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Original Article
Surgical treatment of chronic non-insertional Achilles tendinopathy in runners using bipolar radiofrequency
Tratamiento quirúrgico de la tendinopatía aquílea crónica no insercional en corredores mediante el uso de radiofrecuencia bipolar
J. Arnal-Burróa,
Corresponding author
juanarnal@hotmail.com

Corresponding author.
, D. López-Capapéb, C. Igualada-Blázqueza, A. Ortiz-Espadab, A. Martín-Garcíac
a Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Servicio de Cirugía Ortopédica y Traumatología, Clínica CEMTRO, Madrid, Spain
c Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Infanta Leonor, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Non-insertional Achilles tendinopathy is a condition with a high incidence in sports medicine and orthopaedic departments&#44; and it is especially common in runners and athletes&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> It may also affect sedentary individuals&#44; for whom associated microangiopathy is a risk factor&#44; as are being overweight and diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It affects amateur as well as professional sportsmen and sportswomen&#44; and it is typical in activities which include running and jumping&#44; such as football and racket sports&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a> The highest prevalence of this disease occurs in high level runners&#44; where it affects 7&#8211;9&#37; of athletes&#44; among whom it is 10 times more common than it is in control groups with the same age distribution&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a> The lifetime risk of Achilles tendon lesions in general among runners has been estimated to stand at 52&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">5</span></a> The exponential growth in the sociological phenomenon of running in Western countries<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">6</span></a> means that the prevalence of this condition is increasing&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Tendinopathy develops due to a combination of two types of factor&#58; mechanical &#40;overuse&#41; and biological &#40;lack of repair&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> This explains its high prevalence in long distance runners&#44; although it does not affect all of them&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The maximum force transmitted by the strong calf muscles is concentrated in the region of the body of the tendon&#44; which may withstand forces of 9000<span class="elsevierStyleHsp" style=""></span>N&#44; i&#46;e&#46;&#44; 13 times bodyweight&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a> Nevertheless&#44; it is here that Carr et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">9</span></a> used angiography to show that there is hypovascularisation where the vessels from the calcaneus and muscle join&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Micro-tears occur in runners in the type I collagen bundles&#44; and under normal conditions they would be repaired&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">10</span></a> However&#44; if the mechanical stimulus persists and surpasses the capacity for repair&#44; the collagen deposited does not have sufficient time to mature&#44; and it is replaced by disorganised bundles of type III collagen between areas of myxoid degeneration&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Cellular metaplasia occurs at the same time&#44; in which fibroblasts are replaced with myofibroblasts that concentrate in the peritendon&#44; creating adherences and collapsing vessels&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">12</span></a> Large amounts of growth factor are given off by the vascular endothelium&#44; and neovascularisation<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> occurs&#46; This is the second phenomenon which together with degeneration characterises non-insertional Achilles tendinopathy&#44; with an incidence in symptomatic tendons of from 70&#37; to 90&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> This neovascularisation is accompanied by aberrant nerve fibres that cause pain&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There are several options for treatment&#44; and none of them has been established as the gold standard&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> The only consensus is that conservative therapies should be used at the start of treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Nevertheless&#44; we found that in more than one-third of patients conservative treatment fails&#44; leading to the need to evaluate the indication for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients are often not offered alternative therapies at this time&#46; This situation sometimes includes an emotional component&#44; as patients are unable to compete or at the least have to permanently change their activity&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">To date most of the procedures used were restricted to longitudinal tendotomies&#44; macroscopically incising tissues that look devitalised&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Our aim is to present the results of the surgical procedure that consists of the freeing and&#47;or division of the peritendon&#44; adhesiolysis and radiofrequency in patients who are runners with tendinopathy of the mid-part of the Achilles tendon&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods&#58; our series</span><p id="par0060" class="elsevierStylePara elsevierViewall">We present a retrospective and descriptive study of a series of cases&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The series includes all of the patients operated from February 2010 to January 2013 for tendinopathy of the body of the Achilles tendon that fulfilled the following inclusion criteria&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Patients operated using the technique described by the surgeon S&#46; Orava&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> All patients were informed of the procedure and gave their written consent&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Active patients who practised sport including running every day until they developed tendinopathy&#46; The cohort includes a majority of elite professional athletes as well as very high level amateur athletes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Previous failure of at least 6 months of conservative treatment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Postoperative follow-up of at least 12 months&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">The following exclusion criteria were established&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Previous surgery in the affected Achilles tendon&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Partial tears within the tendon detected by MNR or during the operation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Concomitant insertional tendinopathy in the same limb&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">All the patients gave their informed consent for surgery and also consented to the use of their data for publication&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The surgical technique included the opening of the crural fascia&#44; peritendon adhesiolysis using a scalpel and microtendotomy&#46; The microtendotomy was undertaken in the zone of the tendinopathy in the body of the tendon by means of bipolar radiofrequency &#40;the Topaz MicroDebrider<span class="elsevierStyleSup">&#174;</span> by Arthorcare&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The tendon was perforated using radiofrequency perpendicular to the surface of the tendon&#44; with a distance between perforations of 5<span class="elsevierStyleHsp" style=""></span>mm and applying pulses at an interval of 500<span class="elsevierStyleHsp" style=""></span>ms&#46; The tendon may vary in thickness from one zone to another&#44; so that superficial and deep perforations were made&#44; creating a square three-dimensional pattern&#46; The tip of the radiofrequency device has a surface area of 0&#46;502<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> and a radius of action of 2&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The wound was sutured with non-absorbable thread and the calf and foot were bandaged&#46; Active mobility and isometric exercises were permitted from immediately after the operation&#44; and partial loading using two crutches was permitted the first week&#46; The stitches were removed at 2 weeks and exercise was permitted using an exercise bicycle&#46; At 3 weeks&#44; if the wound had good scar formation&#44; swimming-pool exercise commenced&#44; and after the fourth week exercise using an elliptical trainer was allowed&#46; A physiotherapy protocol was added to this&#44; with drainage of the oedema and manual stretching therapies&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The series consists of 17 cases in 13 patients operated by the same senior surgeon in the CEMTRO Clinic&#44; Madrid&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The demographic data and sports history of each patient are shown&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The results were evaluated on the Nirsch-Pain scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">14</span></a> which includes questions about everyday life as well as about functional repercussions in sport&#46; The visual scales such as VISA-A<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">15</span></a> which are usually used for the Achilles tendon were not used here&#46; This was because the condition is related so closely with sports activity that they would not have been useful for patients who only felt pain during exercise&#46; All the patients filled out the questionnaire on the same day of the operation&#44; as well as subsequently during follow-up&#58; at 2&#44; 4&#44; 6 and 12 months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The second parameter patients were asked about during check-ups was the return to previous levels of performance&#44; in terms of objective sport intensity criteria &#40;the time-distance ratio&#41; or frequency&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Prior to surgery patient&#39;s sports activity was modified&#44; provisionally replacing running exercises with other less traumatic ones&#46; They were prescribed muscle-building exercises such as closed kinetic chain exercises&#44; as well as cycling&#46; Eccentric exercises according to the Alfredson<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> protocols were combined with physiotherapy and the use of nutritional aids&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In all the sports people in the cohort this disease led to a major reduction in their performance as well as withdrawal from competition&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">The average age of the cohort at the time of the operation was 36 years&#44; while five Achilles tendons were operated in women and 12 in men&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The chief symptom due to which the patients visited was pain &#40;100&#37;&#41; located directly in the tendon body and occasionally radiating out proximally&#44; followed by thickening of the tendon &#40;70&#37;&#41;&#46; The pain was more intense at the start of training in the least advanced cases&#44; while in the most advanced cases it prevented normal walking&#46; Diagnosis was clinical&#44; although in all cases magnetic resonance was used to rule out the presence of partial tears and concomitant insertional disease&#44; as well as to stage the degree of tendon degeneration&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The average score on Nirschl&#39;s scale for the tendon involved at the moment of surgery was 4&#46;1 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; This shows that while the pain had little effect on the activities of everyday life&#44; it was a major restriction in sport&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">In 16 of the 17 tendons operated the symptoms had totally disappeared 12 months after the operation &#40;94&#37; rate of cure&#41;&#46; The pain did not disappear soon after the operation&#44; but rather in the majority of cases this occurred during postoperative rehabilitation&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Pain disappeared when running at an average of 17 weeks after surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The symptoms while running had not completely disappeared in one patient after 12 months&#59; this was one of the patients operated bilaterally&#46; Pain had disappeared completely in one leg&#44; while relief was incomplete in the other at 80&#37; &#40;passing from 5 to 1 on the Nirschl scale&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Nine of the 13 patients operated &#40;or 12 of the 17 tendons&#41; returned to their previous level of performance and training prior to the onset of their symptoms&#46; This represents a 70&#37; rate of performance recovery in the 12 months after surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Bipolar radiofrequency has been used before in different fields of orthopaedics&#46; A randomised clinical trial recently showed that radiofrequency is a promising alternative in the treatment of refractory epicondilitis&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a> and this disease is probably one of those with a physiopathological mechanism most similar to non-insertional Achilles tendinopathy&#46; It has also been shown to be effective in other chronic degenerative tendinopathies such as fasciitis plantar or patella tendinosis&#44; with 95&#37; of good or excellent results&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">17</span></a> It has also been shown to be effective in the treatment of rotator cuff tendinosis in the context of subacromial impingement syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">18</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Very few works have been published on the medium to long-term follow-up of the use of bipolar radiofrequency in the treatment of Achilles tendinopathy&#46; This is the first study of a homogeneous cohort of sports people which does not include sedentary patients with comorbidity that caused tendinopathy&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Although there is now no set protocol for the treatment of Achilles tendinopathy&#44; almost all authors defend commencing with conservative treatment&#46; Some authors such as Alfredson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">19</span></a> have proposed non-surgical treatment algorithms&#46; Nevertheless&#44; as they mix sedentary patients with others who do sports this may reduce the external validity of their studies&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The conservative treatments best supported by findings are eccentric exercises&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">1</span></a> which are widely used in Scandinavian countries&#46; They involve specific programmes lasting for several weeks or months&#44; and their initial results were very hopeful&#46; However&#44; more recent trials comparing some of these therapies with gentle non-systematic exercises either found no differences or far less optimistic results&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> On the other hand&#44; patient compliance with long-term daily exercises achieves a low level of adherence to the treatment&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Together with eccentric exercises&#44; shockwaves are the conservative therapy that is best supported by the evidence&#46; They act in three ways&#44; by promoting collagen synthesis&#44; destroying amyelinic fibres and hollowing out interstitial tissue&#46; All of this will activate scarring mechanisms&#46; A recent meta-analysis states that this technique is effective after 3 months in refractory non-insertional tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">21</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Respecting pharmacological treatments&#44; the use of NSAIDs is contraindicated by almost all authors&#46; This is because they interfere with cell repair mechanisms&#44; and some studies prove that inflammatory molecules such as prostaglandins are not present in this entity&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">22</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">In the same way that NSAIDs do not seem to be useful&#44; corticoid peritendon injections have not been shown to be effective in this condition&#44; although they are for acute peritendonitis&#46; As is the case for all tendons&#44; injections into this tendon must be avoided due to their catabolic effects&#46; Unlike NSAIDs&#44; cryotherapy has been shown to reduce metabolic needs as well as two thirds of capillary flow&#44; which in neovascularisation means reducing the extravasation of proteins that prolong pathogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">4</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Some articles with a high level of evidence have been published that state that there are no significant differences between the use of platelet-rich plasma and a placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a> Nevertheless&#44; other studies have obtained good results with the use of platelet-rich plasma in patients with non-insertional Achilles tendinopathy&#44; without distinguishing subgroups according to their sports activity&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">There are factors which have been shown to predispose runners to tendinopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">25</span></a> These include footwear&#44; training on hard surfaces&#44; lateral instability of the ankle and high arches&#44; and special attention should be paid to these&#46; This is why before indicating surgery we study and modify training habits as a fundamental part of the conservative treatment of our cohort&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">According to the majority of publications conservative techniques as a whole are successful in approximately 2&#47;3 of patients&#46; Many works cite permanent changes of activity&#44; based mainly on replacing running with some other type of activity&#44; without which they would probably not achieve such high success rates&#46; On the other hand the results of conservative treatment have been shown to be highly unpredictable in cases which evolved over several months&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">We did not find the same success rates in our experience&#44; given that our patients did not consider ceasing to run or definitively changing their activity as a treatment options&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">All of the patients in the series presented tendinopathy that was refractory to combined conservative treatment under our supervision&#46; Other previous conservative treatments which they may have followed without our indication were not taken into account&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Respecting surgical treatment&#44; the majority of authors agree that it should be used in the 25&#8211;35&#37; of patients who do not improve with conservative treatments&#46; They state that a waiting time of at least 6 months should be allowed before considering surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#44;3</span></a> It is here that patients of our type usually invest a large amount of time and money in seeking a solution&#44; without finding a standard surgical option&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Surgery aims on the one hand to reactivate or at least stimulate the intrinsic repair mechanisms which failed in conservative options&#46; There are a range of techniques to do this&#46; One example is to make longitudinal incisions&#44; which classically has been taken to be a procedure that promotes the recovery of normal tendon structure&#59; nevertheless&#44; no articles prove that this brings about a clinical improvement&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The other fundamental surgical procedure is the stripping of fibrotic adhesions as well as anomalous vessels and aberrant nerve fibres&#46; Van Dijk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">13</span></a> consider the cutting of the fibres that colonise the tendon from the paratendon to be the objective of treatment using endoscopic technique&#44; without acting on the degenerate tendon itself&#46; There are also other adhesiolysis techniques described by Mafulli et al&#46;&#44; such as the ultrasound-guided injection of large volumes of serum into the pre-Achilles zone<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a> and adhesiolysis by passing Ethibond thread through longitudinal incisions in the tendon &#40;stripping technique&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">The use of percutaneous radiofrequency has been described for insertional Achilles tendinopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> and while this may improve tissue repair&#44; it will not act on peritendon fibrotic adhesions and neovascularisation&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The proximal freeing of the gastrocnemius gives good results in sedentary patients&#44; in whom the postoperative strength of the leg operated does not differ from its preoperative strength&#59;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">30</span></a> however&#44; this may not be the most suitable technique for patients who do sports&#44; given the possibility that the operated leg may lose the strength necessary for running in comparison with the healthy leg&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">To try to improve Achilles tendon mechanics after cutting the peritendon pathological tissues&#44; some authors recently suggested lengthening the tendon using the hallucis longus flexor&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">31</span></a> and this may require a subsequent change of activity&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">We believe that in patients who are going to demand a high level of mechanical performance&#44; as is the case in our cohort&#44; surgical treatment firstly requires the stripping of all pathological tissue from around the tendon&#46; Doppler ultrasound will show a high increase in vascular flow in the tendon which should not be visible in normal tendons&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">32</span></a> This vascularisation will be what we strip away in the first phase of the operation&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">We then act on the tendon itself&#44; activating its overwhelmed repair mechanisms&#46; We use bipolar radiofrequency for this&#46; This technique was first used to treat myocardial ischaemia&#44; in which coblation showed an increase in functional vascularisation&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a> The terminal used applies a saline serum that spreads over the tissue at a speed that can be adjusted&#44; which when it makes contact with the electrode creates a jet of steam that consists of an ion-charged plasma field that dries the tissues&#46; Its main advantage vs electrocoagulation is that it acts at physiological temperatures&#44; and its field of action can be adjusted&#44; thereby reducing iatrogenic damage to adjacent structures&#46; This technique is highly reproducible&#44; given the absence of a long learning curve&#46; It is safe due to the small amount of tissue that is dried and the fact that it always occurs at a physiological temperature&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Careful follow-up is as important as appropriate surgical treatment&#44; given that the symptoms may take some time to disappear&#46; During this time it is of fundamental importance for our patient profile to keep fit&#44; so that they will have to perform activities other than running while gradually increasing the intensity at which the operated tendon works&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">To conclude&#44; we may say that non-insertional Achilles tendinopathy is an entity that is becoming more common in visits to sports injury clinics due to the increasing popularity of running&#46; Although conservative treatment should be the first choice&#44; specific aspects of highly demanding patients have to be taken into account&#46; If conservative treatment fails&#44; microstripping and coblation of the calcaneus tendon in sportsmen and women is a safe and reproducible technique&#46; It achieves a high rate of return to symptom-free activity as well as to the previous level of sport performance&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0295" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed comply with the ethical regulations of the corresponding human experimentation committee&#44; the World Medical Association and the Helsinki declaration&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors declare that they followed the protocols of their hospital on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0305" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in the article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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            0 => "Tendinopathy"
            1 => "Radiofrequency"
            2 => "Achilles tendon"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec620629"
          "palabras" => array:3 [
            0 => "Tendinopat&#237;a"
            1 => "Radiofrecuencia"
            2 => "Tend&#243;n de Aquiles"
          ]
        ]
      ]
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    "tieneResumen" => true
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To present the surgical technique with release of peritendon and radiofrequency as an effective treatment for athletes with chronic tendinopathy of the Achilles tendon body&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective case series descriptive type study&#46; The series consists of 17 Achilles tendon surgeries in 13 patients&#44; who habitually run&#46; The study included patients with non-insertional Achilles tendinopathy refractory to conservative treatments&#46; After a minimum follow-up of 12 months&#44; clinical improvement of the athletes was assessed using the Nirschl pain scale&#44; as well as athletic performance&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An improvement was obtained in 94&#37; of symptoms and a return to the previous performance in 70&#37; of cases in the 12 months follow-up&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Peritendon release combined with bipolar radiofrequency is presented as an effective solution in this condition&#44; for which there is currently no consensus on the best treatment&#46; In patients in whom the non-insertional Achilles tendinopathy persists after an appropriate conservative treatment for a sufficient period &#40;at least 6 months&#41;&#44; open adhesiolysis combined with bipolar radiofrequency is a safe and with a high success rate clinical and functional intervention&#46; In high performance athletes this technique allows a return to previous activity in a high percentage of cases&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Discussion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentar la t&#233;cnica quir&#250;rgica con liberaci&#243;n del peritend&#243;n y radiofrecuencia como un tratamiento eficaz para los pacientes con tendinopat&#237;a cr&#243;nica del cuerpo del tend&#243;n de Aquiles en deportistas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio descriptivo tipo serie de casos retrospectivo&#46; La serie se compone de 17 tendones de Aquiles operados en 13 pacientes&#44; todos ellos practicantes habituales de carrera a pie&#46; Fueron incluidos aquellos pacientes con tendinopat&#237;a no insercional del tend&#243;n de Aquiles refractaria al tratamiento conservador&#46; Se realiz&#243; un seguimiento m&#237;nimo de 12 meses&#44; evalu&#225;ndose la mejor&#237;a cl&#237;nica con ayuda de la escala de Nirschl-Pain&#44; as&#237; como el rendimiento deportivo de los atletas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se obtuvo un 94&#37; de desaparici&#243;n de los s&#237;ntomas y una vuelta al rendimiento previo del 70&#37; de los casos en los 12 meses de seguimiento&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La liberaci&#243;n del peritend&#243;n combinada con radiofrecuencia bipolar se presenta como una soluci&#243;n eficaz en esta enfermedad sobre la cual no existe en la actualidad un consenso acerca del mejor tratamiento&#46; En los pacientes que tras un tratamiento conservador adecuado durante un periodo suficiente &#40;al menos 6 meses&#41; persiste la tendinopat&#237;a no insercional del tend&#243;n de Aquiles&#44; la adhesi&#243;lisis abierta asociada a radiofrecuencia bipolar constituye una intervenci&#243;n segura y con una alta tasa de &#233;xito&#44; tanto cl&#237;nica como funcional&#46; En el deportista de alto rendimiento esta t&#233;cnica permite la vuelta a la actividad previa en un alto porcentaje&#46;</p></span>"
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            "identificador" => "abst0025"
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            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Discusi&#243;n"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arnal-Burr&#243; J&#44; L&#243;pez-Capap&#233; D&#44; Igualada-Bl&#225;zquez C&#44; Ortiz-Espada A&#44; Mart&#237;n-Garc&#237;a A&#46; Tratamiento quir&#250;rgico de la tendinopat&#237;a aqu&#237;lea cr&#243;nica no insercional en corredores mediante el uso de radiofrecuencia bipolar&#46; Rev Esp Cir Ortop Traumatol&#46; 2016&#59;60&#58;125&#8211;132&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Phase&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rigidity or slight pain after the activity&#46; The pain generally disappears after 24<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rigidity or slight pain before the sports activity that is relieved by warming upThe symptoms are not present during daily activity&#44; but return afterwards and last up to 48<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rigidity or slight pain before the sports or occupational activity&#46; The pain is partially relieved by warming up&#46; It is minimally present during everyday activity&#44; but does not alter the same&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The same as phase 3&#44; but the pain is more intense&#44; leading the patient to modify execution of the sports activity&#46; The slight pain appears with everyday activities&#44; but does not cause any major change to them&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Significant pain &#40;moderate or greater&#41; before&#44; during and after sports activity&#44; causing alteration in the same&#46; The pain is also present with everyday activities&#44; but it does not cause a major change in them&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The same as phase 5&#44; but the pain persists even with absolute repose&#46; The pain interrupts the simple activities of everyday life and prevents doing the housework&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phase 7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The same as phase 6&#44; but the pain disturbs sleep&#46; Pain is present in repose and intensifies with la activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The Nirschl pain scale&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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ISSN: 19888856
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