Table 6.
Surgical techniques
| N of procedures | N of surgeons | Position | Approach | Description | |
|---|---|---|---|---|---|
| Open debridement | |||||
| Benazzo et al. [4] | A. 20 | A. 1 | A. Prone | A. Lateral longitudinal incision | A. Two–three longitudinal tenotomies and excision of degenerated areas (not sutured) |
| B. 32 | B. 2 | B. Prone | B. Lateral longitudinal incision | B. Excision of the degenerations through a longitudinal tenotomy after which a muscle bundle of the soleus muscle was bluntly dissected and distally left attached. The proximal end of the muscle bundle was anchored into the longitudinal incision with absorbable sutures | |
| Johnston et al. [11] | A. 10 | A. Medial longitudinal incision | A. Resection of thickened peritenon after which a one cm portion was resected and the AT was decompressed | ||
| B. 7 | B. Medial longitudinal incision | B. Resection of thickened peritenon after which a one cm portion was resected. If the AT was thickened or swollen, a longitudinal incision was made and degenerations were debrided | |||
| Kvist and Kvist [13] | 201 | Prone | Lateral incision (7 cm) | Fascial incision, after which adhesions between the paratenon and crural fascia and the crural fascia and the skin were removed. Thickened paratenon was excised (not sutured) | |
| Lohrer and Nauck [15] | A. 15 | A. 1 | A. Transverse incision (4 cm) + s.o.s. expanded longitudinally medial or lateral, creating a Z- or L-shape | A. The AT was released, after which transachillear scarification, parallel to the fibres, was performed with a surgical scalpel | |
| B. 24 | B. 1 | B. Transverse incision (4 cm) + s.o.s. expanded longitudinally medial or lateral, creating a Z- or L-shape | B. The AT was released, after which a longitudinal incision was made to excise degenerated lesions. The AT was reconstructed with sutures. With a surgical scalpel transachillear scarification was performed, parallel to the fibres | ||
| Maffulli et al. [18] | 10 | 1 | Prone | Medial longitudinal incision | The paratenon was excised and suspicious areas were explored by three–five longitudinal tenotomies and degenerations were excised (not sutured) |
| Maffulli et al. [21] | 86 | Prone | Medial or lateral curvilinear longitudinal incision (10-12 cm) | The paratenon was excised and suspicious areas were explored by three–five longitudinal tenotomies and degenerations were excised (not sutured) | |
| Nelen et al. [26] | A. 93 | A. Medial longitudinal incision | A. Incision of crural fascia and paratenon, after which the medial, lateral and dorsal aspect of the AT were released (no circular dissection, ventral side AT left untouched). Hypertrophic paratenon was excised | ||
| B. 26 | B. Medial longitudinal incision | B. Debridement tendinosis (sutured side to side) | |||
| C. 24 | C. Medial longitudinal incision | C. Extensive debridement tendinosis, after which the AT was reinforced with a rectangular flap of lateral or medial tendon aponeurosis, turned down on itself and sutured in the defect with resorbable sutures | |||
| Ohberg et al. [27] | 24 | Lateral longitudinal incision | Hypertrophic paratenon was excised, and a longitudinal incision was made to debride degenerations (sutured side to side) | ||
| Paavola et al. [29] | A. 171 | A. 1 | A. Prone | A. Lateral longitudinal incision | A. Fascial incision, after which adhesions between the paratenon and the crural fascia were excised |
| B. 50 | B. 1 | B. Prone | B. Lateral longitudinal incision | B. Fascial incision, after which adhesions between paratenon and crural fascia were removed and a longitudinal incision was made to excise intratendinous lesions (sutured side to side) | |
| Paavola et al. [28] | A. 16 | A. 2 | A. Prone | A. Lateral longitudinal incision | A. Fascial incision, after which adhesions between paratenon and crural fascia were removed |
| B. 26 | B. 2 | B. Prone | B. Lateral longitudinal incision | B. Fascial incision, after which adhesions between paratenon and crural fascia were removed and a longitudinal incision was made to excise intratendinous lesions (sutured side to side) | |
| Sarimo and Orava [31] | 24 | Medial or Lateral longitudinal incision (3–5 cm) | Fascial incision, after which adhesions between paratenon and crural fascia were removed and multiple radiofrequency microtenotomies were performed | ||
| Minimally invasive tendon stripping/tenotomies | |||||
| Alfredson et al. [2] | 10 | Lateral longitudinal incision | US–CD-guided dissection of the AT from the ventral soft tissue by use of a knife followed by haemostasis with diathermia | ||
| Alfredson [1]a | A. 18 | A. Prone | A. Lateral longitudinal incision (1–2 cm) | A. US–CD-guided dissection of the AT from the ventral soft tissue by use of a knife followed by haemostasis with diathermia | |
| B. 19 | B. Prone | B. Medial or lateral needle insertion | B. US–CD-guided release of the AT from the ventral soft tissue by use of a needle | ||
| Alfredson [1]a | 88 | Prone | Lateral longitudinal incision (1–2 cm) | US–CD-guided dissection of the AT from the ventral soft tissue by use of a knife, followed by haemostasis with diathermia | |
| Alfredson et al. [3] | 13 | Medial longitudinal incision (1–2 cm) | US–CD-guided dissection of the AT from the ventral soft tissue by use of a knife followed by haemostasis with diathermia | ||
| Calder et al. [6] | 34 | Medial incision (2–3 cm) | Release of the AT, after which the plantaris tendon was released from the AT and transected distally. The proximal end of the plantaris tendon is sectioned at the musculo-tendinous junction and delivered through a stab incision | ||
| Maffulli et al. [20] | 39 | 1 | Prone | Five stab incisions: 2 medial; 1 central; 2 lateral | Multiple US-guided percutaneous longitudinal tenotomies were created through five stab incisions |
| Naidu et al. [24] | 29 | Prone | Midline longitudinal incision (1–2 cm) | A blunt tracheal hook was passed up and down the AT to perform adhesiolysis. After closure of the paratenon, corticosteroids were infused peritendinously | |
| Testa et al. [36] | 63 | Prone | Stab incision central over degeneration | Adhesiolysis by 0.5 % carbocaine infiltration. Next, six US-guided percutaneous longitudinal tenotomies through one incision, three up- and three downwards, varying 45° were performed | |
| Endoscopic procedures | |||||
| Maquirriain [22] | 27 | 1 | Prone | Two midline portals | Endoscopic debridement of paratenon and release of the crural fascia were performed. Thereafter, two longitudinal tenotomies were performed |
| Pearce et al. [30] | 11 | Prone | Proximal portal medial + distal portal lateral | Endoscopic debridement of paratenon and release of the plantaris tendon were performed | |
| Steenstra and van Dijk [33] | 16 | Prone | Proximal portal medial + distal portal lateral | Endoscopic debridement of paratenon and release of the plantaris tendon were performed | |
| Open surgery: gastrocnemius lengthening | |||||
| Duthon et al. [10] | 15 | 1 | Supine | Medial incision (5 cm) | The gastrocnemius muscle was separated from the soleus muscle by blunt dissection after which the gastrocnemius muscle was cut transversally (not sutured) |
| Open surgery: autologous tendon transfer | |||||
| Martin et al. [23] | 44 | Supine | Medial longitudinal incision (10 cm) | The distal four–six cm of the AT was excised after which the FHL was harvested and interpositioned (secured proximally with a Pulvertaft weave, distally a tunnel is drilled in the calcaneus and the FHL is secured with an interference screw or reflected onto self and sutured) | |
Outlined are number of procedures; number of involved surgeons; positioning; approach and used surgical technique
AT Achilles tendon, US ultrasound, CD color doppler
aSame study comparing release of ventral AT with knife versus needle