ZCs just don’t get to that hundred percent range that an open does.” ([16:48])
• Professional honesty: Trending back toward open in part due to complications and less-satisfying results with MIS, acknowledges a learning curve, hopes technique will improve with research and systematic refinements.
• Plans a comparative study of push-off strength post-op (Zadek vs. open).

4. Technical Pearls for Minimal Invasive Zadek Osteotomy

[19:55–30:29]

• Schipper offers detailed technical pearls:
  • Use a 6,000 rpm burr with copious chilled saline to avoid thermal damage ([19:55]).
  • Emphasizes adequate wedge size and correct screw placement; “goal is to have it be, you know, around three and a half bur widths… that’s how I know I’m getting enough.” ([25:17])
  • Satisfactory outcomes driven by taking a sufficiently large wedge (“biggest mistake is not taking enough wedge”) and placing two screws for stability.
  • Tips on patient positioning and tools (beanbag lateral, mini C-arm, 10-cm burr) ([28:35]).

Memorable Clinical Story:

• “I had a severe rheumatoid arthritis patient … she did great. ... Type 2 diabetic, some of the biggest plantar calcaneal enthesophytes you’ve ever seen … they did great. ... I could never go back to doing open as my primary option.” ([29:18])

5. Comparisons with Other Procedures

• Gastrocnemius Recession:
  • Zadek provides mechanical “de-tensioning” and increased dorsiflexion (approx. 8°)—but Dr. Schipper notes isolated gastroc recession hasn’t been a home run, especially for insertional disease ([31:17]).
  • “The Zadek must work… because of that mechanical irritation of that posterior superior corner on the tendon.” ([20:28])
• FHL Transfer:
  • Now reserved for revisions, not as a first-line adjunct in primary cases by all three surgeons ([37:02–37:45]).
  • Recent literature does not show additional primary benefit; used for large re-tears or failed primary repairs.

6. MIS Bunion Analogy and Technique Maturation

[43:16–44:47]

• The group compares the evolving learning curve and technique development for MIS calcaneal surgery to the “generational” improvements seen in MIS bunion surgery.
• Dr. Jackson: “For MIS bunions, we're on the fourth generation—because we got better after one, two, and three… I think we’re somewhere in between generation two and three [for Zadek’s].”

7. Post-op Protocols

[39:01–42:46]

• Dr. Jackson (Open)

  • 2 weeks non-weight-bearing in plantarflexion splint, then progressive weight-bearing with heel lifts, typically back in laced shoe around 10 weeks.

• Dr. Schipper (Zadek)

  • 6 weeks in a boot; weight-bearing resumes at 2 weeks; PT starts at 6 weeks; uses no heel lifts as dorsiflexion is protective ([40:10]).
  • “Dorsiflexion is protective for the Zadek… so it’s a little counterintuitive…” ([40:31])
  • Stresses importance of patient compliance and the advantage of two screws for early stability.

Notable Quotes

• “It's really that tenderness across the Achilles insertional sleeve. That's what I'm really referring to as Achilles insertional tendinosis.”
  — Dr. Oliver Schipper ([02:44])

• “I have had wound healing complications [with open], those stink a lot. I think those patients tend to hurt for longer.”
  — Dr. Ben Jackson ([14:16])

• “When you do an open Achilles insertional reconstruction…sometimes, people [have] residual pain at the insertion… those were some of the challenges.”
  — Dr. Oliver Schipper ([06:06])

• “These patients, oftentimes, their pain was gone at like their two-week appointment, their six-week appointment… just kind of wild.”
  — Dr. Oliver Schipper ([08:18])

• “I feel like my ZCs just don’t get to that hundred percent range that an open does.”
  — Dr. Ben Jackson ([16:48])

• “The biggest mistakes surgeons make is they don’t take enough wedge. … My wedge hasn't changed. If anything, it's, it's been maybe slightly bigger than when I first did it.”
  — Dr. Oliver Schipper ([28:57])

• “I could never go back to doing open as my primary option. I just really think it's changed my practice for the better.”
  — Dr. Oliver Schipper ([29:18])

• “I think that we’re definitely progressing in a way that people are going to be doing less and less open. … I think, like a lot of techniques, the more people are doing it and giving good, honest reporting of their results, the better we're going to get at it.”
  — Dr. Ben Jackson ([42:57])

Timestamps for Important Segments

• [01:51] — Dr. Schipper defines insertional Achilles tendinosis.
• [05:12] — Start of operative approach discussion; Dr. Schipper’s practice evolution.
• [07:14] — Zadek osteotomy defined and explained.
• [13:44] — Dr. Jackson discusses his mixed experience and technical challenges with Zadek.
• [19:55] — Dr. Schipper shares MIS technical pearls.
• [25:17] — “Three and a half bur widths” rule for Zadek wedge size.
• [29:18] — Dr. Schipper: “I could never go back to doing open as my primary option.”
• [31:17] — Comparison of Zadek to gastrocnemius recession.
• [37:02] — FHL transfer reserved for revision; literature insights.
• [39:01] — Post-op rehab protocols compared.
• [42:57] — Technique evolution and future of open vs. MIS.

Takeaways and Conclusions

• Open vs. MIS: Both open and minimally invasive options (specifically the Zadek osteotomy) have a role, but technique, surgeon experience, and patient selection determine outcomes. MIS approaches offer promisingly quicker recoveries and lower complication rates “in the right hands.”
• Learning Curve: MIS (Zadek) outcomes are operator-dependent and the field is still “second or third generation,” with technique refinements ongoing.
• Future Direction: Expect further technical maturation, more publications, and continued evolution away from open toward minimally invasive strategies, mirroring the trajectory of MIS bunion surgery.
• Patient Communication: Surgeons must understand all available techniques, as patients often inquire about specific procedures.
• Collaboration & Honesty: The episode underscores the importance of honest reporting, shared experience, and collective progress in foot and ankle surgery.

Hosts and contributors:

• Dr. Nick Strasser (Host)
• Dr. Oliver Schipper (DC, Anderson Orthopedic Clinic)
• Dr. Ben Jackson (Columbia, SC, PRISMA & South Carolina University)

For further learning: Check the AOFAS video library, LinkedIn pages with technique videos, and the minimally invasive foot and ankle surgery textbook for more on the Zadek osteotomy and related techniques ([23:43]).