How To Conquer Achilles Insertional Calcific Tendinosis
With the patient under spinal anesthesia in the prone position and a thigh tourniquet inflated to 350 mmHg, I carried out a midline incision over the posterior Achilles tendon. I incised the paratenon and separated it medially and laterally. I extended the longitudinal midline incision through the Achilles tendon down to its attachment on the posterior calcaneus.
Directing the incision medially and laterally, I subsequently raised the distal Achilles tendon attachment off the calcaneus to expose the calcification. I left the medial and lateral attachments intact. Minimal thickening of the Achilles tendon was present.
I removed the calcification with a sagittal saw and bone rongeur, placed bone wax on the exposed bone and secured the tendon to the calcaneus utilizing the Achilles SutureBridge (Arthrex). I utilized 2-0 vicryl for further repair of the tendon and closed the paratenon with 3-0 vicryl. Skin closure occurred with 4-0 nylon and a horizontal mattress suture. I dressed the wound in the normal fashion and applied a posterior plaster slab.
Postoperatively, the patient took anticoagulation medication and was non-weightbearing for two weeks. At the first postoperative visit, I removed the slab and sutures, and placed the patient in a removable walking boot with a 1-inch heel raise.
At this point, the patient ceased taking the anticoagulation medication and was allowed to ambulate. She received instructions to remove the boot and perform range of motion exercises twice daily and plantarflexion against resistance with surgical tubing. The exercises start with the foot at 90 degrees to the leg and then plantarflexing against resistance.
Every two weeks, she would return for assessment and have the heel raise lowered by ¼ inch. At 10 weeks, physiotherapy began and at 12 weeks, I removed the boot. She returned at three months postoperatively and demonstrated improved strength. She could not perform single limb balance and still demonstrated an antalgic gait.
At six months, she resumed her exercise and weight loss program. She stated there was some pain with walking but she could tolerate it. She returned at 12 months having lost 30 pounds and stated that the heel was almost completely free of any discomfort.
Dr. Haverstock is the Division Chief and Assistant Clinical Professor of Surgery in the Division of Podiatric Surgery within the Department of Surgery with the University of Calgary Faculty of Medicine in Calgary, Alberta. He is a Fellow of the American Society of Podiatric Dermatology.
For further reading, see “Current Concepts In Retrocalcaneal Heel Spur Surgery” in the November 2009 issue of Podiatry Today or “Keys To Diagnosing And Treating Achilles Insertional Pain And Retrocalcaneal Exostosis Pain” in the September 2010 issue.