Debride, Refill, Fertilize: Technique Description with Corresponding Case Report of a Novel, Minimally Invasive Treatment for Achilles Tendon Partial Tears
Main Article Content
Michael Khadavi, MD
http://orcid.org/0009-0002-2304-5917
Ann Wingard, DO
http://orcid.org/0009-0001-0041-3564
Alexandre Lavigne, MD
http://orcid.org/0000-0003-4668-4543
Kirk McCullough, MD
http://orcid.org/0000-0001-8535-6230
http://orcid.org/0009-0002-2304-5917
Ann Wingard, DO
http://orcid.org/0009-0001-0041-3564
Alexandre Lavigne, MD
http://orcid.org/0000-0003-4668-4543
Kirk McCullough, MD
http://orcid.org/0000-0001-8535-6230
Abstract
Treatment of midportion Achilles tendinopathy and partial tear pathology is particularly challenging, with surgical treatments characterized by prolonged recoveries, modest outcomes, and up to 11% complication rate, while more recent minimally invasive strategies including percutaneous tenotomy, platelet-rich plasma injection, and tendon hydrodissection have at best demonstrated mixed results. We hypothesize that failures from available surgical and minimally invasive treatments occur because they address only part of the pathology (e.g., orthobiologics focused on promoting tendon growth without addressing the burden of diseased, degenerative tendon tissue). Similarly, percutaneous or surgical debridement while removing pathologic tissue unfortunately leaves large voids in the tendon with hopes of creating a vascular and healing response that will fill the void. Herein, we present a novel multifaceted approach with a corresponding case report of three sequential, minimally invasive therapies utilizing unique yet complimentary mechanisms of action: debridement with percutaneous ultrasonic tenotomy, tissue void grafting with allograft connective tissue matrix, and promotion of tendon repair/regeneration with harvested bone marrow concentrate. This case is of a 39-year-old male recreational athlete who failed two years of conservative care and orthobiologic injections for his midportion Achilles tendinopathy and partial tear. Following treatment with percutaneous ultrasonic tenotomy and injection of allograft connective tissue matrix along with autologous bone marrow concentrate, he returned to most athletic activities by three months and ultimately achieved a full asymptomatic and functional recovery by six months with complete healing of his partial tendon tear on follow-up magnetic resonance imaging.
Keywords:
Achilles tendinopathy, tenotomy, bone marrow concentrate, connective tissue matrix, orthobiologics, ultrasound
Article Details
How to Cite
KHADAVI, Michael et al.
Debride, Refill, Fertilize: Technique Description with Corresponding Case Report of a Novel, Minimally Invasive Treatment for Achilles Tendon Partial Tears.
Medical Research Archives, [S.l.], v. 13, n. 3, mar. 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6379>. Date accessed: 06 apr. 2025.
doi: https://doi.org/10.18103/mra.v3i3.6379.
Section
Case Reports
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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18. Tallon C, Coleman BD, Khan KM, Maffulli N. Outcome of surgery for chronic Achilles tendinopathy. A critical review. Am J Sports Med. 2001;29(3):315-320.
19. Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br. 2002;84(1):1-8.
20. Lohrer H. Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area. J Orthop Surg Res. 2020;15(1):395.
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25. Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review. Sports Health. 2021;13(3):258-264.
26. Wang H, Yu R, Wang M, et al. Insulin-like growth factor binding protein 4 loaded electrospun membrane ameliorating tendon injury by promoting retention of IGF-1. J Control Release. 2023;356:162-174.
27. Liu X, Zhu B, Li Y, et al. The Role of Vascular Endothelial Growth Factor in Tendon Healing. Front Physiol. 2021;12:766080.
28. Blair P, Flaumenhaft R. Platelet alpha-granules: basic biology and clinical correlates. Blood Rev. 2009;23(4):177-189.
29. Everts P, Onishi K, Jayaram P, Lana JF, Mautner K. Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020. Int J Mol Sci. 2020;21(20).
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31. de Vos RJ, Weir A, van Schie HTM, et al. Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial. JAMA. 2010;303(2):144-149.
32. Barreto ESR, Antunes Junior CR, Silva IC, Alencar VB, Faleiro TB, Kraychete DC. Is Platelet-rich Plasma Effective in Treating Achilles Tendinopathy? A Meta-analysis of Randomized Clinical Trials. Clin Orthop Relat Res. 2024.
33. Cassano JM, Kennedy JG, Ross KA, Fraser EJ, Goodale MB, Fortier LA. Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):333-342.
34. Yuksel S, Gulec MA, Gultekin MZ, et al. Comparison of the early period effects of bone marrow-derived mesenchymal stem cells and platelet-rich plasma on the Achilles tendon ruptures in rats. Connect Tissue Res. 2016;57(5):360-373.
35. Thampatty B, Li H, Im H, Wang J. EP4 receptor regulates collagen type-I, MMP-1, and MMP-3 gene expression in human tendon fibroblasts in response to IL-1β treatment. Gene. 2007;386(1-2):154-161.
36. Ziegler CG, Van Sloun R, Gonzalez S, et al. Characterization of Growth Factors, Cytokines, and Chemokines in Bone Marrow Concentrate and Platelet-Rich Plasma: A Prospective Analysis. Am J Sports Med. 2019;47(9):2174-2187.
37. Machlus KR, Italiano JE, Jr. The incredible journey: From megakaryocyte development to platelet formation. J Cell Biol. 2013;201(6):785-796.
38. Gissi C, Radeghieri A, Antonetti Lamorgese Passeri C, et al. Extracellular vesicles from rat-bone-marrow mesenchymal stromal/stem cells improve tendon repair in rat Achilles tendon injury model in dose-dependent manner: A pilot study. PLoS One. 2020;15(3):e0229914.
39. Yin Z, Chen X, Zhu T, et al. The effect of decellularized matrices on human tendon stem/progenitor cell differentiation and tendon repair. Acta Biomater. 2013;9(12):9317-9329.
40. Mao Y, John N, Protzman NM, et al. A decellularized flowable placental connective tissue matrix supports cellular functions of human tenocytes in vitro. J Exp Orthop. 2022;9(1):69.
41. Merry K, Napier C, Waugh CM, Scott A. Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications. J Clin Med. 2022;11(16).
42. Khadavi M, Rehor D, Roney A, Podesta L, Smith DR. Regional Anesthesia for Orthobiologic Procedures. Phys Med Rehabil Clin N Am. 2023;34(1):291-309.
43. Hernigou P, Homma Y, Flouzat Lachaniette CH, et al. Benefits of small volume and small syringe for bone marrow aspirations of mesenchymal stem cells. Int Orthop. 2013;37(11):2279-2287.
44. Abadin AA, Orr JP, Lloyd AR, Henning PT, Pourcho A. An Evidence-Based Approach to Orthobiologics for Tendon Disorders. Phys Med Rehabil Clin N Am. 2023;34(1):83-103.
45. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38(2):255-262.
46. Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-471.
47. Peerbooms JC, Lodder P, den Oudsten BL, Doorgeest K, Schuller HM, Gosens T. Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial. Am J Sports Med. 2019;47(13):3238-3246.
48. Kirschner JS, Cheng J, Hurwitz N, et al. Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial. PM R. 2021;13(12):1340-1349.
49. Chimenti RL, Stover DW, Fick BS, Hall MM. Percutaneous Ultrasonic Tenotomy Reduces Insertional Achilles Tendinopathy Pain With High Patient Satisfaction and a Low Complication Rate. J Ultrasound Med. 2019;38(6):1629-1635.
50. Thueakthong W, de Cesar Netto C, Garnjanagoonchorn A, et al. Outcomes of iliac crest bone marrow aspirate injection for the treatment of recalcitrant Achilles tendinopathy. Int Orthop. 2021;45(9):2423-2428.
51. Stein BE, Stroh DA, Schon LC. Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation. Int Orthop. 2015;39(5):901-905.
2. Komi PV, Fukashiro S, Jarvinen M. Biomechanical loading of Achilles tendon during normal locomotion. Clin Sports Med. 1992;11(3):521-531.
3. Sadeghi S, Taghizadeh H. Microstructural modeling of Achilles Tendon biomechanics focusing on bone insertion site. Med Eng Phys. 2020;78:48-54.
4. Tits A, Blouin S, Rummler M, et al. Structural and functional heterogeneity of mineralized fibrocartilage at the Achilles tendon-bone insertion. Acta Biomater. 2023;166:409-418.
5. Palmes D, Spiegel HU, Schneider TO, et al. Achilles tendon healing: long-term biomechanical effects of postoperative mobilization and immobilization in a new mouse model. J Orthop Res. 2002;20(5):939-946.
6. Yasuda T, Kinoshita M, Abe M, Shibayama Y. Unfavorable effect of knee immobilization on Achilles tendon healing in rabbits. Acta Orthop Scand. 2000;71(1):69-73.
7. Reddy GK, Stehno-Bittel L, Enwemeka CS. Matrix remodeling in healing rabbit Achilles tendon. Wound Repair Regen. 1999;7(6):518-527.
8. de Jonge S, van den Berg C, de Vos RJ, et al. Incidence of midportion Achilles tendinopathy in the general population. Br J Sports Med. 2011; 45(13):1026-1028.
9. Chen W, Cloosterman KLA, Bierma-Zeinstra SMA, van Middelkoop M, de Vos RJ. Epidemiology of insertional and midportion Achilles tendinopathy in runners: A prospective cohort study. J Sport Health Sci. 2023.
10. Allenmark C. Partial Achilles tendon tears. Clin Sports Med. 1992;11(4):759-769.
11. Jarvinen TA, Kannus P, Paavola M, Jarvinen TL, Jozsa L, Jarvinen M. Achilles tendon injuries. Curr Opin Rheumatol. 2001;13(2):150-155.
12. von Rickenbach KJ, Borgstrom H, Tenforde A, Borg-Stein J, McInnis KC. Achilles Tendinopathy: Evaluation, Rehabilitation, and Prevention. Curr Sports Med Rep. 2021;20(6):327-334.
13. Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in the damaged and healing tendon. Arthritis Res. 2002;4(4):252-260.
14. Yang G, Rothrauff BB, Tuan RS. Tendon and ligament regeneration and repair: clinical relevance and developmental paradigm. Birth Defects Res C Embryo Today. 2013;99(3):203-222.
15. Arvind V, Huang AH. Reparative and Maladaptive Inflammation in Tendon Healing. Front Bioeng Biotechnol. 2021;9:719047.
16. Gatz M, Spang C, Alfredson H. Partial Achilles Tendon Rupture-A Neglected Entity: A Narrative Literature Review on Diagnostics and Treatment Options. J Clin Med. 2020;9(10).
17. Medeiros DM. Conservative treatment of Achilles tendon partial tear in a futsal player: A case report. Physiother Theory Pract. 2021;37(10):1158-1165.
18. Tallon C, Coleman BD, Khan KM, Maffulli N. Outcome of surgery for chronic Achilles tendinopathy. A critical review. Am J Sports Med. 2001;29(3):315-320.
19. Maffulli N, Kader D. Tendinopathy of tendo achillis. J Bone Joint Surg Br. 2002;84(1):1-8.
20. Lohrer H. Minimum 3.5-year outcomes of operative treatment for Achilles tendon partial tears in the midportion and retrocalcaneal area. J Orthop Surg Res. 2020;15(1):395.
21. Lohrer H, David S, Nauck T. Surgical treatment for achilles tendinopathy - a systematic review. BMC Musculoskelet Disord. 2016;17:207.
22. Paavola M, Orava S, Leppilahti J, Kannus P, Jarvinen M. Chronic Achilles tendon overuse injury: complications after surgical treatment. An analysis of 432 consecutive patients. Am J Sports Med. 2000;28(1):77-82.
23. Phisitkul P. Endoscopic surgery of the Achilles tendon. Curr Rev Musculoskelet Med. 2012;5(2):156-163.
24. Carreira D, Ballard A. Achilles tendoscopy. Foot Ankle Clin. 2015;20(1):27-40.
25. Vajapey S, Ghenbot S, Baria MR, Magnussen RA, Vasileff WK. Utility of Percutaneous Ultrasonic Tenotomy for Tendinopathies: A Systematic Review. Sports Health. 2021;13(3):258-264.
26. Wang H, Yu R, Wang M, et al. Insulin-like growth factor binding protein 4 loaded electrospun membrane ameliorating tendon injury by promoting retention of IGF-1. J Control Release. 2023;356:162-174.
27. Liu X, Zhu B, Li Y, et al. The Role of Vascular Endothelial Growth Factor in Tendon Healing. Front Physiol. 2021;12:766080.
28. Blair P, Flaumenhaft R. Platelet alpha-granules: basic biology and clinical correlates. Blood Rev. 2009;23(4):177-189.
29. Everts P, Onishi K, Jayaram P, Lana JF, Mautner K. Platelet-Rich Plasma: New Performance Understandings and Therapeutic Considerations in 2020. Int J Mol Sci. 2020;21(20).
30. Miller LE, Parrish WR, Roides B, Bhattacharyya S. Efficacy of platelet-rich plasma injections for symptomatic tendinopathy: systematic review and meta-analysis of randomised injection-controlled trials. BMJ Open Sport Exerc Med. 2017;3(1):e000237.
31. de Vos RJ, Weir A, van Schie HTM, et al. Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial. JAMA. 2010;303(2):144-149.
32. Barreto ESR, Antunes Junior CR, Silva IC, Alencar VB, Faleiro TB, Kraychete DC. Is Platelet-rich Plasma Effective in Treating Achilles Tendinopathy? A Meta-analysis of Randomized Clinical Trials. Clin Orthop Relat Res. 2024.
33. Cassano JM, Kennedy JG, Ross KA, Fraser EJ, Goodale MB, Fortier LA. Bone marrow concentrate and platelet-rich plasma differ in cell distribution and interleukin 1 receptor antagonist protein concentration. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):333-342.
34. Yuksel S, Gulec MA, Gultekin MZ, et al. Comparison of the early period effects of bone marrow-derived mesenchymal stem cells and platelet-rich plasma on the Achilles tendon ruptures in rats. Connect Tissue Res. 2016;57(5):360-373.
35. Thampatty B, Li H, Im H, Wang J. EP4 receptor regulates collagen type-I, MMP-1, and MMP-3 gene expression in human tendon fibroblasts in response to IL-1β treatment. Gene. 2007;386(1-2):154-161.
36. Ziegler CG, Van Sloun R, Gonzalez S, et al. Characterization of Growth Factors, Cytokines, and Chemokines in Bone Marrow Concentrate and Platelet-Rich Plasma: A Prospective Analysis. Am J Sports Med. 2019;47(9):2174-2187.
37. Machlus KR, Italiano JE, Jr. The incredible journey: From megakaryocyte development to platelet formation. J Cell Biol. 2013;201(6):785-796.
38. Gissi C, Radeghieri A, Antonetti Lamorgese Passeri C, et al. Extracellular vesicles from rat-bone-marrow mesenchymal stromal/stem cells improve tendon repair in rat Achilles tendon injury model in dose-dependent manner: A pilot study. PLoS One. 2020;15(3):e0229914.
39. Yin Z, Chen X, Zhu T, et al. The effect of decellularized matrices on human tendon stem/progenitor cell differentiation and tendon repair. Acta Biomater. 2013;9(12):9317-9329.
40. Mao Y, John N, Protzman NM, et al. A decellularized flowable placental connective tissue matrix supports cellular functions of human tenocytes in vitro. J Exp Orthop. 2022;9(1):69.
41. Merry K, Napier C, Waugh CM, Scott A. Foundational Principles and Adaptation of the Healthy and Pathological Achilles Tendon in Response to Resistance Exercise: A Narrative Review and Clinical Implications. J Clin Med. 2022;11(16).
42. Khadavi M, Rehor D, Roney A, Podesta L, Smith DR. Regional Anesthesia for Orthobiologic Procedures. Phys Med Rehabil Clin N Am. 2023;34(1):291-309.
43. Hernigou P, Homma Y, Flouzat Lachaniette CH, et al. Benefits of small volume and small syringe for bone marrow aspirations of mesenchymal stem cells. Int Orthop. 2013;37(11):2279-2287.
44. Abadin AA, Orr JP, Lloyd AR, Henning PT, Pourcho A. An Evidence-Based Approach to Orthobiologics for Tendon Disorders. Phys Med Rehabil Clin N Am. 2023;34(1):83-103.
45. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010;38(2):255-262.
46. Mishra AK, Skrepnik NV, Edwards SG, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42(2):463-471.
47. Peerbooms JC, Lodder P, den Oudsten BL, Doorgeest K, Schuller HM, Gosens T. Positive Effect of Platelet-Rich Plasma on Pain in Plantar Fasciitis: A Double-Blind Multicenter Randomized Controlled Trial. Am J Sports Med. 2019;47(13):3238-3246.
48. Kirschner JS, Cheng J, Hurwitz N, et al. Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial. PM R. 2021;13(12):1340-1349.
49. Chimenti RL, Stover DW, Fick BS, Hall MM. Percutaneous Ultrasonic Tenotomy Reduces Insertional Achilles Tendinopathy Pain With High Patient Satisfaction and a Low Complication Rate. J Ultrasound Med. 2019;38(6):1629-1635.
50. Thueakthong W, de Cesar Netto C, Garnjanagoonchorn A, et al. Outcomes of iliac crest bone marrow aspirate injection for the treatment of recalcitrant Achilles tendinopathy. Int Orthop. 2021;45(9):2423-2428.
51. Stein BE, Stroh DA, Schon LC. Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation. Int Orthop. 2015;39(5):901-905.