A Minimally Invasive Approach To Select Rearfoot Pathology

In our most recent blog post, we introduced the concept of minimally-invasive surgical techniques for select rearfoot soft tissue and osseous pathologies. In this post, we would like to share some cases from our practice where such an approach had a positive impact, specifically, using ultrasonic debridement. Combining our experience with the evidence available in the literature, we feel that this option warrants additional consideration in the foot and ankle surgeon’s procedural toolbox.

Case 1: Exostectomy And Achilles Tendon Debridement

A 30-year-old male presented with a two-year history of pain on the posterior calcaneus exacerbated by sports. He had failed conservative treatment during his cricket season and opted for surgical intervention after the season concluded. The patient marked the areas of pain preoperatively on the posterior heel. The case took place under general anesthesia and with prone positioning on the operative table. We performed an open gastrocnemius recession to address the underlying equinus contracture. Using fluoroscopy, we identified the superior posterior portion of the calcaneus and made two small incisions medial and lateral to the Achilles tendon. Both incisions are necessary to allow for easier access, as we find the instrumentation is not long enough sometimes to reach the opposite side.

Next, we inserted the ultrasonic bone cutting handpiece was inserted with fluoroscopic guidance to resect the posterior portion of the patient’s Haglund’s deformity. After this, we directed the handpiece more distal posteriorly to reach the retrocalcaneal exostosis and attempt to flatten some of the prominence. We turned the beveled tip of the handpiece away from the Achilles tendon, so as to minimize disruption of the insertion. The soft tissue debrider handpiece, with ultrasound-guidance, then entered the distal portion of the Achilles tendon, marked by the patient preoperatively. Ultrasound inspection of the distal Achilles tendon demonstrated a hypoechoic area, which we debrided with the ultrasonic debrider. At this time, manual palpation to the distal Achilles tendon and posterior calcaneus demonstrated a noticeable reduction of the prominence. Lastly, we injected bone marrow aspirate concentrate (BMAC) into the debrided Achilles tendon and near the insertion site with ultrasound guidance.

Postoperatively, the patient was non-weight-bearing in a posterior splint. At the one-week follow-up, he then transitioned into a high-tide removeable boot to permit partial weight-bearing as tolerated. Passive and active range of motion exercises began at three-weeks post-operatively. The patient transitioned into regular shoes at six weeks. Typically in our experience, these patients do not require physical therapy. Strenuous physical activities may resume based on how quickly the Achilles insertion site is pain free.

The left image above shows radiographic evidence of Haglund’s deformity and retrocalcaneal exostosis in a patient with a two-year history of posterior calcaneal pain. In the middle photo, the patient marked the area of pain preoperatively and the surgeon introduced an ultrasound aspirator debrider to the areas of greatest pain from a medial and lateral approach by avoiding detaching the Achilles tendon or disrupting its insertion. In the photo on the right, the postoperative film shows reduction of bony prominences. The amount of bone removed should be just enough to prevent irritation to the Achilles tendon and aggressive bone resection should be avoided.

Case 2: Recalcitrant Plantar Fasciitis With Infracalcaneal Exostosis

A 48-year-old male presented with a 15-year history of heel pain that did not respond to conservative treatment. Plain films and magnetic resonance imaging (MRI) revealed thickened plantar fascia and a large infracalcaneal exostosis. Preoperatively, the patient marked the areas of greatest pain. The patient received general anesthesia and was supine on the operating table. An open gastrocnemius recession addressed the underlying equinus contracture. We then made a small incision is made about one-to-two cm distal to the plantar fascial insertion on the medial side of the calcaneus. We inserted the ultrasound bone debrider handpiece with fluoroscopic guidance to make sure it is on the infracalcaneal exostosis. Periodic fluoroscopic imaging confirms proper placement and gradual reduction in the size of the exostosis. Next, we re-introduced the soft tissue ultrasonic debrider handpiece through the same incision and directed it into the thickened portion of the plantar fascia, seen as a hypoechoic region with ultrasound imaging. After sufficient debridement, we injected bone marrow aspirate concentrate into the treated plantar fascia. We allowed immediate partial weight-bearing in a high-tide removable boot. At three weeks, the patient started passive and active range of motion. At six weeks, the patient returned to regular shoe gear and slowly returned to strenuous activities as tolerated.

In the top row of images, plain films and MRI demonstrate infracalcaneal exostosis and thickened plantar fascia. The bottom left photo shows where the patient marks the areas of pain preoperatively. Intraoperatively, fluoroscopy directs the ultrasound debrider to the infracalcaneal exostosis prior to debriding, as seen in the bottom middle image. The bottom right image shows a postoperative film with in the size of the infracalcaneal exostosis.

In Conclusion

For athletes and active individuals, postoperative recovery time is often a deterrent to having surgery. Such delay results in these chronic pathologies possibly compromising tissue integrity, making return to activity level more difficult. Ultrasonic aspiration and debridement offer a minimally invasive way to treat soft tissue and osseous pathologies by offering less soft tissue trauma and potentially quicker return to activity. Although this technique can be time-consuming with large exostoses, the precision and accuracy of the debridement minimizes disruption of the insertion sites of tendons and ligaments thereby potentially providing less weakening and faster return to physical activities.

Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, MI. He is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President-Elect of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.

Dr. Kipp is a second-year podiatric resident at McLaren Oakland Hospital in Pontiac, MI.