Hello everybody, my name is Tyler Gonzalez. I'm from the University of South Carolina and today I'll be talking about MIS percutaneous aortic osteotomy for insertional Achilles tendinopathy. Here are my relevant disclosures, some pertain to this talk. So insertional Achilles tendinopathy is a very common problem we as orthopedic foot and ankle surgeons face. Management of this pathology remains controversial especially for surgical management and especially in athletes given the involvement of the Achilles tendon. Often insertional Achilles tendinopathy is associated with Haddon's deformity and retrocalcaneal bursitis and often associated with a tight gastroc complex. So treatment options, we've all dealt with this in our in our clinics and practice. Often there's a first-line therapy is non-operative management which includes anti-inflammatories, physical therapy, immobilization, steroids, some believe in retrocalcaneal bursa steroid injections. However when that fails this often leads to surgical management. This is a very common procedure which I'm sure all of us have done. Most common being an open midline splitting but also there's endoscopic and minimally invasive techniques and today that's what we'll be focusing on the more percutaneous techniques. So just as an aside, so what is minimally invasive surgery? I think this is something that is becoming much more prevalent in orthopedic foot and ankle surgery. A lot more literature coming out in various techniques of hallux valgus, lesser toes, calcaneal osteotomies and but what is it? So it's not just utilizing a burr, in my opinion it's a philosophical principle. It's about doing the least invasive surgery you can to obtain the desired result and produce a good outcome. It's really about soft tissue awareness and minimizing soft tissue damage and stripping which likely will lead to less pain, less swelling, less discomfort with hopefully improved outcomes. But it's not just about your skin incision, it's also overall like I just stated about soft tissue management. So I think this is a great quote by Dr. Mangone who was asked what is minimally invasive foot and ankle surgery and he states minimally invasive surgical techniques usually have less soft tissue stripping which results in less pain and tissue trauma for the patient. There is not a set length or size of the incision that defines the difference but minimally invasive incisions are about 75% smaller than traditional open incisions. I think this is spot on. Again we are, this field is evolving and we continue to do research but the overall principles are the same. But again nothing cures all so we have to continue to study this and assess if it does truly improve our outcomes over traditional methods. So one of the most common ways of treating insertional Achilles tendinopathy is through an open debridement but we all know there's associated complications with this. Some of those include an extended recovery especially if you're doing a gas rock recession. Often it's debated how much tenant do we take? When do we do an FHL? I think these issues still remain controversial and especially in the athletic population. Long time to return to sport, there's associated wound problems especially in those with risk factors such as diabetes and obesity. There's often waxing and waning pain with the incision with the overall swelling which can create shoe wear issues with a posterior heel and it's their sural nerve issues given the larger incision potentially and even it's not ideal for athletes. So when we're looking at options for treating insertional Achilles tendinopathy we have a lot of choices and how do we decide those? Well actually in 1939 Dr. Zadig presented the Zadig osteotomy which is a dorsal closing wedge osteotomy of the calcaneus for Achilleobursitis and this is kind of was popularized at this time and then somewhat fell out of favor due to wound complications but this is when it all started. So the Zadig osteotomy is a dorsal closing wedge osteotomy and there's still research that's being done by our group and others to look at the optimal wedge length and size but in general the literature as of now recommends about a seven to ten millimeter dorsal wedge but you want to leave a plantar hinge about five to eight millimeters so that that closes down and the osteotomy is stable. This is a some of a picture of fixation after the wedge has been removed and the the healing of it. So what are the indications for a Zadig osteotomy? Well they include the ones that are similar to an open debridement, Achilles insertional tendinosis, Haglund's deformity, calcitic menoplasia, partial tearing of the insertion of the Achilles, retrocalcaneobursitis and these can all be in combination or in isolation. So what is the data on this? Obviously a lot of these more percutaneous approaches are are fairly novel or kind of reinvented but is there data because we don't want something to be snake oil and just say it works without looking at it. So what has actually been studied? Well the theory behind the Zadig osteotomy is that when you remove this dorsal wedge the insertion point of the Achilles tendon is raised taking the tension off of it. The posterior tuberosity is then displaced anteriorly and the calcaneus is shortened and now the tendon pressure at the insertion is reduced additionally the bursa and the posterior heels decompressed. This has been described in the literature as as such and also you know in this vein some people believe doing a gastroc recession for insertional Achilles tendinopathy is all that needs to be done and that is a you know a functional lengthening of the Achilles complex and this does something similar without actually cutting the gastroc fascia or damaging any of the muscle. The Zadig osteotomy has been shown to remove mechanical and anatomic defects causing insertional Achilles tendinopathy within the same surgery. So with the Zadig osteotomy the Achilles tendon is never augmented the biomechanical environment surrounding the Achilles is altered as described before and this allows the tendon to heal. Therefore in the Zadig osteotomy can be recommended for athletes so that no Achilles attachment is required which would significantly affect their return to sport. So when we look at the literature this is a study by Nordeo who looked at 26 patients with a minimum of six month follow-up with an average of 12 month follow-up they had significant improvements in FFI and VAS scores there was one revision for a non-union the plantar cortex broke and one patient did not improve from the Zadig but they didn't improve with an open resection. This is a paper out of FAI utilizing the Zadig osteotomy in athletes which showed minimum three-year follow-up good to excellent results in 96% of their patients ALFAS scores improved significantly they were all professional athletes which about half a little less than half returned to the same level of competition at around four months and there was one revision for a displacement of the osteotomy which occurred because the plantar hinge broke. This paper by Tornier looked at 22 patients with one year follow-up they were all athletes in to some degree whether recreational competitive or professional the average dorsiflexion improved almost seven and a half degrees and all the functional outcome scores were significantly improved AOFAS EFAS and EFAS sports and there were no non-unions or revisions at one year. Our group looked at the learning curve I think most minimally invasive surgeries are showing that there is a learning curve our data we looked at 153 patients with minimum one-year follow-up and we found that the learning curve was about 12 cases and it kind of plateaued around 28 minutes and we looked at the complication rate before and after the the 12 cases and found really before and after the the 12 cases and found really no different in complications including non-unions or revision before after those 12 cases this is currently being submitted for publication. Now this is a another study that we're performing as a multi-center study of the outcomes of a percutaneous static osteotomy with a minimum two-year follow-up we have 86 patients currently with an average of 45 months follow-up and so far our complications are fairly minimal you know they there's one superficial wound infection that was treated with oral antibiotics that resolved a tibial nerve neuropraxia which resolved at three months with no further treatment one case of plantar fasciitis that self-resolved two cases of painful hardware from the screws being somewhat too prominent and they had to go back to the order to be removed there was one non-union that was revised and currently one patient that didn't improve after zetac osteotomy but hasn't wanted an open revision yet and so that hasn't been done. So when we look at our functional outcome data we looked at pre-operative compared to post-operative pain disability and activity limitations for FFI and found a statistically significant improvement in every one of these metrics. When we looked at our VAS scores improved 7.68 to 0.48 which was statistically significant and about 98 percent of our patients were satisfied with their procedure from seeing results. So overall it appears that this is a viable option more literature needs to come out but it is there is good functional outcomes and showing high return to sport. So one thing I want to go over next is is how do you do this and what are the options or various techniques. So the setup and positioning of the zetac osteotomy there are multiple different ways to do it this is just one technique. I position on lateral decubitus with a beanbag on a mini c-arm as shown here this allows me to stand on one side of the c-arm to do the osteotomy. You got to be careful and make sure we stay out of the stay inside the safe zone to avoid any sore nerve damage. You can mark the skin percutaneously under fluoro to identify the wedge to help guide your burr placement and identify your incision. You can also use a percutaneous k-wires to act as a guide which is the technique I use. This helps direct my osteotomy and stay in the appropriate position to remove the appropriate size wedge but this is just one technique where there are many that are out there. This is a fluoroscopic image showing that percutaneous guide. So there are various techniques to performing the zetac osteotomy and I think you have to do this and get it in your hands and see what's best for you. This is a technique we've submitted for publication that I found just works well on my hands. It's a quadrant system along with the k-wires helps me from getting lost. So you start lateral and head medial and then you've had plantar to dorsal and then posterior to anterior and you cut in these quadrants which I feel allows you to do a very accurate cut and minimize the time of performing the cut which is both good for the patient and minimize any theoretical risk of thermal necrosis. Additionally one of the problems you can have is residual bone blocks that will affect your reduction of the osteotomy and I feel utilizing this technique allows you to make more accurate cuts and remove any bone that will potentially block your reduction. And here's a here's you'll be seeing that cut from the dorsal side and it is known you have to be careful to not take more medial or lateral bone so that you don't create a coronal plane deformity or transverse plane deformity in varus or valgus. So here's just a little schematic of drawing um the the kind of quadrant system cut. Here's a quick video showing the technique for the osteotomy. So the reduction move is really dorsiflexion of the ankle. As you dorsiflex you can see the osteotomy close down. If you're using the wire technique they often become more parallel. Often as the osteotomy closes down you can see some of the bone debris or what I like to call the bone juice come out of the percutaneous incision. If it doesn't close down it's usually because either you have too large of a plantar hinge so the osteotomy can't close down or there's a bony block to the osteotomy. Oftentimes I'll use a freer to feel that where that is and then burr that down but but those are usually the common reasons why. If you have too large of a plantar hinge go methodically don't take too much down right away just go millimeter by millimeter and keep repeating the reduction until it closes down. Next slide I'm going to show you a quick technique video of me doing it in the operating room. As you can see here we completed our osteotomy and the wires are oblique to each other at this time we'll dorsiflex the ankle and as we dorsiflex you can see that the osteotomy is closing down and the wires become much more parallel indicating completion of the osteotomy. As you can see here this is just a picture showing the on the left side the obliquity of the wires and as you close down the osteotomy you can see them become more parallel. You can also see the plantar hinge on the left side a nice plantar hinge it doesn't break and you can see closing down the osteotomy. This is another technique where simply depending on your this is another technique where simply depending on your if you have residents or other assistants in the OR you can use a co-band to hold the ankle and dorsiflexion to place your wires which is a very nice hands-free reduction move that you can use and also allows you to get a very nice lateral and Harris heel view. So screw fixation usually I use 7-0 cannulated headless compression screws I think it's dealer's choice there's no literature showing one's better than the other. Some use one screw I use a second I use one first dorsally a superior screw to reduce the osteotomy and then one right at the plantar break to plant plantar base to protect any potential hinge breakage or migration. This is kind of a final fluoroscopic imaging showing placement of the screws. So then close with 3-0 nylons after irrigating very simple and here are some final fluoroscopic imaging showing position of the screws as well as complete healing of the osteotomy which heals very well. So post-op everyone has a little bit different of a protocol this is just mine everyone can modify it to their comfort level. I do two weeks in a post-op non-weight-bearing just kind of protect the patient and the wounds then at two weeks I put them in a boot and let them begin a progressive weight-bearing protocol and then from week four to six I really get them moving more. If the patient's obese I just go a little slower than this but most patients can move fairly quickly because it's very stable osteotomy. At six to eight weeks they're advanced out of the boot into a normal shoe. I start advancing their activities they can bike elliptical and do their normal walking and then if they need it we can start physical therapy around six weeks with gradual progression to sports at 12 weeks. So complications just like any procedure there there's risk of complications, wounds, infections, nerve damage but in this osteotomy I think there are some specific ones relative to an open resection. One there's risk of non-union which we've seen in the literature and that's related to that loss of the plantar hinge so being very careful to making sure you keep that intact and not break it and if you do maybe placing a second screw. I have had some patients with plantar fasciitis this tends to resolve I think that's related to the biomechanical change in the plantar fascia race on this osteotomy which we're still exploring but that that's definitely a factor but I haven't that's always resolved with some physical therapy. There is risk of displacement of the osteotomy again if the plantar hinge breaks and there's risk of sore nerve injury so being careful to uh for your sore nerve to be in that safe zone. Additionally just like any minimally invasive surgery you do with a Shannon Burr there's also risk of skin burring if you generate too much heat so we usually recommend using cool water irrigation which helps as well as if there is a small burn on the skin just resecting it before you close will minimize any risk of that wound not healing. So here are just some cases showing the types of deformities and insertional Achilles tendinopathy that that I've done. Here's a patient large Haglund's large insertional enthesophyte and this is you know one year follow-up clearing uh complete healed uh patient's doing great and I think what's amazing about this surgery is the immediate outcomes. Here is the patient I go up and down two weeks post-op and down two weeks out from the Zetac but you have that pain in the back of the heel like you used to oh no okay this is just a little like a little burn a little scratch any pain there okay great another case probably less of a Haglund's deformity here. Here are the immediate and final post-op x-rays of the patient you can see that the osteotomy really healed in well um and good position final position of the osteotomy. Here is a patient six weeks post-op six weeks out post-op six weeks out from Zetac up up down up down good any pain back here no pain back there good excellent no pain back there good excellent So we can see here another patient with a Haglund's deformity and uh distal insertional enthesophyte and here are the final post-op x-rays you can see great healing of the osteotomy and he's done very well and had actually both sides done. So what do I overall think are some key points pearls or golden nuggets we can take away from this talk well I think when you start the Zetac osteotomy there is an associated learning curve but we chose about 12 cases and the risk of complications uh really doesn't increase before or after so I think first off making an incision in a safe zone to avoid the serral nerve is obviously very important you really into improve your outcomes minimize your risk of non-union you really want to maintain that plantar cortical bridge five to eight millimeters and you don't take too much to start if you need to take more you can always do that in the end and do that slowly and progressively. You really want to remove about a centimeter of bone dorsally I think that really allows the posterior tuber to move anteriorly and decompress the posterior aspect of the heel the bursa and get you that tension off the Achilles you desire. Fixed with one or two screws I think it's dealer's choice if you can't reduce it with dorsiflexion you either have a bony block or you're not you're have not taken too much plantar hinge and you have to take more. I think with obese patients I go a little slower just that's in my hands I don't there's no literature to support that that is what I do and then the early to mid-term results are good functional outcomes with lower vision rates and high return to sport. We need to study this more but overall I think we're heading in a very good direction so thank you very much this is my email cell phone if you need to contact me or have any questions please do so have a great day

minimally invasive surgery

insertional Achilles tendinopathy

Zadig osteotomy

complications

functional outcomes

surgical technique