How To Repair A Bony Spur On The Achilles

HISTORICAL PERSPECTIVE

Achilles tendinopathy is defined equally a degenerative process of the Achilles tendon and can exist categorized as insertional or noninsertional tendinopathy.¹ Insertional Achilles tendinopathy frequently involves intratendinous calcification of the Achilles tendon insertion and a prominent superolateral calcaneus tuberosity known every bit a Haglund's deformity. Haglund² first described the superolateral calcaneus prominence in a case study. The incidence of insertional Achilles tendinopathy is upwardly to 30%, affecting both recreational and aristocracy athletes.³ The insertional footprint of the Achilles tendon is 1.4 mm wide and 10 mm long. At the calcaneal insertion, the retrocalcaneal bursa inserts onto the superior facet, the soleus inserts onto the medial-middle facet, and the gastrocnemius inserts onto the lateral-middle facet and inferior facet.⁴ There are intrinsic and extrinsic risk factors that play a role in developing insertional Achilles tendinopathy. Intrinsically, the Achilles tendon has poor vascularity, with the distal ii to vi cm of the tendon beingness relatively avascular.⁵ The poor vascularity leads to intrasubstance tendon degeneration (tendinosis), whereas the more vascular paratenon and retrocalcaneal fat are more susceptible to an inflammatory response. Other intrinsic risk factors include obesity, hypertension, diabetes, and steroid use.^vi Extrinsic factors include overuse with repetitive running and jumping.ⁱ Biomechanically, the Achilles tendon is subjected to large stresses during the opinion stage and can be loaded up to ten times ane'southward torso weight. The combination of poor vascularity and microtrauma at the Achilles insertion leads to degeneration, hurting, and dysfunction.

INDICATIONS AND CONTRAINDICATIONS

Bourgeois treatment for insertional Achilles tendinopathy includes nonsteroidal anti-inflammatory drugs, rest, wide shoe vesture, heel lifts, gastrocnemius stretching, activity modification eccentric exercises, supination orthotics, and dark splints.⁷ Nonoperative handling should be continued until the patient is asymptomatic for 2 weeks. Overall, a pregnant number of patients with insertional Achilles tendinopathy proceed to have symptoms despite conservative handling. Verrall et al⁸ showed that a half dozen-week eccentric Achilles heel-drop protocol tin can pb to an 82% satisfaction rate in athletes with chronic Achilles tendinopathy. However, the subset of athletes with insertional Achilles tendinopathy, there was only a 50% satisfaction rate and 21% of athletes underwent surgical intervention within xiv months. Paavola and colleagues showed that during their 8-year observational report, 29% of patients with Achilles tendinopathy went on to undergo surgical treatment. Nichiolson et al⁹ demonstrated that patients with insertional Achilles tendinopathy with magnetic resonance imaging (MRI) evidence of all-encompassing tendinosis had poorer outcomes after nonoperative treatment.

The indications for surgical handling of insertional Achilles tendinopathy is appropriate when a patient's symptoms are recalcitrant to nonoperative therapies. Contraindications for surgical treatment include patients with an active infection, overall poor health, vascular compromise, and poor skin integrity. Previous surgical approaches that have been described in the literature include the lateral,^x medial,^xi medial-J incision,¹² dual,^one and endoscopic.¹³ Significant wound complications are associated with these approaches. In 2002, McGarvey et al¹⁴ popularized the midline longitudinal incision, which is ordinarily used today. Insertional Achilles repair with double-row suture anchors has increasingly become more than common among clinicians.¹⁵ Thus, we will draw our unique double-row repair technique for insertional Achilles tendinopathy.

PREOPERATIVE PLANNING

Patients with insertional Achilles tendinopathy present clinically with posterior heel swelling, pain, and a prominent superolateral calcaneus tuberosity.¹⁶ Individuals will accept a sensation of stiffness around their heel in the early mornings and posterior heel pain during the day. Restrictive shoe clothing may also contribute to pain around the Haglund's deformity. On exam, patients volition take a palpable nodule forth the Achilles tendon in patients with more all-encompassing tendinopathy. In that location may also be hurting along either side of the Achilles tendon, indicative of retrocalcaneal bursitis. The painful retrocalcaneal bursa should be removed at the time of surgery. An important clinical examination is a Silfverskiöld test, which tin detect a gastrocnemius or Achilles contracture. A gastrocnemius contracture is defined every bit having <5 degrees of passive talocrural joint dorsiflexion with the articulatio genus in total extension. An Achilles contracture is defined every bit having <10 degrees of passive talocrural joint dorsiflexion when the knee is in xc degrees of flexion. A patient with a gastrocnemius or Achilles contracture may be contributing to their Achilles tendinopathy and can make adequate debridement more hard. Prone examination of the affected limb will reveal a face-to-face Achilles tendon without a palpable gap. The affected foot will have a normal resting tone and the Thompson test should exist negative.

A weight-bearing evidently radiograph of the lateral foot should be obtained to appraise for intrasubstance calcification at the Achilles insertion (Fig. one). Large amounts of tendon calcification denote marked tendon degeneration and may warrant advanced imaging to delineate the extent of Achilles tendon interest. In improver, evaluation of a prominent Haglund's deformity should besides be noted. Individuals with a cavus foot may have an increased calcaneal pitch that may increment the impingement of the superolateral calcaneus tuberosity onto the Achilles insertion. MRI tin exist obtained to assess for intrasubstance delamination or degeneration.⁹ If extensive tendon involvement is seen on MRI, so either a proximal Achilles tendon debridement or flexor tendon transfer may exist warranted intraoperatively.

FIGURE 1:

Lateral foot apparently radiograph demonstrating a Haglund's deformity (white asterisks) along with insertional Achilles tendon calcifications (white pointer).

TECHNIQUE

Surgical Technique for Retrocalcaneal Spur Removal

The popliteal block anesthetic and general anesthesia are administered by the anesthesia squad. The patient is then intubated by anesthesia. After this, the patient is then positioned onto the operative table in the prone position with their heels placed just distal to the edge of the operative table to allow for adequate ankle dorsiflexion during the case. Subsequently proper prepping and draping, a sterile four-inch Esmarch tourniquet is wrapped up to the mid-dogie to exsanguinate the limb. The Esmarch tourniquet is held in place with a Kelly clamp. It is besides acceptable to use a thigh-high tourniquet. A half dozen-cm longitudinal midline skin incision is made using a #xv blade direct over the Haglund's deformity with the ankle in maximal dorsiflexion (Fig. 2). The incision should be carried to the inferior aspect of the calcaneus tuberosity for acceptable visualization of the Achilles tendon insertion. The deep incision is and so carried in line with the skin incision directly onto the bone. No superficial skin flaps are made to protect the vascularity of the surgical wound. The distal insertion of the Achilles tendon at the inferior facet of the calcaneus is sharply peeled from the medial and lateral calcaneus tuberosity inside the separate tendon to fully expose the Haglund's deformity. Care is taken during the medial dissection to prevent lacerating the flexor hallucis longus tendon. It is also important that during the subperiosteal dissection of the Achilles insertion non to completely detach the Achilles tendon. This can be washed by leaving the very medial and lateral attachment of the tendon to the bone intact.

Effigy 2:

A full-thickness half dozen-cm longitudinal incision is made direct over the Haglund'due south deformity to betrayal the superolateral calcaneal bony prominence.

Once the Haglund deformity is fully exposed, a big rongeur is used to excise the entire retrocalcaneal bursa to visualize the superior well-nigh extent of the Haglund deformity (Fig. 3). the posterior subtalar joint. Exposure of the subtalar joint is critical to accurately marking the resection level of the Haglund's deformity and to non violate the subtalar joint with the aquiver saw. Next, self-retaining retractors are placed on the medial and lateral aspect of the Haglund deformity to protect the Achilles tendon. An oscillating saw is so used to perform a calcaneal exostectomy (Fig. 4). Adequate resection of the Haglund lesion is confirmed on a lateral fluoroscopic image of the pes (Fig. 5). After removing the posterior tuberosity, the oscillating saw is placed at a 45-degree angle on either side of the resected area of the calcaneus to bevel whatsoever prominent edges of the bone. We likewise use a small rasp to ensure that the calcaneus has a smooth surface and and so that there are no sharp edges that tin can carp patients. One time this is completed, the Achilles tendon is addressed.

FIGURE 3:

A big rongeur is used to excise the unabridged retrocalcaneal bursa to visualize the superior most extent of the Haglund deformity (white asterisks).

Effigy 4:

An oscillating saw is then used to perform a calcaneal exostectomy (A). The aquiver saw is then turned 45 degrees to bevel the prominent bony edges from the resected calcaneus (B).

Effigy five:

Intraoperative lateral fluoroscopic image of the foot demonstrating the resected Haglund'south deformity (white asterisks).

Surgical Technique for Achilles Debridement and Repair

The Achilles tendon is and so inspected to determine the extent of tendinopathy. The diseased tendon will seem similar crab meat and will lack the longitudinal striations seen in the normal tendon. The diseased tendon may also take intrasubstance calcifications. Using a #10 blade, the deep degenerative Achilles tendon is carefully debrided on its apartment surface to remove bone or thickened gristly tissue (Fig. 6). Care must be taken not to transect the tendon during the debridement. If a substantial amount is tendon is debrided and at that place is insufficient tendon left for suture ballast repair, then consideration for a flexor hallucis longus should be fabricated.

FIGURE 6:

Using a #10 blade, the deep degenerative Achilles tendon is carefully debrided longitudinally.

After the Achilles tendon is debrided, a 3.5 mm drill fleck should be used to drill four holes for suture anchors placement. The iv holes are placed 1 cm proximal to the inferior posterior calcaneus tuberosity and the holes are drilled in a foursquare configuration to recreate the wide Achilles footprint. These 4 holes are then tapped using a 4.75-mm tap. After this, the two proximal 4.75-mm Speedbridge anchors (Arthrex, Naples, FL) are placed into the posterior calcaneus tuberosity (Fig. seven). Afterwards this, a suture needle is used to pass the single FiberTape (Arthrex) limb of the medial-proximal anchor through the medial half of the split Achilles tendon. The suture should be passed full-thickness through the Achilles tendon and slightly proximal to the ballast site to increase the tension of the Achilles tendon when information technology is repaired. This step is repeated for the lateral limb. Once both limbs are passed on either side of the Achilles tendon, one suture from each the proximal-medial and proximal-lateral limb are anchored together into the distal-medial anchor. This pace is repeated for the distal-lateral anchor to create a double-row repair. To establish appropriate tendon tension, the pes should be plantarflexed. Next, the preloaded #two FiberWire suture from the medial-distal anchor is then passed within the intrasubstance of the Achilles tendon from distal to proximal in a running style to reapproximate the split Achilles tendon ends (Fig. 8).

FIGURE 7:

After this, the 2 proximal four.75-mm Speedbridge anchors (Arthrex, Naples, FL) are placed into the posterior calcaneus tuberosity (A). Once both limbs are passed on either side of the Achilles tendon, the suture from the lateral tendon is crossed over the peak of the Achilles insertion and anchored into the distal-medial anchor (B).

FIGURE eight:

The preloaded #ii FiberWire suture from the medial-distal ballast is so pass within the intrasubstance of the Achilles tendon (A) from distal to proximal in a running manner to reapproximate the split Achilles tendon (B).

The dermal layer is closed with deep 3-0 absorbable braided suture and the pare is airtight with interrupted iii-0 nonabsorbable monofilament suture. Soft dressings and a well-padded brusque leg bandage are placed with the foot in its resting plantarflexed position for 3 weeks.

Postoperative Management

The patient volition be nonweight-bearing on the operative extremity for 3 weeks to allow for the incision to heal. After 3 weeks, the patient volition and so transition into a pneumatic walking kick and will be allowed partial weight-bearing with an assistive device. From three to 6 weeks, active plantarflexion is allowed, but passive dorsiflexion past neutral should be avoided. Full weight bearing on the operative extremity is initiated 6 weeks postoperatively. Physical therapy is initiated from vi to 12 weeks, consisting of gentle concentric Achilles strengthening. Return to activities is normally at the 4-month mark.

RESULTS

The outcomes following Haglund excision utilizing the posterior midline approach take been shown to be favorable. McGarvey et al retrospectively reported on 21 patients (22 feet) who underwent Haglund'due south excision and side-to-side insertional Achilles repair without suture anchors.¹⁴ At an boilerplate of 33 months follow-up, in that location was an 82% satisfaction rate and 91% return to piece of work rate. Johnson et al¹⁷ studied 22 patients who underwent Haglund'due south excision with Achilles repair utilizing ii unmarried-row bone anchors. At a mean follow-upward of 34 months, the American Orthopaedic Foot and Ankle Society score (AOFAS) improved from 53 to 89, and pain scores improved from 7 to 33. In addition, 91% of the cohort was able to piece of work full time and 77% of the cohort did not have pain with shoe wear. Nunley et al¹⁸ studied 27 patients (29 feet) that underwent Haglund excision and Achilles repair with the single-row os ballast. They found at a follow-up of 4 years, the mean AOFAS score was 96. At 7-yr follow-upward, in that location was no strength deficit compared with the contralateral limb and patients reported a 96% success rate. Greenhagen et al¹⁹ studied 35 patients who underwent Haglund'southward excision with suture bridge fixation of the Achilles tendon insertion. At a hateful follow-up of 28.9 months, the mean AOFAS scores improved from 56.half dozen to 91.7 with a 97% success rate. Biomechanically, Beitzel et al¹⁵ performed a cadaveric study comparing unmarried and double-row insertional Achilles tendon repairs and found that double-row repair had a higher peak load to failure. Cox and colleagues performed a randomized cadaveric biomechanical written report comparison knotted versus knotless suture bridge repair for the Achilles tendon insertion. They found improved strength and improved pb to failure with knotted suture bridge repair.^xx In regards to flexor hallucis longus transfer augmentation, Hunt et al²¹ performed a randomized command trial of 39 patients over the age of 50 with chronic insertional Achilles tendinopathy. One grouping of patients underwent Achilles debridement and straight repair whereas the experimental group underwent Achilles debridement with FHL augmentation. At one-yr follow-upward, there was no difference in AOFAS or visual analog score despite improvement in ankle plantarflexion strength for the FHL augmentation group.

COMPLICATIONS

Complications later on open Achilles insertional surgery are non insignificant.^{17–19,22,23} It is important to counsel patients that continued pain with shoe vesture can occur in 23% of patients postoperatively.¹⁷ Wound dehiscence occurs in six% to 12% of open up insertional Achilles tendon surgery.^17,22 Other complications include infection (6%),²² sural neuritis (0% to 4%),^17,22 Achilles tendon rupture (three.eight%),²³ and deep venous thrombosis (iii.1%).¹⁷

Futurity OF THE TECHNIQUE

In that location is a paucity of literature on the benefits of biologic treatment for nonoperative direction of insertional Achilles tendinopathy.²⁴ Further research needs to be performed to empathize the importance and clinical benefits of performing flexor hallucis longus tendon augmentation for severely degenerative Achilles tendons.

Pearls and Pitfalls

• The heel should be positioned distal to the edge of the bed to allow for adequate dorsiflexion during the procedure.
• An adequate longitudinal midline incision should be fabricated to run into the inferior most attribute of the Achilles tendon insertion.
• A full-thickness tissue flap should be made sharply with a knife to minimize superficial soft tissue stripping and devascularization.
• Acceptable resection of the Haglund'southward deformity should exist fabricated with an oscillating saw without violating the subtalar joint.
• After the Haglund'due south deformity resection, the posterior calcaneus should be palpated for any sharp bony prominences.
• After bony anchor placement, the proximal anchor sutures should be passed slightly proximal through the split up Achilles tendon and the foot should be plantarflexed to provide adequate tendon tension during the repair.
• If in that location is not adequate talocrural joint dorsiflexion, so one should consider performing a gastrocnemius recession.
• The double-row repair allows for a more anatomic restoration of the Achilles tendon footprint.

REFERENCES

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eighteen. Nunley JA, Ruskin G, Horst F. Long-term clinical outcomes post-obit the cardinal incision technique for insertional Achilles tendinopathy. Foot Ankle Int. 2011;32:850–855.

19. Greenhagen RM, Shinabarger AB, Pearson KT, et al. Intermediate and long-term outcomes of the suture bridge technique for the management of insertional Achilles tendinopathy. Foot Talocrural joint Spec. 2013;vi:185–190.

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20. Cox JT, Shorten PL, Gould GC, et al. Knotted versus knotless suture bridge repair of the Achilles tendon insertion: a biomechanical study. Am J Sports Med. 2014;42:2727–2733.

21. Hunt KJ, Cohen BE, Davis WH, et al. Surgical handling of insertional Achilles tendinopathy with or without flexor hallucis longus tendon transfer: a prospective, randomized study. Pes Ankle Int. 2015;36:998–1005.

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Keywords:

insertional Achilles tendinopathy; Haglund deformity; double-row Achilles repair

Copyright © 2020 The Author(southward). Published by Wolters Kluwer Health, Inc.

Source: https://journals.lww.com/techfootankle/Fulltext/2021/06000/Retrocalcaneal_Spur_Removal_and_Achilles_Tendon.6.aspx

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