Document 6479900

Causes of Posterior Heel Pain
Surgical Approaches to
Retrocalcaneal Pathology
including Haglund’s Deformity
Ronald L. Soave, DPM, FACFAS
Chief of Podiatry
New York Methodist Hospital
Achilles Bursitis
Calcified achilles tendon
insertion
Paratendonitis
Achilles tendon pathology
(tears)
Haglund’
Haglund’s Deformity
Conditions associated with
insertional achilles pain
include seronegative
spondyloarthridities such as
Reiter’
Reiter’s syndrome, Psoriatic
arthritis & ankylosing
spondylitis (Siciliano,
Siciliano, 1993)
Anatomic considerations (cont’
(cont’d)
Anatomic considerations
(Photo taken from Kline, 2007)
1= superior ridge of
calcaneus (no
achilles attachment)
2= achilles bursa
(green) lying
anterior to achilles
3= posterior calcaneal
tuberosity (main
insertion of achilles)
What is Haglund’s Deformity?
Painful condition that occurs in
patients with bony prominence
of the posterosuperior lateral
aspect of the calcaneus
(Haglund,
Haglund, 1928)
prominence can lead to
overlying bursitis &
inflammation of surrounding
tissues including achilles
tendon
Also referred to as “pumppumpbump”
bump” since females are prone
for developing condition due to
rigid heels and stiff shoe
counters (Aranow
(Aranow,, 2005)
Sural Nerve
(medial)
medial
Plantaris
Watershed
Area
Broad
Insertion
Radiographic considerations
Fowler & Phillip Angle (n= 4444-69 degrees)
FPA > 75 degrees prone to more symptoms
FPA= 80
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Radiographic considerations
Parallel pitch lineline- osseous projection above the
upper pitch line is considered a Haglund’
Haglund’s
deformity
Skin incisions (cont’d)
• J-Incision:
allows for
adequate access to
Haglund’s bump and
visualization of possible
calcific achilles tendon
• Drawbacks include:
• Close proximity to sural
nerve
•Lack of visualization of
medial aspect of achilles
tendon
Photo courtesy of podiatry.wordpress.com
Haglund’s Deformity
Retrocalcaneal Spurs
Case #1#1- Retrocalcaneal Spur with Calcified
Achilles TendinosisTendinosis- MRI
Surgical Approaches
The use of an anchor for
reattachment of achilles tendon
has decreased the morbidity in
patients undergoing surgery for
posterior heel pain (Saxena,
Saxena,
JFAS, 1995)
Distal Achilles tendinosis with partial tear and adjacent reactive bone
marrow edema in the calcaneus
Very few reports exist in
regards to anchor failure and
complications
2
The Use of Bone Anchors
Case #1#1- Retrocalcaneal Spur with Calcified
Achilles Tendinosis
has become the standard approach for reattachment of
achilles tendon to calcaneus
Gained popularity after studies showed lower morbidity
with fixation of achilles using anchors such as the Mitek®
Mitek®
(Saxena,
Saxena, 1995)
A study of 21 patients with recalcitrant posterior heel pain
showed a 6262-88% improvement in symptoms utilizing
a soft tissue anchor system and posterior partial
calcanectomy with Achilles tenoplasty to improve
insertional Achilles tendinopathy.
tendinopathy. (Mafulli
(Mafulli,, 2004)
A recent study has shown no significant differences in
clinical outcome when comparing complete detachment
and reattachment, proximal lengthening, use of bone
anchors to no or partial detachment of achilles tendon.
(Wagner, 2006).
Surgical ApproachesApproaches- Skin Incisions
Case #1#1- Retrocalcaneal Spur with Calcified
Achilles Tendinosis
Lazy-S Incision- Avoids the sural nerve and tarsal
tunnel by starting medial to midline of tendon and
ending on lateral aspect of calcaneus
Case #1#1- Retrocalcaneal Spur with Calcified
Achilles Tendinosis
Case #1#1- Retrocalcaneal Spur with Calcified
Achilles Tendinosis
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Case #1#1- Augmentation using Pegasus OrthADAPT
Bioimplant®
Bioimplant®
Case #1#1- Retrocalcaneal Spur with Calcified
Achilles TendinosisTendinosis- Results
Pre-op
Avoid placing graft on anterior portion of
achilles to prevent occlusion of anterior
paratenon vessels
Post-op
7 weeks post-op
Case #2#2- Haglund’
Haglund’s Deformity with
Retrocalcaneal Spur Resection
Case #2#2- Haglund’
Haglund’s Deformity with
Retrocalcaneal Spur Resection
Case #2#2- Haglund’
Haglund’s Deformity with
Retrocalcaneal Spur Resection
Case #2#2- Haglund’
Haglund’s Deformity with
Retrocalcaneal Spur Resection
Successful Haglund’s resection with improvement of
posterior calcaneal impingement on Achilles tendon
Incising tendon at midline
Haglund’s bump resected
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Alternatives to Reattaching the Achilles Tendon
Arthrex®
Arthrex® Achilles
SutureBridge
– May provide better
contact pressure &
increased fixation
strength compared to
single suture anchors
(Amendola,
Amendola, 2007).
The Definitive Approach to Retrocalcaneal
Pathology?
Careful clinical examination along with prepre-op MRI may
be useful in determining whether the achilles tendon is
involved in the degree of disease process (tendon size &
substance)
Augmentation of achilles tendon is helpful if ~ 50% of the
tendon is excised from insertion (Calder, 2003).
Bone Anchors should always be considered to reattach
the achilles tendon to allow for increased tensile strength
and thus earlier return to physical activity
Care must be taken to avoid “chasing the bump”
bump”
– Fine line between adequate bump resection and iatrogenic
calcaneal fracture
Reference List
Aronow,
Aronow, M. Posterior Heel Pain (retrocalcaneal
(retrocalcaneal bursitis, insertional and non insertional
achilles tendinopathy).
tendinopathy). Clinics in Podiatric Medicine & Surgery, 22; 1919-43, 2005.
J.D. Calder and T.S. Saxby, Surgical treatment of insertional Achilles
Achilles tendinosis, Foot
Ankle International. 24 (2003), pp. 119–
119–121.
Fowler, A. , Philip, J.F. Abnormality of the calcaneus as a cuase of painful heel: its
diagnosis and operative treatment. Br. J. Surg.
Surg. 52:494, 1945.
Haglund,
Haglund, P. Beitrag zur Kinik der Achillesscehne.
Achillesscehne. AschrAschr-Orthop Chir 49:49, 1928.
Keck, S.W., Kelly, J.P. Bursitis of the posterior part of the heel. JBJS , 47A:267, 1965.
Kline, Al. Haglund’
Haglund’s Correction with Removal of Retrocalcaneal Spur and Transverse
Achilles Tenoplasty:
Tenoplasty: 2 Case Reports; Podiatry Internet Journal, 2007
Maffulli,
Maffulli, N. et al Calcific Insertional Achilles tendinopathy:
tendinopathy: reattachment with bone
anchors. Am J Sports Med. 32 (1): 174174-182, JanJan-Feb 2004.
Reed, S. FullFull-Thickness Rotator Cuff Tears: A Biomechanical Comparison of Suture
Suture
Versus Bone Anchor Techniques. 24 (1): 4646-48, 1996.
Saxena,
Saxena, A. Surgery for Chronic Achilles Tendon Problems Journal of Foot and Ankle
Surgery, 34 (3), 294294-300, May 1995
Siciliano,
Siciliano, C.J., Mozen,
Mozen, N.A. RheumatoidRheumatoid-like Nodules Presenting as Haglund’
Haglund’s Deformity
in an Adult, Nonarthritic Patient Journal of Foot and Ankle Surgery, 32 (5): 484484-489,
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Theobald,
,
M.,
Benjamin,
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Review
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Vascularisation
of
the
Human
Achilles tendon.
Theobald
International Journal of the Care of the Injured, 36: 12671267-1272, 2005.
Wagner E, Gould JS, Kneidel M, et al. Technique and results of Achilles tendon
detachment and reconstruction for insertionalAchilles tendinosis. Foot Ankle Int. 2006;
27:677–684.
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