Harold Schoenhaus, DPM, FACFAS reviews the anatomy of the retrocalcaneal region. Dr Schoenhaus shares surgical approaches that are used for retrocalcaneal exostosis and chronic Achilles tendonitis that do not respond to conservative management.
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Harold Schoenhaus, DPM
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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I'm going to share some thoughts on retrocalcaneal exostosis and associated Achilles pathology.
So when one looks at associated problems of the posterior aspect of the calcaneus, you realize we deal with an Achilles tendon which is inserting into this posterior aspect somewhat more inferior middle to inferior part, there's a protective component where we have this Haglunds portion of the calcaneus which really is protected from the Achilles and the Achilles is protected from that bone by this fibral fatty area, sometimes referred to as an adventitious bursa in front of the Achilles. And over the years I've seen a lot more Achilles tendonitis and problems that are associated with the calcaneus. Almost like a traction type of environment which leads to exostosis formation – enthesopathy, if you will. We see it on the plantar aspect of the calcaneus. Probably easier to deal with than a posterior aspect because of the presence of the Achilles tendon. So one has to be aware of the disease process that's going on at the Achilles as well. Is it a tendonosis? Do you have longitudinal tears? Are there transverse tears? Is there pathology? Is there a bulbous formation of the Achilles tendon? Do we run the risk of the Achilles avulsing off the calcaneus or even taking a portion of bone from the calcaneus with it? Or do we just have a complete tear that can occur within the watershed area?
So our dissection, when we are dealing with patients with this combination problem, be prepared to do an extensive evaluation of the Achilles and how far up or down one must go. And here an MRI is helpful, because it will show you how far up a tear may be present. So you have to be prepared to fill a substance, use some form of graft if necessary, remove the diseased portion and then treat what has to be done relative to the bone. And here's a good example of posterior calcaneal spur – it almost looks like a tomahawk – plantar spur, posterior spur – there's a few ossicles sitting right within the calcaneal portion where the Achilles is going to attach – whether that's avulsed, or you just have calcification, obviously that prominence is painful. And the point that one sees is not a rubbing against the Achilles – that's the effect of the pull of the Achilles at that insertional point.
So obviously, this is not something that I like to inject, for example, with steroids, to treat these conditions. I think that's a very dangerous approach with this inflammatory reaction and painful phenomenon. I'm far more radical when it comes to these type of conditions. And here's your MRI where we see either the beautiful tearing or separation of the Achilles on the portion to your right. The other section, you'll see this stippling within the tendon itself, and as you go up and down the leg to the insertion, that is part of the tearing that one is going to negotiate.
On occasion, there'll be a palpable defect. Certainly, if there's a complete tear, you're going to have a palpable defect. My incisional planning – I'm passing right over conservative management because I don't think the purpose of the talk is to deal with a conservative approach – surgical approaches are like an S shaped incision in the posterior aspect of the Achilles. The reason for it is that longitudinal or straight incisions contract on their long axis. So that when you try to dorsiflex a foot, that scar could
actually inhibit dorsiflexion and be uncomfortable. The S shaped incision allows for that type of dorsiflexion and gives you complete exposure.
Now, here's a good case of this paratenon that I mentioned the other day when I was talking about the amnion as a protective membrane that looks like cellophane. Here's that paratenon that if you try to preserve it, you'll realize it's very thin, it can be tagged, but by the end of the case, you usually can't find it any more, unless you're very, very careful and your tagging techniques are appropriate. So here's a good example of intra-substance tear. You look at the diseased portion of tendon. You have to make a decision – what are you going to do with that? It's no good, that tissue. So I usually excise it. You might curette it. You may see discoid change within it, collagenous type of formation. Get it all out.
Here's another example. Now, once I have also opened up the Achilles, you can realize that you can get down to the posterior aspect of the calcaneus, and do any of the osseous work that you need to do simultaneously, just as long as your exposure is good. I'll also tell you I try to maintain the attachment of the Achilles on the medial and lateral sides. If I can avoid complete detachment I do. That's not to say, however, that in many cases you have to take the Achilles completely off, and then make a decision of how you're going to reattach it to the calcaneus and get the appropriate tenodesis so that you will have good strength of the Achilles once again.
And here we are resecting the offending portion of bone. I will use bone anchors. There's different techniques – there's new technology that's available on how to perform tenodesis, certainly at the Achilles level to assure that you're going to get a reanchoring, reattachment of the Achilles tendon. And obviously these anchors are a pretty good size, and you reattach the tendon back to the bone.
Right, here's another example of MRI showing you tearing within the substance of the Achilles. I like to read all my own MRIs by the way – I don't rely on the report alone. Here's another example of a rather large calcification, so everything in the back is not simply an extrusion or an extension from the calcaneus. Here's a calcification within the tender Achilles, with a normal contoured calcaneus. So here we are going in. It's almost like giving birth. Look at the size of this thing, coming out of the Achilles. It's a complete calcification. And obviously when you shell that amount of bone or calcification from the Achilles, you realize you have very little substance left of the Achilles tendon itself. So now your decision is, what are you going to do? You can take additional tendon. I do not like to borrow flexor tendons and substitute for the Achilles. I will either go to the bank and get tendon graft; I may take tendon from higher up and flap it down into the defect, or use material such as acellular dermis and put struts into the graft. And years ago, this is what we used to go to the bank, and you could even get the Achilles attached to bone. I never liked the look of that tendon. It's dead, and I hope that it's going to do something for us. And here's an example of taking graft, tubularizing it or creating a tube of it, and now we're going to place it right within the Achilles itself.
Length-tension ratio, critically important. Certainly if you detach the Achilles, you're going to get some contraction of the muscle belly, and then how much tension do you put it back under? I think this is one of the areas that we need a tremendous amount of research in. Any of the tendon transfers we do, lengthenings we do – you've heard how many different surgeons up here talking about, they're going to do a gastroc lengthening or a tendon Achilles lengthening? And we, everybody just nods their heads and says, yeah, it needs to be done. But how much do you do? Can you over-lengthen? Can you destroy the function of the strongest tendon in the body because you haven't taken into account length-tension ratio?
Here's an example of anchors going in – non-absorbable suture. Here's a whole graft being placed inside. Look at that beautiful encasement, and then just sew the good portion of the tendon over the area. Here's another example, a rather large spur coming off the calcaneus. Here's that nice beautiful incision. And here's the removal of the excessive bone. If there's a Haglunds present, that comes off. We're all the way down to the posterior margin.
There's different anchoring techniques. I never liked these type of anchors with a little screw in it. The back of the heel – terrible area for pressure from shoes. So you use an anchor like that, it looks good – you have very little soft tissue to cover over that, and it's a disaster. That usually has to come out. And if we're using that spike technique, and then take that out, certainly run the risk of weakening the tendon.
Right, here's another example. I don't care how you get this out, by the way, or what, whether you use power or whether you use osteotomes and mallets – not important. Just get the bone off. Here's an example of using acellular dermis to protect the tendon. Look at that – it's a beautiful membrane now. You can even use this covering over any type of fixation that might be somewhat prominent. We now have a separating membrane between the skin subcutaneous tissue and the Achilles. This is a nasty area where the Achilles can bind down to the skin or the subcutaneous level. You don't have a lot of fat in that area. So here's an example of acellular dermis. You can also use the amniotic material – perfect location to protect.
Now, another approach is a procedure referred to as a Keck and Kelly. Now, a Keck and Kelly is an osteotomy of the calcaneus where you can actually remove a section of bone. There is a wedge being taken out of the calcaneus. You don't detach the Achilles. If there's disease of the Achilles itself, you may have to deal with that, but here what you're trying to do is just alter or change the prominence. You're just moving the calcaneus forward, leaving everything attached – recognizing it's a nice wedge osteotomy from dorsal to plantar, and it's an appropriate amount of bone that has to be removed. And usually when you take that wedge out and you look at that hole and then you say, “How in the heck am I going to close that down?” 'Cause if you try to push on the foot to close the osteotomy, you're leaving a hinge on the plantar aspect, you got a nice defect throughout here – how do you close that? Very simple. With the Achilles still intact, all you do is dorsiflex the foot. So same thing we do when you do a Dwyer calcaneal osteotomy. You take your wedge out and you try to push it closed – it doesn't
go. As soon as you dorsiflex the foot it closes. And then you use whatever method of fixation. So here's what it looks like – so you've taken the wedge out. You actually leave the osseous component that was attached where the Achilles went. That's all left in place, and all you've done is taken a wedge of bone out and push the calcaneus forward. And then it heals beautifully. Calcaneus is a sponge – I love that bone. It heals – you rarely see non-union of the calcaneus when you're performing transpositional osteotomy such as a Koutsogiannis or these type of osteotomies where you're putting bone up against bone.
So what I try to share with you is approaches that one can take for this chronic Achilles tendonitis that usually doesn't respond to conservative management – certainly do place these patients in cam walkers over extended periods of time, non-steroidal anti-inflammatories. Do not inject with steroids. I've had a number of patients referred to me who've had numerous steroid injection and avoles the Achilles right off, or rupture the Achilles tendon. That's a lawsuit waiting to happen! Not a good area for a steroid.
However, the anti-inflammatory can be accomplished with your medications. Surgery in my hands is probably the best approach long-term with these patients, and then the rehab is, you've got to get them back to physical therapy to regain the strength of the gastroc soleus complex.
So I thank you for your time, and I think at this point....