Double row reconstruction of achilles tendon (speedbridge technique) for haglund syndrome results in early weight bearing

Abstract

Background

Reconstruction of tendoachilles (TA) tendon using double row reconstruction (speedbridge technique) following excision of haglund deformity is relatively newer technique. The purpose was to assess the clinical outcome and effects of early postoperative mobilization with speedbridge technique.

Methods

This was a prospective observational study performed between January 2018 to February 2019. All the patients underwent open excision of haglund deformity after complete detachment of TA tendon. Reconstruction of TA tendon was done using fibretape and 4.75 mm biocomposite Swivelock [ArthrexAchilles SpeedBridge Convenience Pack (AR-8928 BC-CP)].Clinical evaluation was done using American Orthopedic Foot and Ankle Society (AOFAS) Hind Foot Score (HFS) and Visual Analogue Scale (VAS). Patients were followed at 6weeks, 6 months,12 months,18 months and 2 years.

Results

11 female and 2 male patients (16 feet) with mean age of 53.00 ± 4.93 years were analyzed. Full weight bearing mobilization was started on an average of 10 days postoperatively.The mean postoperative HFS, at 24 months of postoperative period, was 87.61 ± 4.69 compared to mean preoperative HFS of 53.07 ± 5.93.

Conclusion

Haglund deformity excision and reconstruction of Tendoachilles using double row technique is an agile construct for early mobilization with an excellent clinical outcome.

1. Introduction

Haglund deformity is a chronic debilitating condition charecterised by posterior heel pain and is usually associated with bony overgrowth along the achilles tendon insertion site.¹ Conservative treatment is the mainstay of management in the initial period with the use of physiotherapy, analgesics and stretching exercises. However, in recalcitrant conditions, surgery is the treatment of choice.Both open and arthroscopic surgery has been described. Arthroscopic surgery is not commonly performed owing to its learning curve and skills involved with the procedure. The results and complications associated with this technique are comparable and does not make it as superior compared to the open surgery.²On the other hand, Open surgeries with different technique including mini open, TA tendon sparing technique and lately, use of suture anchor for the reattachment of the tendon are well described in the literature.^3,4 The mini open and TA tendon sparing techniques have one major disadvantage-incomplete removal of bony growth leading to recurrent symptoms. Technique that employs complete removal of TA delays the mobilization of the patients up to 3 months.3, 4, 5, 6 The reason for the delayed mobilization is weak reconstruction of completely detached tendoachilles.³ Single row reconstruction of the detached TA was performed in most of the reported literature. However, with recent advancements of technology, a stronger construct of suture anchor (double row reconstruction) was commercially available that was used in rotator cuff tear in shoulder. This was successfully used to reconstruct the tendoachilles after complete detachment of the same for complete excision of haglund deformity.^5,6 But there was paucity of literature on effects of early mobilization on final functional outcome of such reconstruction. Most importantly, there is no consensus whether this technique precludes the need of prolonged immobilization of 3 months after surgery as described elsewhere after conventional techniques.

In the speedbridge technique, haglund deformity excision is done after central splitting and elevating the tendon. TA reconstruction was done in double row fashion using knotless suture anchors. The primary aim of the present study is to evaluate the possibility of early postoperative mobilization and secondarily, to determine clinical and functional outcome following speedbridge technique of reconstruction of achilles tendon following excision of haglund deformity.To the best of our knowledge, this is the first study to describe the early mobilization of patients when speedbridge technique is used to reconstruct TA tendon in haglund deformity.

2. Material and methods

This prospective observational study was done from January 2018 to February 2019, after obtaining permission from Institute Ethical Committee (IEC no −3/03.02.23). All the patients to our outpatient department with posterior heel pain were evaluated clinico-radiologically to diagnose retro calcaneal bursitis (RCB) and were managed conservatively. Surgical treatment was indicated with recalcitrant RCB (>6 months of conservative). Written informed consent was obtained from all the patients included in the study. As the prevalence of the haglund deformity is not precisely known, standard calculation of sample size was not performed. Patients were included in the study if surgical treatment for haglund deformity was undertaken with minimum follow up of 24 months with age 20–65 years. Patients with diagnosed inflammatory arthropathy (like rheumatoid arthritis, hyperuricemia), uncontrolled diabetes mellitus, associated foot or ankle deformity or arthritis and patients who were not willing to participate in the study were excluded (Table 1). The clinical and functional assessment of all the included patients was done in the preoperative period (Fig. 1) using AOFAS HFS and VAS. Range of motion of the ankle was measured pre operatively as well as post operatively using a hand held goniometer. Patient's routine daily activities, pain using VAS score were recorded in the pre-operative period and lateral x-ray views of the ankle were used for radiological assessment of the deformity (Fig. 2). Routine follow up was performed at 6 weeks, 6 months,12 months,18 months and 24 months. At each follow up,AOFAS HFS and VAS score was determined by two surgeons not involved in surgery and the mean of the two values were taken as final value. Radiographs were taken in immediate post operative period and at 24 months after surgery to assess the bony overgrowth unless indicated.

Table 1.

Inclusion and exclusion criteria of the patients included in the study.

Inclusion criteria	Exclusion criteria
1.Diagnosed patients of haglund syndrome with recalcitrant pain after 6 months of conservative management.	1.Patients diagnosed with rheumatoid arthritis hyperuricemia, associated foot or ankle deformity, uncontrolled diabetes mellitus. 2.Patients not willing to participate in the study.

Fig. 1.

Clinical picture of Haglund deformity in oval.

Fig. 2.

Lateral view X-ray of ankle showing Haglund deformity (in circle).

All the patients underwent surgery on day care basis under regional anesthesia. Patients were instructed to come on the day of surgery after obtaining routine investigations in the outpatient department.

2.1. Operative procedure

In prone position, L-shaped incision was given with vertical limb placed just medial to the Achilles tendon and horizontal limb was just at the level TA insertion. Skin and subcutaneous tissue was raised as one flap, exposing the paratenon sheath. Paratenon sheath was incised and separated from underlying tendon. Tendon was exposed and split in the centre (Fig. 3) and the tendon was detached as distal as possible from its insertion in reverse T fashion. Degenerated tendon and inflamed fibrofatty tissue was debrided using No.15 scalpel. Haglund deformity was excised using saw, osteotome and the surfaces were smoothened by rasp (Fig. 4). Underlying bone was drilled with 1.8 mm drill bit, which provided bone marrow to augment the healing process of the attached tendon. Two Swivelock suture anchors loaded with fibretape [Arthrex Achilles SpeedBridge Convenience Pack (AR-8928 BC-CP)] were inserted into the footprint of tendon (first row) which was made 1.5 cm proximal to distal end of tendon on calcaneus. Then, sutures were passed through the tendon then it was crisscrossed taking one limb each from the suture anchor which was loaded into 2 other Swivelock suture anchors and tendon was attached in the distal row in a knotless method (Fig. 5). Split tendon was sutured and knot was undermined to prevent skin irritation. Paratenon sheath was closed with continuous 3.0 VICRYL Plus (ETHICON VCP 936). Skin was closed using 3.0 monofilament non-absorbable suture (ETHILON NW 3328). Ankle was kept in neutral position in below knee slab for 7 days. Only NSAIDs were used for pain control in post operative period.

Fig. 3.

Haglund deformity (seen encircled) and red arrow showing detached and split Tendoachilles.

Fig. 4.

Complete removal of Bony Bump.

Fig. 5.

Re-attached tendoachilles with double row Speedbridge technique.

2.2. Postoperative mobilization

Post operatively, partial weight bearing mobilization was started as soon as patient was comfortable using walker as tolerated by the patients. Full weight bearing mobilization with Genesis Mid-Calf walker (Breg, Carlsbad, CA, USA) and passive ankle range of motion (ROM) was started between 8 and 12 days from the date of surgery after removal of slab. Compression crepe bandage was applied after slab removal which was discontinued around 3^rdweek and advised active ankle ROM exercises along with knee and hip strengthening exercises.

2.3. Statistical analysis

Categorical variables were presented with numbers (percentage) and continuous variables were presented as mean and standard deviation. The mean values as well as respective standard deviations were rounded off up to two decimal place. SPSS (version 19.0; SPSS Inc., Chicago, IL) was used for analysis. Independent sample t-test was used to compare postoperative scores with preoperative scores. P value was considered significant if < 0.05.

3. Results

11 female and 2 male patients (16 feet- 10 unilateral and 3 bilateral) with mean age of 53.00 ± 4.93 years were operated between January 2018 and February 2019. Two patients were diabetic but controlled with medication. Postoperative ankle range of motion was similar as in the preoperative period. All the patients started full weight bearing between 8 and 12 days postoperatively (average 10th postoperative day).All the patients started their pre-surgical activities after 4 weeks from the date of surgery. However, none of the patients were involved in sports activity.

The mean postoperative HFS calculated at 24 months follow up period was 87.61 ± 4.69 compared to the mean preoperative HFS of 53.07 ± 5.93, which was statistically significant (p value < 0.05). The mean preoperative VAS score was 7.07 ± 0.21 and mean postoperative VAS score was 1.30 ± 0.16 (p value < 0.05) at 2 years. Pre and post operative ankle ROM was statistically insignificant. Two patients, developed superficial surgical site infection. They were treated successfully by superficial wound debridement and advised oral antibiotics for 4 weeks. These two patients were non diabetic. None of the patient complained of recurrence of pain. The patients were asked to wear sports shoes during walking and return to normal life (like use of public transport,using stairs and car driving) was allowed if the patient had normal gait and minimal pain at 6 weeks follow up.

No patient was found to have re-rupture of tendon or implant failure at the final follow up. The results has been summarized in Table 2.

Table 2.

Summary of results.

No of patients operated	15
Patients lost to follow up	2
Patients included in the study	13
Number of feet operated	16
Unilateral	10
Bilateral	3
Age in years (mean ± SD)	53.00 ± 4.93
Sex
1.Male	4
2.Female	12
Duration of surgery (minutes)	37.65 ± 3.67
HFS
1.Pre operative	53.07 ± 5.93
2.6 weeks	68.78 ± 3.76
3.6 months	84.43 ± 5.89
4.12 months	85.23 ± 3.45
5.18 months	87.17 ± 3.38
6.24 months	87.61 ± 4.69
VAS score
1.Pre operative	7.07 ± 0.21
2.At 6 weeks	3.75 ± 1.34
3.6 months	2.13 ± 0.96
4.12 months	1.25 ± 0.72
5.18 months	1.37 ± 1.65
6.24 months	1.30 ± 0.16
ROM of ankle (DF/PF)
1.Pre op	14.56 ± 1.83/47.37 ± 7.12
2.Post op	14.38 ± 0.67/48.73 ± 3.20
Complications
1.Superficial surgical infections	2

SD - standard deviation, HFS- Hind Foot score,VAS-Visual analog scale,DF-dorsiflexion, PF-Planterflexion

4. Discussion

Haglund deformity is one of the debilitating condition of heel that may be associated with retrocalcaneal bursitis.7, 8, 9, 10 The source of pain in Haglund syndrome include posterior calcaneal wall cartilage, inflammatory changes in retrocalcaneal and subcutaneous adventitial bursa and achilles tendon.11, 12, 13, 14Open surgery is indicated in resistant cases, which are not responding to conservative treatment with, or without micro tear in the tendon that addresses all the componenents of pain generating tissues with good exposure.^15,16

The most important intervention we performed in our study was to allow our patients to start full weight bearing within 10 days of surgery. We believe that, the construct was biomechanically strong enough to tolerate the load across the joint, even before integration of the tendon to the underlying bone was complete. Early mobilization has several advantages over prolonged immobilization. Early mobilization helps in better perfusion of tendon and prevents adhesion and stiffness of adjacent ankle and foot joints. There is also possibility of undesirable edema in cases with prolonged immobilization. One major disadvantage of our mobilization protocol was failure of reconstruction. We did not encounter such complication in any case. After reconstruction of the tendon, we performed a complete ankle ROM that confirmed no additional tension at TA insertion repair site which made us confident to undertake such rehabilitation program. Strength of this construct appears to be an equivalent to natural tendon. Being knotless repair, the chances of implant irritation is almost negligible. The protocol of wearing sports shoes was suggested by senior author (VKD) and this is assumed to protect the repair and promotes uniform ankle movement. The patients were instructed to gradually start using public transport and using stairs after 6 weeks (except in one patient who experienced pain at 6 weeks,had limping and mobilized at 2.5 months).Superficial infection did not show any difference in mobilization.

Several small case series have described the similar reconstruction procedure of TA but they have described delayed mobilization up to 6 weeks after surgery2, 3, 4, 5, 6^,19 in contrast to 10 days in the present study. A recently published retrospective study throws light on similar technique and has achieved similar results as of ours, but the article did not mention about mobilization protocol.²⁰ Jiang et al. has shown that single row fixation was adequate when 50–70% of tendon was detached but recommended for double row fixation when tendon was completely detached.³

The advantage of partial detachment is intactness of most of the tendon, however, major disadvantage is an inadequate exposure, which might lead to incomplete removal of bone and inflammatory tissues and inadequate debridement of degenerated tendon. These may be the source for refractory pain and rupture of tendon in post-operative period.¹⁷

Complete detachment of TA is challenging with respect to re-attachment of the tendon. We used reverse T splitting approach of the tendon. It allows for concurrent treatment of several pathological conditions at the insertion site of the Achilles tendon, such as subcutaneous bursitis, ossified mass at the tendon insertion, debulking the degenerated tendon, intratendinous ossification, calcaneal bursitis and haglund's deformity.⁵It provided larger contact area between tendon and bone surface and promotes the healing of the Achilles tendon.^3,18 We have obtained satisfactory result after a follow up of 24 months. Mean AOFAS hindfoot score improved from 53.07 ± 5.93 (pre-operative) to 87.61 ± 4.69 (post-operative). Comparable results were seen in previous published studies, in both open and endoscopic surgeries.2, 3, 4, 5, 6^,19

The major strength of this study is –it is one of the largest study on complete excision of haglund deformity after complete detachment of TA tendon repired with double row suture anchor reconstruction with long follow up of 18 months with a trial of new protocol for early mobilization with satisfactory outcome. This can be used as a pilot study for future large clinical trials with the same technique.

There are few limitations of this study. As it is not a rondomized control trial, it does not advocate superiority of this techniuqe over others. Other limitations of the study are decreased sample size and cost of implant used.

5. Conclusion

Speed bridge technique provides stronger biomechanical reconstruction which allows early mobilization and weight bearing of the patients unlike other techniques. We strongly recommend this technique for resistant painful haglund deformity planned for surgical intervention considering its merits and excellent outcome.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent (patient/guardian)

Informed written consent of the patients were obtained before publishing the paper. It was confirmed that identity will not be revealed and it is being used solely for academic purpose.

Institutional ethical committee (IEC) approval

IEC approval obtained (IEC no −3/03.02.23).

Author contribution

Dr. Suman and Dr.Vijay D were involved in the conception of the idea for the study. Dr Suman, Dr.Santanu were involved in the literature searching. Dr.santanu was involved in interpreting the results, data extraction and analysis. Dr Santanu and Dr. Suman were involved in writing the initial proof. All three authors were involved in writing the manuscript post analysis. Dr.Santanu and Dr.Vijay D were involved in overseeing and proof reading the manuscript. All the authors read the final manuscript and gave consent for publication.

Level of clinical evidence

Level IV, Therapeutic study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Disclaimer

Part of the article was presented as e -poster in SICOT 2021 congress.

Declaration of competing interest

The authors of this paper have no conflicts of interest to declare in the preparation and submission of this manuscript.

Abbreviations

TA

Tendoachilles

AOFAS

American Orthopedic Foot and Ankle Society

HFS

Hind Foot Score

ADL

Activities of Daily Life

RCB

Retro Calcaneal Bursitis

VAS

Visual Analogue Scale

ROM

Range Of Motion