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Thread: Do I really Need Achilles Tendon Lengthening & Tendon Transfer?

  1. #1

    Do I really Need Achilles Tendon Lengthening & Tendon Transfer?

    Hi All,
    I saw an orthopedic surgeon regarding an overlapping toe on my left foot. The second toe overlapped the big toe. Before the doc even mentioned the overlapping toe he started asking about the inversion and foot drop on the left foot. I explained it had been like that for years but recently it may have gotten worse and was bothering me a bit more in the morning. It’s always extremely tight and inverted in the a.m. and it’s usually an hour before it’s loose enough that I can put it flat on the foot pedal of my chair. I wear a night splint and I’m getting an AFO for times when I’m in my chair.

    The doc said he could lengthen the Achilles tendon to fix the drop foot and a tendon transfer for the inversion. He said one problem that could occur is that he over corrects w/the tendon transfer, which would leave the ankle at a little less than 90 degrees. One concern I have w/the lengthening is the spasticity in my left foot; that heel cord is very tight and its worse in the morning as is the clonus. I’m concerned about how this might affect the tendons the doc operated on after the surgery. Could clonus damage the work the surgeon did if it were to happen shortly after surgery?

    Has anyone else in the group had a similar surgery and how did it go? What was recovery period like? I’m still undecided as to weather I want to go ahead w/this surgery. While the stiff drop foot and clonus can make things even harder in the a.m. it does calm down eventually and a good AFO will help too. I’m 44 years old and have been in a chair and dealt w/the inverted drop foot for approx. 20 yrs. I could probably go another 20 but the doc said the foot might get worse over time. I don’t think he’s a chop happy doc out for money because he offered to do the surgery for free. He’s one of the top ortho surgeons at the Hospital for Special Surgery.

    I do plan on going for a second opinion but was thinking of going to a physiatrist instead. I feel he may know more about what would happen w/the foot if I did not have the surgery. Any info on this is really appreciated!


    Dan G.
    Dan G. in CT

  2. #2
    We generally would not do surgery in a case like yours unless the contracture was causing problems with function or skin breakdown. There are risks associated with the surgery: anesthetic risks as well as risks for bleeding, hematoma and infection, much less the risks of hospitalization.

    I would definitely recommend you see a physiatrist and a good PT to see if conservative management (ROM and splinting) would be appropriate, and to be sure that you are not getting excessive pressure on the side of the foot from the deformity.

    As far as the orthopedist, how much experience does he have doing this with people with SCI vs. other disabilities (such as CP)? Surgeons do surgery. When you are a hammer, everything looks like a nail!!!

    (KLD)

  3. #3
    Tendon transfer surgery is not a simple procedure. I would ask him the pro's and con's, how many he's done, expected length of recovery, etc.
    I think that your idea of seeing a physiatrist is a good one- PT may also help as may your AFO.
    CKF

  4. #4
    I was just told that my 12 year old son needs tendon transfers in both feet. He has CP (with moderate ankle clonus) and his feet have been becoming rigid and turned in over the past year or so.
    Did you decide to have the surgery and if you did, how did it go? How was the recovery and has it helped much?

  5. #5
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    I would definitely NOT do this surgery. I agree with KLD that surgeons are, well, all about surgery. The risks seem too high and the benefits, even without complications, seem minimal. Let him practice on someone else.

  6. #6
    I did have the surgery and its helped tremendously. I had to wear a cast during the four week recovery. My case was severe, according to my doc. If your son's is moderate, perhaps he can get by w/different bracing? Have you gotten a 2nd opinion?

    write back if you have more questions. good luck.
    Dan G. in CT

  7. #7
    Hi All

    My case is similar to yours, Dan, my left foot is inverted and my second toe also overlaps my big toe. I also have spasticity in my left foot and it caused my tendon to become contracted. i started having ankle pain last yr and i noticed it was hard to bear wt on my foot on the morning, the pain went away after being on my feet for a few minutes. When i went to my orthopaedic dr he suggested the surgery. i tried a few things such as PT and botox and i also got a few second opinons before going ahead with the surgery.

    I just recently had achilles tendon lenthening and tendon transfer surgery. I'm in a walking boot now and am currently going to PT. My problem is my leg seems to be very spastic. It actually started right after i had the surgery when my leg was still in the cast. When i get a spasm, my toes curl in and my leg bends at the knee and i have a hard time straightening my leg. the dr said that the tendons sometimes spasm after surgery but i'm not sure if its supposed to spasm this much. the dr did give me a muscle relaxer but it doesnt feel like its helping it feels like it relaxes everything but my leg . it also does it when i got to PT. i'm thinking about going to my neurologist to have him take a look at me.

    I just wanted to know if you had anything similar happen to you and how is your leg doing now

  8. #8

    dose my friend need surgary to lengthen her tendon?

    I have a friend that has Achilles tendonitis. She is at her wits end trying to deal with the pain. The doctor tells her she should just stop working all together. I want help her because she is in so much pain all the time. I have read up on the problem and she has this bony enlargement of the back of the heel that goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity. She has inverted feet and she is not able to walk with out pain let alone going up steps. I have read a little about the surgary treatments they have out there like lenghening of the tendon...... and was wondering is this something that could benefit her and if not do you know something that would?


    thanks,

  9. #9
    Quote Originally Posted by Quadzila@optonline.net View Post
    Hi All,
    I saw an orthopedic surgeon regarding an overlapping toe on my left foot. The second toe overlapped the big toe. Before the doc even mentioned the overlapping toe he started asking about the inversion and foot drop on the left foot. I explained it had been like that for years but recently it may have gotten worse and was bothering me a bit more in the morning. It’s always extremely tight and inverted in the a.m. and it’s usually an hour before it’s loose enough that I can put it flat on the foot pedal of my chair. I wear a night splint and I’m getting an AFO for times when I’m in my chair.

    The doc said he could lengthen the Achilles tendon to fix the drop foot and a tendon transfer for the inversion. He said one problem that could occur is that he over corrects w/the tendon transfer, which would leave the ankle at a little less than 90 degrees. One concern I have w/the lengthening is the spasticity in my left foot; that heel cord is very tight and its worse in the morning as is the clonus. I’m concerned about how this might affect the tendons the doc operated on after the surgery. Could clonus damage the work the surgeon did if it were to happen shortly after surgery?

    Has anyone else in the group had a similar surgery and how did it go? What was recovery period like? I’m still undecided as to weather I want to go ahead w/this surgery. While the stiff drop foot and clonus can make things even harder in the a.m. it does calm down eventually and a good AFO will help too. I’m 44 years old and have been in a chair and dealt w/the inverted drop foot for approx. 20 yrs. I could probably go another 20 but the doc said the foot might get worse over time. I don’t think he’s a chop happy doc out for money because he offered to do the surgery for free. He’s one of the top ortho surgeons at the Hospital for Special Surgery.

    I do plan on going for a second opinion but was thinking of going to a physiatrist instead. I feel he may know more about what would happen w/the foot if I did not have the surgery. Any info on this is really appreciated!


    Dan G.
    Dan,

    I realize that this is a very late answer to a question asked in 2007. However, I have a different opinion from those being expressed by others. I think that the orthopedic surgeon that you consulted is making an appropriate suggestion. Lengthening that tendon will significantly reduce the clonus and spasticity in your left foot. The surgery is not risky, although the healing from the surgery may take a month or so. I don't think that you need to worry that the clonus might damage the tendon because the clonus and spasticity should decrease when the tension is released.

    There is a risk that he may overlengthen the tendon, therefore weakening the gastrocnemius muscle but this can be overcome with exercise afterward and the risk is low if the muscle is as spastic as you describe. It is also possible that he may not lengthen the tendon enough and it doesn't resolve the problem. However, this is not "experimental surgery". If done properly, it can have significant beneficial effects on walking. Some people worry that tendon lengthening surgery may weaken the tendon. This is rare if the surgery is done properly. Several years ago, I posted an article about tendon lengthening and I think that it is still valid today because the techniques have not changed all that much.

    http://sci.rutgers.edu/forum/showpos...57&postcount=1

    Wise.
    Last edited by Wise Young; 02-09-2009 at 07:35 PM.

  10. #10
    Quote Originally Posted by krystie View Post
    I have a friend that has Achilles tendonitis. She is at her wits end trying to deal with the pain. The doctor tells her she should just stop working all together. I want help her because she is in so much pain all the time. I have read up on the problem and she has this bony enlargement of the back of the heel that goes by many names including retrocalcaneal bursitis, pump bump or Haglund's Deformity. She has inverted feet and she is not able to walk with out pain let alone going up steps. I have read a little about the surgary treatments they have out there like lenghening of the tendon...... and was wondering is this something that could benefit her and if not do you know something that would?


    thanks,
    Krystie, if your friend has Achilles Tendonitis from Haglaund's deformity, she should wait until the tendonitis resolves before any surgery should be considered. The tendonitis is usually treated with non-steroidal analgesics (aspirin, motrin, etc.), change of shoes or adding a heel insert to reduce tension on the Achilles, and then physical therapy to stretch the Achilles tendon. If those efforts are ineffective, surgical excision of the Haglund prominence can be done, especially if there are calcium deposits.

    It is important that your friend be evaluated by an orthopedic surgeon who has a lot of experience with heel surgery. There are many causes of Achilles tendonitis and the diagnosis requires somebody with a lot of experience to avoid unnecessary surgery. In most cases, this condition can and should be treated conservatively and surgery applied only if conservative therapies are ineffective. Surgical failures for this condition may be 10% or greater, depending on the surgeon [1]. Likewise, diagnosis and treatments of inverted foot can be quite complicated and I suggest obtaining multiple opinions before any surgery. I attach some other references [2-4].

    Wise.

    References
    1. Wagner E, Gould JS, Kneidel M, Fleisig GS and Fowler R (2006). Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int. 27: 677-84. Clinica Alemana, Santiago, Chile. BACKGROUND: Insertional Achilles tendinosis is a clinical entity that commonly occurs with other posterior heel disorders such as retrocalcaneal bursitis, Haglund deformity, intratendinous ossification and pretendinous bursitis. Complete detachment and reconstruction of the Achilles tendon was evaluated as a method of treatment for this condition. METHODS: Seventy-five patients (81 heels) were treated over a 5-year period for chronic insertional Achilles tendinosis. These were divided in two groups: a nondetached group (26 patients, 31 heels, average age 55 years) included all patients with debridement of the Achilles tendon with no or partial detachment of the tendon, and a detached group (49 patients, 50 heels, average age 56.1 years) that included all patients with complete detachment, debridement, and reattachment with suture anchors of the Achilles tendon associated with proximal V-Y lengthening of the proximal aponeurosis. Sixty-one patients (65 heels) were contacted for an interview questionnaire, 22 patients from the nondetached group (26 heels) and 39 patients from the detached group (39 heels). The average followup for the nondetached group was 47 months and for the detached group 33 months. Items evaluated included pain, activity limitation, gait change, walking distance, return to sport or work, and level of satisfaction. RESULTS: No statistically significant differences were noted in relation to any of the items evaluated. In the nondetached group, the satisfaction rate was 92%, and 8% were dissatisfied. In the detached group, 74% were completely satisfied and 18% were satisfied with reservations. Eight percent were dissatisfied. Complications included minor wound dehiscence (one in the nondetached, five in the detached group), wound infection (one in the nondetached group, two in the detached group) and sural neuritis (two in the detached group). CONCLUSIONS: Complete detachment of the Achilles tendon and reattachment with suture anchors and a proximal V-Y lengthening was a reliable and effective method of treatment for severe chronic insertional Achilles tendinosis as was debridement of the tendon insertion without detachment for less severe involvement.
    2. Saxena A (2003). Results of chronic Achilles tendinopathy surgery on elite and nonelite track athletes. Foot Ankle Int. 24: 712-20. Department of Sports Medicine, Palo Alto Medical Foundation, 795 El Camino Real, Palo Alto, CA 94301, USA. HeySax@aol.com. Twenty-seven track athletes/runners with chronic Achilles tendinopathy underwent a retrospective review of 37 surgical Achilles procedures performed between 1990 and 1999. There were 22 males and 5 females. Average age of the group was 36.6 years (range, 16-75 years). The mean "return to activity" (RTA) was 10.6 +/- 6.3 weeks. For elite athletes, RTA was 7.9 = 4.8 weeks. For nonelite athletes, RTA was 15.0 +/- 6.2 weeks, and was statistically higher (p = .003). There was no significant difference between males' and females' RTA. Average follow-up for the group was 4.7 years (range, 1-10 years). Runners on average ran more than 60 miles a week. There were 14 elite and 13 nonelite athletes, including four Olympians, five sub-4-minute milers, and four National Champions. Return to competition and "100%" were 25.0 and 25.4 weeks, respectively, for the elite group. Return to competition for the nonelite group was 27.0 +/- 11.0 weeks. Eighteen patients underwent peritenolysis with a mean RTA of 7.7 weeks. Of this group, four patients with concomitant bony procedures had significantly slower RTA as opposed to the 14 patients who had peritenolysis only (mean, 4.5 weeks). Four patients had Achilles debridement for mucoid degeneration, and a mean RTA of 12.8 weeks. Eleven patients had Haglund-type procedure (retrocalcaneal exostectomy) had a mean RTA of 15.1 weeks. Six Achilles tendocalcinosis repair patients had a mean RTA of 12.0 weeks. There were three reoperations, two of which were performed by the author. Using the Testa Achilles tendon surgery rating scale, this group of patients had 34 "excellent" and 3 "good" results. The patients who underwent a reoperation were able to achieve "good" or better results.
    3. Leitze Z, Sella EJ and Aversa JM (2003). Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am. 85-A: 1488-96. Department of Orthopaedics, Yale University, New Haven, Connecticut 06520-8071, USA. BACKGROUND: Pain in the retrocalcaneal space can be incapacitating. Patients who do not respond to nonoperative treatment may seek a surgical solution. The first purpose of this paper was to describe and evaluate the efficacy of a minimally invasive procedure to address retrocalcaneal pain caused by retrocalcaneal bursitis, a Haglund spur, and impingement. The second purpose was to compare the endoscopic technique with a standard open technique. METHODS: Our prospective study included thirty-three heels in thirty consecutive patients with chronic pain in the retrocalcaneal space for which nonoperative treatment had failed and endoscopic decompression was performed. The mean age was forty-nine years (range, nineteen to seventy-nine years). This group was compared with a group of seventeen heels in fourteen patients with the same diagnostic criteria who were treated with an open technique. Both groups of patients were evaluated preoperatively and postoperatively with the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale, and the patients treated with the endoscopic procedure were also evaluated postoperatively with the University of Maryland 100-point Painful Foot Center Scoring System. RESULTS: In the endoscopic group, the AOFAS scores averaged 61.8 points preoperatively and 87.5 points postoperatively (p < 0.001). The endoscopic procedures yielded nineteen excellent, five good, three fair, and three poor results at an average of twenty-two months postoperatively. (Three patients were excluded from the study.) In the open-treatment group, the AOFAS scores averaged 58.1 points preoperatively and 79.3 points at an average of forty-two months postoperatively (p = 0.006). The scores after the endoscopic procedures were numerically, but not significantly (p = 0.115), better than those after the open procedures. The time to recovery was the same in the two groups. The endoscopic procedures were performed more quickly than the open procedures (forty-four compared with fifty-six minutes) and were associated with fewer complications (a 3% compared with a 12% rate of infection, a 10% compared with an 18% rate of altered sensation, and a 7% compared with an 18% rate of scar tenderness). CONCLUSIONS: Endoscopic decompression is a feasible and efficient procedure for the treatment of retrocalcaneal disorders. It produces final results equal to or better than those of an open technique, with a similar recovery time, fewer complications, and a better cosmetic appearance.
    4. Heneghan MA and Pavlov H (1984). The Haglund painful heel syndrome. Experimental investigation of cause and therapeutic implications. Clin Orthop Relat Res. 228-34. Haglund syndrome, a common cause of pain in the posterior heel, consists of a painful swelling of the local soft tissues (the so-called pump bump) and prominence of the calcaneal bursal projection. The condition is caused by compression of the distal Achilles tendon and surrounding soft tissue between the os calcis and the posterior shoe counter. Osseous plantar projections appear to be a critical etiologic factor in Haglund syndrome. With an experimental model, it has been demonstrated that osseous projections on the plantar surface of the calcaneus adversely influence the bone-soft tissue relation of the posterior heel. Shoe heel elevation has been shown to be clinically effective in alleviating symptoms. It is demonstrated with an experimental model that elevation of the shoe heel decreases the pitch angle. This diminishes the prominence of the bursal projection and allows the foot to slip forward, displacing the posterior calcaneus away from the shoe counter.
    Last edited by Wise Young; 02-09-2009 at 07:48 PM.

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