How To Repair Calcaneal Step Deformities
Using a posterior splint or night brace along with heel lifts has also proven helpful. To help control excessive frontal plane motions of the heel, emphasize deep heel cups (14 to 16 mm) within the orthotic devices. Using prefabricated soft heel cups may also reduce irritation and limit motion of the heel bone within the shoe. NSAIDS, regular use of heat in the morning and ice in the evening, along with physical therapy modalities, have also proven helpful in many cases. I do not advocate the use of corticosteroid injections for calcaneal step deformities as there have been repeated cases of Achilles atrophy, which may lead to spontaneous rupture.
Step-By-Step Surgical Tips
Despite conservative care, results are often discouraging in athletes. I am now performing the extracorporeal shock wave therapy for Achilles insertional pain, but long-term results are pending. In a previous Podiatry Today article (see “Surgical Solutions For Treating Posterior Heel Deformities,” January 2001, pg. 23-26), I described the surgical procedure for the Keck & Kelly osteotomy.2 I reiterate that for patients who have a long horizontal calcaneus and/or those who have a high calcaneal inclination, you must consider performing the calcaneal osteotomy. This reduces the posterior tilt of the calcaneus, preventing Achilles irritation and subsequent pain recurrence.
After treating numerous retrocalcaneal exostoses through various surgical approaches, I favor a straight linear longitudinal midline incision. Begin approximately 1 cm above the posterior superior prominence of the calcaneus and extend the incision to the distal aspect of the calcaneus. Deepen the incision down to the level of the paratenon overlying the Achilles. Sometimes the paratenon is frayed due to the bony prominence of the calcaneal step or chronic synovitis. Meticulously dissect the paratenon and save it for closure.
The deep incision is straight to bone, parallel with the initial incision. At this time, sharply dissect the tendon from the bone medially and laterally with a scalpel or key elevator. Using an osteotome and mallet, chisel redundant bone off laterally, including the calcaneal step deformity. Perform the same step medially.
It is important to smooth out the posterior surface of the calcaneus to allow for a new insertional surface for tenodesis. It is also important to maintain the Achilles attachments, distal medial and distal lateral, below the calcaneal step deformity area.
Proceed to palpate the posterior superior prominence of the calcaneus. Most of the time I resect any prominent portion of the Haglund’s deformity. Use an osteotome and mallet from lateral to medial and rasp the remaining bone smooth to prevent irritation of the Achilles tendons. Intraoperatively, I have been aggressive in removing a large portion of the posterior superior prominence of the calcaneus without any detrimental effects. You should certainly be aware to stay well posterior to the posterior process of the talus so as not invade the posterior subtalar joint. Also look for a retrocalcaneal bursal sac, which is located just superior to the bone you just removed. If present and abnormal, remove the bursa.
Lastly, examine the Achilles tendon. Palpate for any nodules and look for any frayed or damaged portions of the tendon. Remove any abnormalities. If necessary, you may thin the tendon when it is fibrotic in appearance.
At this point, irrigate the surgical site well with sterile saline solution and examine the tendon again for intra-Achilles calcification and check the bone for rough areas that may irritate the Achilles tendon.
Two or three bone anchors are placed within the distal insertional area at the posterior calcaneus. I prefer to use the Mitek super anchors or Wright Medical Anchorlok 3.5 mm tendon anchoring devices. While two are adequate, I use three anchors for heavier set individuals. The anchors have size 0 non-absorbable suture to firmly hold the Achilles onto the calcaneus.