Podcast Summary: The Best of the AOFAS Masterclass Series: Insertional Achilles Tendonitis

Podcast Information:

• Title: The AOFAS Orthopod-Cast
• Host/Author: AOFAS Podcast Committee
• Episode: The Best of the AOFAS Masterclass Series: Insertional Achilles Tendonitis
• Release Date: January 29, 2025

Introduction

In this comprehensive episode of The AOFAS Orthopod-Cast, the AOFAS Podcast Committee delves deep into the intricacies of managing insertional Achilles tendonitis. Hosted by Dr. Anish Kadakia, the discussion features insights from Dr. Jason O'Dell of McLeod Orthopaedics and Dr. Lauren Gainey, Program and Fellowship Director at UConn. The episode offers a blend of clinical experiences, surgical techniques, and postoperative management strategies, making it an invaluable resource for orthopedic specialists and practitioners dealing with foot and ankle pathologies.

Initial Nonoperative Management

The conversation begins with the foundational approach to treating patients presenting with insertional Achilles tendonitis. For instance, Dr. Kadakia poses a scenario involving a 40-year-old female runner experiencing six weeks of heel pain.

Dr. Lauren Gainey [02:07]:
"My first conversation with them typically involves sending them to physical therapy. I encourage physical therapy as a first step, emphasizing that while there might be an increased risk of rupture, it's still extremely unlikely."

Dr. Jason O'Dell concurs, highlighting the rarity of tendon ruptures in actively treated patients without prior steroid injections.

Dr. Jason O'Dell [02:44]:
"I think it's quite rare to see somebody who you're actively treating for that then proceed to rupture in the absence of having had a steroid injection."

Success Rates and Patient Counseling

The panel discusses the efficacy of physical therapy (PT) in treating insertional versus non-insertional Achilles tendonitis. Non-insertional cases often respond well to eccentric strengthening exercises, with success rates around 70-80%. However, insertional cases present a different challenge.

Dr. Lauren Gainey [04:14]:
"I typically tell them 50 to 60% improve with physical therapy. Recurrence of pain is common because the underlying bone spur and tendon abnormalities remain."

This candid discussion underscores the importance of setting realistic expectations with patients, acknowledging that while PT can alleviate symptoms, underlying structural issues may persist.

Transition to Operative Treatment

When nonoperative measures fail, the conversation shifts to surgical options. The panel explores indications for surgery, emphasizing the importance of thorough patient evaluation and imaging.

Dr. Anish Kadakia [05:40]:
"After six weeks of failed PT, what's the next step? Options include PRP, steroid injections, and ultimately surgery if conservative measures don't yield desired results."

Surgical Techniques: Open vs. Minimally Invasive Surgery (MIS)

A significant portion of the discussion centers around the debate between open surgery and minimally invasive techniques for treating insertional Achilles tendonitis.

Dr. Jason O'Dell [09:26]:
"For patients who don't respond to PT, I often recommend open surgical reconstruction. This involves a midline open approach with bone resection and tendon repair using four anchors."

Contrastingly, the concept of MIS is introduced, though Dr. Kadakia admits limited personal experience with it.

Dr. Anish Kadakia [21:51]:
"Minimally invasive techniques are being explored, but they present technical challenges and haven't gained widespread adoption compared to open methods."

Specific Surgical Approaches and Protocols

Dr. O'Dell elaborates on his surgical protocol, detailing the use of anchors, suture techniques, and the incorporation of amniotic allografts to enhance healing.

Dr. Jason O'Dell [10:20]:
"I use convergent anchors and a woven suture technique to ensure a robust repair. Additionally, I incorporate tissue paper-thin amniotic allografts to support tendon healing, allowing for earlier suture removal at two weeks."

The discussion also touches on adjunctive procedures like gastrocnemius recession, with differing opinions on its necessity.

Dr. Lauren Gainey [15:04]:
"I perform gastrocnemius recession only in cases with significant tendon calcium deposits and tightness, ensuring it contributes to relieving insertional tension."

Postoperative Rehabilitation

Effective rehabilitation is crucial for optimal recovery. The panel outlines varying postoperative protocols, emphasizing the balance between immobilization and early mobilization.

Dr. Lauren Gainey [27:38]:
"Post-surgery, patients are non-weight bearing in a plantar flexion splint for two weeks, followed by a boot with heel lifts. Weight-bearing is gradually introduced around eight weeks, transitioning to regular footwear by ten weeks."

Dr. Jason O'Dell [27:58]:
"My protocol involves two weeks of non-weight bearing in a cast post-splint removal, progressing to a boot with wedge supports and eventual transition to gym shoes by nine weeks."

Complications and Management

Wound healing complications are a significant concern, especially with open surgical approaches. The panel shares strategies for managing such complications, balancing nonoperative and surgical interventions.

Dr. Anish Kadakia [29:36]:
"I opt for black boots with foam backing for Achilles interventions to reduce pressure on surgical wounds, minimizing healing issues."

Dr. Jason O'Dell [31:52]:
"In cases of wound complications, I employ topical wound vacs and antibiotics, managing minor openings nonoperatively unless signs of chronic infection emerge."

Coding Considerations

Accurate surgical coding ensures proper reimbursement and documentation. The panel discusses best practices for coding insertional Achilles tendonitis surgeries, emphasizing the importance of distinct codes for concurrent procedures.

Dr. Lauren Gainey [39:40]:
"I code for secondary Achilles reconstruction and use CPT code 28118 for partial calcaneus excision associated with insertional spurs."

Dr. Anish Kadakia [40:38]:
"Proper coding involves detailing each procedure with unrelated diagnoses to avoid bundling, ensuring all aspects of the surgery are reimbursed appropriately."

The Role of Flexor Hallucis Longus (FHL)

Flexor Hallucis Longus tendon transfer is a technique employed in certain cases to enhance tendon repair integrity.

Dr. Lauren Gainey [35:07]:
"I perform FHL transfers in approximately 10-15% of cases, particularly in patients with extensive tendon degeneration visible on MRI."

Dr. Jason O'Dell [37:08]:
"I utilize FHL transfers in over 50% of cases involving Achilles avulsions and selective cases where significant tendon removal occurs."

Use of Platelet-Rich Plasma (PRP)

PRP therapy emerges as a topic of debate, with differing opinions on its efficacy and role in managing Achilles tendonitis.

Dr. Jason O'Dell [42:34]:
"PRP might offer long-term benefits, showing superior outcomes at one year compared to corticosteroids, though immediate effects are similar."

Dr. Lauren Gainey [44:57]:
"The placebo effect plays a role, especially when patients invest financially, enhancing their perception of improvement."

Conclusion and Takeaways

The panel converges on several key points:

1. Initial Nonoperative Management: Physical therapy remains the first-line treatment for insertional Achilles tendonitis, with a 50-60% success rate.

2. Surgical Intervention: When conservative measures fail, open surgical reconstruction is commonly preferred, with meticulous attention to surgical technique to minimize complications.

3. Rehabilitation Protocols: A structured postoperative regimen is essential, tailored to individual patient needs and surgical specifics.

4. Complication Management: Proactive strategies and patient counseling are vital in handling wound complications, emphasizing timely intervention to prevent chronic issues.

5. Coding Accuracy: Proper surgical coding is crucial for administrative efficiency and financial reimbursement, requiring detailed documentation of all procedures.

6. Adjunctive Therapies: Techniques like FHL transfers and PRP therapy are valuable tools, though their application depends on specific patient presentations and surgeon expertise.

Notable Quotes:

• Dr. Lauren Gainey [02:07]:
  "I encourage physical therapy as a first step, emphasizing that while there might be an increased risk of rupture, it's still extremely unlikely."

• Dr. Jason O'Dell [10:20]:
  "I use convergent anchors and a woven suture technique to ensure a robust repair."

• Dr. Anish Kadakia [21:51]:
  "Minimally invasive techniques are being explored, but they present technical challenges and haven't gained widespread adoption compared to open methods."

This episode serves as a vital resource for orthopedic practitioners, offering nuanced perspectives on the management of insertional Achilles tendonitis. From initial conservative treatments to advanced surgical interventions and postoperative care, the insights provided by Drs. O'Dell and Gainey equip clinicians with the knowledge to enhance patient outcomes effectively.