Essential Insights On Treating Retrocalcaneal Exostosis
After reattaching the tendon to bone, repair the V or Y incision through deep fascia, paratenon and tendon as one layer with 2-0 absorbable and/or non-absorbable sutures. Approximate the subcutaneous tissue with a 4-0 absorbable suture and close the skin with a 5-0 absorbable or non-absorbable suture. Apply adhesive wound strips, a saline-moistened sponge, a dry sterile dressing and a below-knee Jones compression cast. One would typically take postoperative radiographs on the day of surgery or within the first postoperative week.
What You Should Know About Postoperative Care
In the immediate postoperative period, utilize a below-knee Jones compression cast to minimize edema and associated postoperative pain. The surgeon usually changes the dressing in the first five to 10 post-op days. If the edema is under control, apply a below-knee synthetic cast. Apply the cast with the ankle and subtalar joints in their neutral position.
Keep the patient non-weightbearing for four to eight weeks in the cast. If the patient continues to demonstrate edema, pain or is obese, he or she may wear a cast for a longer period. After the period of non-weightbearing immobilization, the patient gradually returns to weightbearing. This is typically accomplished with a walking synthetic cast (i.e., CAM walker type cast) for an additional three to six weeks.
Following cast removal, start appropriate rehabilitation including range of motion exercises for the ankle and subtalar joints, and strengthening exercises of the calf musculature. Continue compression with supportive material or an ankle brace until most of the edema has resolved and the patient is able to ambulate with minimal difficulty. Long-term orthoses and appropriate shoes are advised.
How To Resolve Complications
The primary complications associated with this approach are related to the Achilles tendon. Rupture of the tendon is always a possibility in any surgical approach involving temporary detachment of the tendo-Achilles. However, this is unusual if one provides proper postoperative treatment and care, and the patient is adherent.
Postoperative tendonitis of the Achilles tendon is more common. If this occurs, it typically starts when the patient begins unsupported weightbearing and gradually resolves over the next two to four months. If the tendonitis does not resolve, institute appropriate treatment similar to that for any Achilles tendonitis. If the pain continues, the clinician should reassess the posterior heel area to rule out any other conditions that might be contributing to the ongoing pain syndrome.
Sundberg and Johnson state that “excessive subcutaneous scarring” is a drawback of the classic Fowler-Philip surgical approach.6 However, the classic Fowler-Philip approach utilized a curved transverse incision through both the skin and deeper structures. In my experience, combining the posterior longitudinal skin incision with the inverted V or Y extension through the deeper structures has rarely led to any significant scarring problems. However, handling of the soft tissues in a meticulous fashion and the use of anatomic dissection cannot be overemphasized. If a postoperative wound dehiscence or painful cicatrix develops, treat those conditions in an appropriate fashion.
Surgeons should not hastily decide to perform a retrocalcaneal exostectomy with reflection, debridement and reattachment of the tendo-Achilles. The procedure requires a significant postoperative recovery period and is associated with several dreaded postoperative complications. I have found the modified surgical approach, as described above, to be a simple, reproducible and reliable surgical procedure when it is indicated.
Dr. Downey is the Chief of the Division of Podiatric Surgery at Penn Presbyterian Medical Center in Philadelphia. He is also a Senior Faculty Member of the Podiatry Institute.
Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified in foot and ankle surgery. He is in private practice in Little Rock, Ark.
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