Current Concepts In Retrocalcaneal Heel Spur Surgery
- Volume 22 - Issue 11 - November 2009
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Once one has reflected the overlying soft tissue off the Achilles tendon, employ a central tendon splitting approach. The extent of the tendon detached depends on the size of the osseous structure one is removing. After reflecting the overlying soft tissue, excise any intratendinous calcification and degenerative tendinosis from the healthy tendon. Then carefully excise the retrocalcaneal bursa from the surrounding structures. Using a saw, rongeur and rasp, one would remove the posterior spur and posterior superior osseous prominence. Remodel the calcaneus and remove any sharp or rough edges. Lavage the area to remove all loose resected bone.
After determining that adequate soft tissue and osseous debridement is complete, reattach the detached Achilles tendon using suture anchor systems. One would first use an absorbable suture to repair any frayed tendon edges. Then reattach the tendon using the suture anchor system. If you have carried out a smaller area of detachment, you can use two single suture anchor systems. If a larger area of exposure necessitates a more aggressive tendon detachment, one can use a bridging suture technique.
Place bone wax on the exposed bone to control postoperative hematoma formation and scar tissue formation. Then repair the split tendon by using a running buried absorbable suture. Perform further repair of the medial and lateral tendon slips to the calcaneal periosteum as needed. Carry out the subcutaneous closure with an absorbable suture and close the skin with staples or a non-absorbable suture. If an equinus contracture still exists that is contributory to the condition, the surgeon can carry out a gastroc slide as an adjunctive procedure.
What You Should Know About Post-Op Management
At the completion of the procedure, apply a compression dressing/posterior slab to the lower leg with the foot sitting at approximately 10 degrees of plantarflexion. At two weeks, remove the posterior slab and dressing, inspect the surgical site and remove the sutures or skin staples.
Then place the patient in a walking cast and continue immobilization for another two to four weeks. At the end of this stage of immobilization, initiate range of motion exercises. At eight weeks, discontinue the walking cast and have the patient start wearing a supportive shoe with a heel lift for another eight weeks.
Physiotherapy starts at week 10 and this should include range of motion, plantarflexion strengthening exercises, gait training and edema reduction as necessary. The patient continues home rehabilitation exercises provided by the physiotherapist. Once the strength has improved, one can initiate orthotic therapy in those patients who require biomechanical support.
In the obese, sedentary population, consider the appropriate anticoagulation regimen to prevent deep venous thrombosis.
Complications may include infection, skin edge necrosis, hypertrophic scar formation, sural neuritis or hyperesthesia along the scar. Recurrent pain may occur if the surgeon does not resect an adequate amount of bone.
Surgical management of insertional Achilles tendinopathy can provide an excellent outcome in patients with recalcitrant posterior heel pain who have not responded to non-operative management. There are a number of approaches available to the surgeon as well as techniques for tendon reattachment. One must spend time educating the patient regarding the postoperative course of recovery. Complete healing and resumption of pain-free activity can take up to 12 months.
Dr. Haverstock is an Assistant Clinical Professor of Surgery and the Chief of the Division of Podiatric Surgery in the Department of Surgery at the University of Calgary.