Michael Troiano, DPM discusses imaging modalities available to evaluate patients with associated retrocalcaneal pathologies, clinical and radiographical differences between those pathologies, as well as surgical approaches to adDress associated retrocalcaneal pathologies.
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Michael Troiano has disclosed that he is a consultant for Stryker and Smith and Nephew.
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Speaker: Our next speaker graduated from Temple University in 2004. He completed his residency at the Gradate Hospital in Philadelphia. He is in private practice at the Center for Foot and Ankle Disorder in Philadelphia. He is an adjunct clinical professor at Temple University's School of Podiatric Medicine in the department of surgery. He teaches biomechanics. He is board certified in foot and ankle surgery and reconstructive ankle surgery by the American Board of Podiatric Surgery. He is going to talk about the management of Haglund's and posterior calcaneal spurring.
Dr. Troiano: Alright, good morning. So we are going to change gears about 180 degrees. I'm going to talk about something that is near and dear to me, which is something that it has been a better part of 15 years that I have been in practice and I can tell you that when I first started I didn't see a ton of these and in the past five years, I probably see one every week. We have had many discussions about what's causing retrocalcaneal exostosis, Haglund's deformity and insertional tendinopathy of the Achilles. I don't know if it's the advancing weight, although I live in Philadelphia and in all fairness, the weight has gone down in the past decade of the average patient, just a little bit. I don't know if it's more stress, more activity, more kind of wounded warrior type people, weekend warriors but this is something that I see like I said on a daily basis and unfortunately as you are going to learn there is not a lot of nonsurgical ways to treat this.
So conservative management whether it be Haglund's deformity, whether it be an insertional enthesopathy of the Achilles, whether it be a posterior spur or myositis ossificans or everything we are going to discuss today is the same. It includes activity modification, basically decrease your activity, immobilization and CAM walker with a couple of lifts or cast for period of time, night splints to keep the Achilles stretched, physical therapy, which would include Graston, scraping, prolotherapy and dry needling, all categorized together. And then you have your kind of Zebra's [phonetic] [00:02:42] like PRP. Does it work, does it not work. I have had some good results. I have had some not great results. Traditionally against placebo, it's indicated that there is no difference but I have patients that swear by it. So whether or not it's psychosomatic or whether it works I think there is some more literature that needs to be gathered. And then you have extracorporal shockwave therapy as well, which falls into that category. So one thing that I would like you to take home today is Haglund's deformity and pump bump are not the same thing. This is a pump bump. This is a Haglund's deformity. As my introduction, I taught for the past 10 years pathomechanics at Temple University School of Podiatric Medicine. Pathomechanic is something near and dear to me. Pump bump is something that you are going to see in compensated rear foot varus or compensated forefoot valgus. It's the rocking of the heel going back and forth. In other words, the heel is going to rock back and forth against the shoe every single time that person walks and basically the bone proliferates, it gets irritated and you get this pump bump. Very painful, usually more so in women than men. People used to think that pump bump was a Haglund's deformity but it's not the same thing.
Haglund's deformity is higher up on the calcaneus. You can see the location. It's more central posterior and Haglund's deformity is very difficult to tell from insertional enthesopathy of the Achilles without an x-ray. So again pump bump is caused biomechanically by friction on the shoe. Now, we are going to start to look at insertional enthesopathy and Haglund's deformity. So this is the spot of insertional enthesopathy. This is the spot of Haglund's deformity where the arrow is. And these are the two spots that bother people. Now you can have both and many times they are hand-in-hand. So insertional enthesopathy as you can see is calcification climbing up the Achilles whereas the Haglund's deformity is a misshape of a calcaneus. Why do you get an insertional enthesopathy? Well, if you think back to day 1 of podiatry school, you remember Wolff's law. A bone will react to the force placed upon it. So if you have a tight Achilles tendon, the Achilles is tight over time and the bone doesn't like the pull anymore and reacts to the force that's put upon it. Then you get the spurring, however, this x-rays obviously is one dimensional and the spur that someone gets is three dimensional phenomenon. So what looks like kind of not a big deal here is actually a full shelf around the posterior aspect of the heel, which is very painful. It makes shoe gear very difficult, it makes driving a vehicle very difficult when the spur and associated Achilles kind of slammed into the floor board of the car as you are pushing the pedals back and forth and it makes basically any back-filled shoe or shoe with a back period very difficult to wear. Basically, patients are relegated to open back sandals and things like that. So again differences are insertional enthesopathy and Haglund's deformity. Advanced imaging, MRI. MRI is something that you do not necessarily need to diagnose this but it helps your surgical planning, why?
Because while we can take an x-ray and we can look and say oh, there is a spur. Yes, there is a Haglund's deformity. We can't really look at the integrity of the Achilles. Why that's important we are going to get into in a minute. But many of these pump bumps, many of these Haglund's deformity -- many of these Haglund's deformity insertional enthesopathy unlike the pump bumps involve the Achilles. The Achilles because of that Wolff's law has been pulling for quite some time. It's very common to get intrasubstance degeneration, intrasubstance longitudinal or transverse tears and then of course you begin to get inflammation of the bursal sac. So here you can see the inflamed bursa and then there you can see longitudinal tearing of the Achilles sometimes with calcium which will actually climb up the Achilles. So that needs to be shelled out in order to effectively debulk the Achilles and decrease that patient's pain. There is such thing as Haglund's triad. It includes Achilles tendinopathy, retrocalcaneal bursitis, and Haglund's deformity. So this is where the MRI really helps you look at how much of retrocalcaneal bursitis you have and how much Achilles tendinopathy you have because that's really going to change your treatment algorithm. So how do we measure for Haglund's deformity. There is two solid ways to measure. The first is a Fowler-Philip angle. Basically, you take the inclination of the calcaneus here and the posterior side of the calcaneus and if this angle is greater than 66, you have Haglund's deformity. That's great, however, the one that I like more is parallel pitch lines or our parallel pitch lines. The reason being this is actually going to help you surgically plan your procedure. What you are looking at is the inclination of the calcaneus here and then you are going to tag the posterosuperior aspect of the subtalar joint and you are going to drop a perpendicular from here to here.
And once you have your perpendicular, you are going to measure this value. Let's assume that it's 6 cm. You are going to go anywhere on this line and you are going to measure up 6 cm and put another dot. Then you are going to connect that dot to that dot and everything above this top line is Haglund's deformity and needs to be removed. Why is that important? It's important because in Haglund's deformity like this, which is not so big, you can take a saw and just kind of knock it off. However, when Haglund's deformity starts to eat into the width of the calcaneus or girth of the calcaneus we have to consider other adjuvant or adjunct procedures, which we will discuss in a minute. So here is a typical parallel pitch line. Again inclination of the calcaneus, posterosuperior aspect of the joint 90 degrees, measure up and you have one parallel line to the first, everything above is Haglund's deformity. In this case, it's about a centimeter of which. Alright, these patients also have this palpable heave. Now there is not a lot of soft tissue subcutaneous tissue in between the skin and the heave of bone, which means that these people are prone to wound dehiscence should you undergo surgical intervention. So these patients need to know right from the jump that they will be in a cast for one month's time and they will be off of this foot for about two months' time. And during that period of time, we cannot take someone who have them with their heel dug into the bed. In fact, they have to offload this whole time. So they have to make major provisions to be home and offload it and taken care of during this period of time. Now, I said MRIs will help you surgically plan. The axial MRI is actually the most valuable. Why? Because of this, the Achilles. So Nicholson 2007 did a study and rated people into the size of the AP diameter on the MRI of the Achilles tendon and it's the Achilles tendon's proportion of degeneration classed into type and percentage.
So what we see if we go back here is those with an A to P diameter of the Achilles tendon 6 to 8 mm with a nonuniform degeneration have about surgery 13% of the time. That means if these people are going to respond to conservative therapy to some degree, 90% of the time. Grade 2 and grade 3 is the Achilles tendon being greater than 8 mm uniform degeneration and then less than or greater than 50% of the tendon width of that degeneration. Surgery is indicated 91% and 70% respectively. So that means that gross preponderance of your patients are going to fall into category 2 and 3 because I can tell you that I have certainly measured a number of these Achilles tendons and I very, very infrequently have found an A-to-P diameter less than 6 mm or 8 mm. By far, they are much bigger. I will call your attention to this. 8 mm greater than 50% tendon width, less than 50% tendon width. These people of grade 3 require surgery less often because their tendon is usually bigger to start with and although the degeneration is larger in actuality because they have more stock to begin within the tendon, they usually don't require surgery as often. But again we are not talking about a ton here, we are talking about 20%. So by and large 2 and 3 patients -- grade 2 and 3 patients go on to surgical intervention. So what do you do when you have tendinosis of Achilles tendon because again that shelf of bone is going to begin to climb up the Achilles tendon vis-à-vis Wolff's law or you are going to get myositis ossificans, meaning bleeding of the tendon, which will in turn into calcium and bone as time goes on.
So here is a prime example of myositis ossificans. This person, years ago, was kicked in a soccer game. Tendon bled, obviously did not rupture. Lot of soft tissue anterior to the tendon, which calcified and now you have this big wedge of bone and heave of bone intrasubstance of the of the Achilles. So another study, Tremonti [phonetic] 2016 identifies that 65% to 80% of patients with insertional Achilles tendinopathy have a heel spur. And it's the size of osteophytes rather than presence of the osteophytes that contribute to the symptoms. We are not talking about plantar spurs, we are talking about posterior spurs. So size and intra-Achilles tendon degeneration, intrasubstance degeneration again connotes surgical intervention because you have to get that out in order to get rid of the pain. So going forward, we now have to identify whether or not we are going to detach the tendon in our surgical intervention. In 1999 and 2003, two sentinel studies were done and I summarized them here because they are important. If the degeneration and the spurring makes up less than 50% of the Achilles, then the insertion can be safely detached. However if it's greater than 50%, double row fixation has been recommended and when I say that we are talking about detaching just the small portion of the Achilles doing our work and then suturing it back together. No real need for heavy anchors or anything else like that. Maybe one or two just to hold the tendon back together. However, if it's greater than 50%, then we need to use double line anchors. However, if it's greater than 50% of the tendon and this person is middle age, you have to consider the FHL augmentation, which in this day and age by and large relatively easy because we have interference screws like Arthrex and Wright Medical that have these bio-composite screws that will kind of hold the spot of the FHL.
So it's not so difficult. The old way, we have re-route the Achilles or re-route the FHL and suture to the Achilles and augment it. Now, it's whole lot easier. But we have to consider this is quickly becoming the standard of care and FHL augmentation -- most of our patients are going to fall into this middle age 50% tendon debridement with the spur with some intrasubstance degeneration and we know from the prior studies 70% to 90% of those patients are going to require surgical intervention. So it's a procedure that you have to be comfortable with if this is something that you are going to treat. So here is a prime example of greater than 50% of the degeneration of the tendon with some spurring that needs to be removed. This is the prime example of someone that's going to need an FHL transfer. By and large, the FHL is right there, so it's not so difficult to harvest but something that there is a learning curve too. Incisional planning, there are some angiosomes here. This is dehiscible incision meaning that because there is not a lot of subcutaneous tissue very oftentimes, this incision gets put in a precarious situation. I will not operate on anyone with hemoglobin A1c over 7 in this case. They need to be offloaded 100%. I will send them to physical therapy and get a little certificate from them saying that they have graduated physical therapy because when this goes bad, it goes bad and you know the other thing is I have been in many situations where not too too-many but several situations where I was very thankful to have a microvascular plastic surgeon because these people need free flaps when things go bad and they have exhausted all wound care modalities. So surgical decompression, you want to preserve the angiosomes.
Angiosomes actually meet right at the middle of the incision, so you want to keep your dissection to minimal. Neurovascular compromise, the sural nerve actually will break off anatomically as low as where we are right here. So you have to cognizant of the sural nerve. It's an easy incision because you can directly access the spur and visualize everything nicely but again trepidatious incision. Next thing you are going to do is tag the paratenon. The paratenon -- obviously the Achilles has no sheath to it, so it doesn't have a great blood supply, which is why it's a design flaw that's always kind of ruptures in this watershed region. So you don't want to induce or rupture by scarring the paratenon back together. So I tag it. I always preserve it and then repair it later. Now, you are going to identify your intrasubstance tears. How you repair them is up to you. Sometimes, you can baseball stitch them back together. Sometimes it's better you just take the 10 blade and shell everything out and leave the outward shell of the Achilles intact. Here is another example of longitudinal tears of the watershed. Something that could be baseball stitched back together because if you move it, it's too much bulk. So here we are encountering an intrasubstance tear at the insertion of the Achilles and once everything is done old-fashioned way would be to use these metal Mitek anchors or what have you to re-harvest the Achilles and reef the Achilles back to the calcaneus. However, these metal implants whether they are titanium or stainless steel were oftentimes prominent. They would come out to pull out straight. The strength wasn't great and let's recognize that when someone shows you a sawed bone or model of these anchors in the bone, that’s a very, very tightly minimally porous substance that they are drilling these anchors into. So they look great. They have pull out strength but in your 60, 70-year-old patients with osteoporosis and what have you, these anchors pull out very easily and guess what, everybody falls. Everybody after you have this surgical intervention has a misstep or fall or steps down and there is not much holding the Achilles to the anchor anymore, so they pop right out.
Revision surgery is guaranteed. So after we shell out the mass, we are going to have these big dead space and we need to decide what to do with it. Again greater than 50%, you are looking at an FHL augmentation. Less than 50%, then you have some options -- excuse me greater than 50% the way that we used to do it was to shell out the tendon and then using the Achilles tendon autograft. Why? Because the autograft didn’t -- to harvest the FHL was very difficult. You could damage the [indecipherable] [00:18:39], you could damage the tibial nerve. It was pain in the butt to augment it and get it really nice and tightly. So this is more 20 years ago. You would take the Achilles autograft. You would spin it so that you kind of maintain the natural curvature of the Achilles as we know it spirals down in medial as it goes distally and then you would sew it together and kind of augment the intrasubstance of the Achilles where the dead space was and use that as a graft. Then you will have to maintain the length tension relationship, oblique curve, tendon is strongest at 120% of its length. They are most functional at 120% of its length and then you would anchor the tendon into position. Once you did that and you close the tendon over and you'd kind of have a tendon inside of tendon, hope it all conglomerated and healed and then you are good to go. Another example of this case is when you actually take the Achilles tendon and after you remove the posterosuperior aspect of the calcaneus. Now, you are going to take your Achilles tendon graft and you are actually going to use the graft as a new calcaneus. In other words, you are going to dock that piece of calcaneus into the actual bone and then you will take this big screw. This is one from Depew and you know has these barbs on the end of it and this is the cadaveric Achilles tendon that you are basically inserting onto the calcaneus and hoping to god that it bleeds and scars together, gets incorporated and doesn't cause infectious process, right?
So not a lot of great options way back and you would have these x-rays and obviously because it's not a lot of soft tissue or subcutaneous tissue, that hardware is coming out at some point because it's -- you know no one is going to sustain that big piece of metal in their foot for too long and that was as bad as Haglund's deformity. So new fixation options. Fixation options that we have now in the middle, this is cork screw from Arthrex. On the side, these are the Arthrex new Haglund's -- what they call -- gosh, the name escapes me, I am sorry -- but I have used them for a while. This is [00:20:54] [indecipherable] or zip type and then this is sonic anchor. The sonic anchor is made by Stryker. This is a Stryker sponsored lecture, however, I have given this lecture unsponsored because it's what I have used for the past five or six years now and I can tell you that my results have been phenomenal, not just in Achilles tendon surgery, in resection of an os naviculare with advancement, like Kidner procedure, diabetic foot limb salvage or what have you and you have to take out a fifth metatarsal, peroneus brevis and transfer the brevis into the cuboid. And what makes this little anchor a little special is the girth of it is only about 2.5 mm. What happens is it kind of melts in the ultrasound to the bone and traps the suture underneath it. You are going to see an example of that relatively soon. But again, you take the suture, you drill a hole and as this ultrasound generator heats up the plastic basically, it finds the pores of the bone and traps the suture underneath the bone.
So not only it can be used in cortical bone, but it can be used in very, very porous cancellous bone as well. It has a very high pull out strength. Size difference between the traditional accepted is 4.75 mm versus 2.5 mm of the sonic anchor. The other thing is you can stack these side to side with only a millimeter to 2 mm of width between the two. That means that how many times have you put an anchor in, you don’t like it, you don't like the position. It's too close to the edge of the bone or you think you might be in the joint or what have you. You can take it out, drill it out, pull it out and then go 1 to 2 mm away and put it right in as opposed to drilling next to 5-mm hole then deciding you don't like it and then having to be several millimeters away otherwise a calcaneus or whatever bone you are operating on is going to crack. So my technique for this is again to make a longitudinal incision directly over the calcaneus. You are going to use an osteotome or mallet or saw or what have you to get the bone to bleed. We want bleeding bone here, so Bovie the bone to stop it from bleeding, fight the want to put bone wax over the bone to stop it from bleeding. You don't want to do that. In this case, you want bleeding to scar your Achilles back down. Now you are going to shell out. This is me taking 10 blade and just removing all the intrasubstance degeneration of the Achilles, debulking it because if you put it back on, it's still bulked up. The patient will feel it almost similar to the Haglund's deformity even though it's gone. Then after you debulked it, we are going to take an x-ray, make sure that we reshape the Haglund's deformity. We are happy. We have a nice soft curve of the calcaneus here and now we are going to plug our anchors in. What I do is I drill four anchors similar to the Arthrex SpeedBridge -- that was the name I couldn’t think of earlier, I am sorry. I drilled two proximally and two distally and then I put in two anchors here, grabbed the Achilles and sutured it down.
And then I take the remaining suture and I take one from here and one from here and dock it into that hole and then one from here and one from here and dock it into that hole. So pictorial representation is above. And then you are going to suture the Achilles back to itself and dock the sutures together and then repair the paratenon. If you would like to use acellular dermis like H. Matrix or Graftjacket or what have you to preserve the gliding mechanism of the Achilles, that's fine as well. Sometimes, they use it. Sometimes they don't. If it's a redo, I almost always use an amniotic membrane to keep the Achilles from scarring back down to the subcutaneous tissue, what little subcutaneous tissue that is there. So here is another picture of a sonic anchor, a little bit more predictable. Here I have used a V to pull it away and reshape the calcaneus with a saw. Here is our drill holes and now you can see the sonic anchors going in and here is the little video. What you do is you track the suture under the anchor, hold down this pedal, which you can see melts the suture -- the anchor right into the bone, you wait five minutes for it to cure or harden -- excuse me five seconds for it cure or harden. Five seconds is over. You take the mechanism out and then I tug on it. I put some force on here to make sure there is no pull out strength and I am pulling pretty hard. So the anchors are not coming out. The sutures are trapped under there and then you go forward, grab the Achilles, tie it down and then like I said use those other two holes to cross the suture. So in other words, you are going to take this suture and this suture and put it into this hole and that suture and that suture put into that hole after you dock the Achilles back together. That's my way of doing it. You don't have to do it that way.
Again for a cuboid, you can do it differently versus navicular versus whatever bone you are anchoring. After you are done with that, you suture the Achilles, bring it back into position, layered closure and always of course test, Thompson's test on the table to make sure that the Achilles is in line. I always prep the other side to make sure that the Achilles looks exactly the same on both sides to ensure that I have put it under the proper length tension relationship. Keck and Kelly is the procedure that I was alluding to earlier when your Haglund's deformity is too large. The purpose is if you take too much of the calcaneus, you run calcaneal fracture if your Haglund is too wide. So what you do instead is you break the calcaneus, you take out a wedge and by taking the wedge out, you are basically flipping the most posterior aspect of the Achilles and the calcaneus underneath that parallel pitch line. So you are taking the wedge out. So lateral incision very similar to [indecipherable] [00:27:00] or lateral calcaneal slide osteotomy. You are going to go down, preserve the periosteum, take your wedge out and then after you take your wedge out, you are going to look at your C-arm, use the Achilles to help you close the wedge and now you can see the parallel pitch lines are now underneath -- or the Haglund's deformity is now underneath the parallel pitch line. Now, you are going to go back and take your saw and just zip off the top of this and make it a nice soft curve and you are good to go. So you don’t really have to disturb too much of the Achilles in this case because the Achilles is effectively put underneath the parallel pitch lines. Postoperative, again short leg cast, gravity equinus for two weeks and then you are going to switch into a CAM non-weight bearing with a lift, remove a little piece of lift every single two weeks until they are full weightbearing at six to eight weeks. At that point, sutures are obviously going to come out when they need to. No usually earlier than three weeks to a month do I take them out. Then after that, aggressive physical therapy, first nonweightbearing and then fully weightbearing after that.
In conclusion, there are favorable outcomes with surgery, which is important because 70% to 90% of people require it. Double anchor fixation is my preferred way and it's important to me in a low profile with equivocal strength of any of the anchors that you use. My preferred in this day and age is the sonic anchor. Thank you very much.
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