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Exploring A New Surgical Approach To Address Achilles Calcification
Posterior heel pain is a common complaint of the podiatric patient. The pain can be a result of multiple factors including retrocalcaneal exostosis, Achilles tendinitis or retrocalcaneal bursitis. The exostosis can be directly posterior or posterolateral, which is known as Haglund’s deformity when all three conditions are present.
We propose a new procedure using an autogenous Achilles tendon graft after retrocalcaneal exostectomy when inadequate length remains after debridement of the calcified tendon and exostosis.
Haglund in 1921 described the bony prominence in the posterior heel caused by certain shoes worn by “cultured people.”1 The syndrome also includes a retrocalcaneal bursitis caused by the bony prominence. Shoe pressure with ankle joint dorsiflexion causes inflammation of the bursa sac that lies between the Achilles tendon and the calcaneus serving as padding to the tendon in dorsiflexion from the posterior-superior aspect of the calcaneus.2
The last part of the triad is Achilles tendinitis. Achilles tendinopathy results from an overuse or chronic strain that leads to connective tissue degeneration. This degeneration occurs in runners and many other athletes.3 It also may be associated with other metabolic disorders such as diabetes, obesity and steroid use. Fluoroquinolone use is another possible cause.4
Chronic tendon pain represents a prolonged degeneration of the Achilles tendon itself.5 A cavus foot or increased pronation can cause this and shoes that do not fit properly or are worn out can aggravate it. With time, the chronic trauma to the tendon leads to a decreased level of tissue CO2. The increased pH can lead to calcium and phosphorus salt invading the tendon. Fibrocartilage formation may also occur due to a decreased blood supply in the area, which may eventually lead to calcifications.6 Calcifications occurring within the tendon consist of three different types.7 Type I is at the insertion into the calcaneus. Type II is present 1 to 3 cm proximal to the insertion and Type III calcification in the Achilles is more proximal (up to 12 cm from the distal attachment).
What Are The Conservative And Surgical Treatment Options?
Conservative care for Achilles calcification includes shoe therapy, pads, anti-inflammatories, orthotic devices, heel lifts, injection therapy, physical therapy, casting, shockwave therapy, weight loss and activity modification.1,3,4,7 Conservative care has been effective in 75 to 89 percent of the cases.1,8,9
The best imaging options include radiographs, which can show the retrocalcaneal exostosis or calcification of the Achilles tendon or both. Magnetic resonance imaging (MRI) or ultrasound may also be effective for assisting in the diagnosis.4
For those patients who fail three to six months of conservative care, surgery may be indicated.2 The one downside to surgical intervention is that studies show it may be up to 12 months before the patient is pain-free.3
Surgery for the retrocalcaneal exostosis can consist strictly of removing the bump although one of the main reasons for failure is not resecting enough of the posterior bone. One may also remove the bursa sac if it is inflamed. The Achilles tendon is the last element to examine. The tendon may need debridement since it can become hypertrophied at the insertion. Surgeons also may need to remove any calcification within the tendon.1,3-8 This potentiates a major problem with Type I calcification. A serious problem exists if the calcification encompasses the entire Achilles insertion wherein following debridement and exostectomy, there is not enough tendon length to reattach the Achilles to the calcaneus.
How To Perform The New Surgical Procedure
We propose a new procedure to use an autogenous Achilles anterior flap for reattachment of the Achilles tendon.
After achieving adequate anesthesia and using a thigh tourniquet with the patient in a prone position, utilize a posterolateral incisional approach. Perform subperiosteal dissection and reflect the involved Achilles from the insertional exostosis of the calcaneus. Resect the hypertrophic bone with a bone cutting saw and osteotome. Inspect the tendon for any remaining intratendinous bone and remove with sharp dissection.
If there is a large amount of bony involvement and inadequate tendon length remains, a tendon augmentation is required to bridge the remaining gap for reattachment of the Achilles to the calcaneus under physiologic tension. Placing the foot in a neutral position with the ankle at 90 degrees to the foot, measure the gap to determine the length of the tendon graft required for the repair. Procure the autograft by obtaining a split-thickness Achilles graft in the amount of the measured gap space plus 1 cm.
Perform the Achilles tendon flap technique with the split-thickness autograft, leaving the distal end of the Achilles tendon intact. Perform a longitudinal, lateral to medial sharp incision of the Achilles with the incision exiting proximally and anteriorly toward the ankle. Then draw the proximal leading free edge of the deep tendon flap distal with the anatomically deep surface of the tendon now presenting superficial in line with the anatomically superficial surface of the Achilles tendon. This presents a non-adherent surface of the autograft toward the skin. This will also create the desired length of the Achilles tendon for anchoring into the calcaneus under physiologic tension.
Surgeons can use a bone anchor of their choice to fixate the tendon to the calcaneus. Then appropriately irrigate the surgical site and close it in anatomical layers with your suture of choice. Postoperatively, the patient is in a non-weightbearing below-knee cast for three weeks. Follow this with three weeks of weightbearing in a below-knee cast.
Case Study One: When Conservative Treatment Does Not Relieve Severe Posterior Heel Pain
The first patient is a 46-year-old male with a history of bilateral posterior heel pain. The patient related having tenderness for approximately three years with a bump on his posterior heels. The pain progressively increased over 30 days prior to the appointment after “stepping funny” in his shop. The patient noted pain that was 5/10 on the Visual Analogue Scale, which had increased to a 10/10. The quality of the pain was sharp at times but usually consisted of a dull ache. Upon further examination, the patient denied any significant comorbidities. The surgical history was unremarkable but the patient reported a family history of heart attacks and arthritis.
Previous treatment consisted of shoegear changes and rest. Following failed conservative therapy of peritendinous steroid injections, anti-inflammatories, a night splint, contrast soaks and casting, the patient opted for surgical reduction of the retrocalcaneal exostosis deformity. We employed an Achilles tendon flap technique since the Achilles had calcified and yielded inadequate length for reattachment.
The postoperative course was unremarkable at two years. The patient has since returned and had the same procedure on the contralateral limb with similar results.
Case Study Two: Correcting A Longstanding Achilles Deformity
The second patient is a 65-year-old female who had a history of posterior right heel pain for approximately nine years. The symptoms consisted of burning, sharp pain that became a chronic dull ache at times. The patient’s pain level ranged from 1.5 out of 10 up to 8 out of 10 on the Visual Analogue Scale throughout the course of the preoperative therapy. The patient had a prior history of seeing multiple doctors with therapy consisting of rest, soaks, injections, orthotics, bracing, physical therapy and casting, but she had continued tendinous symptoms. The initial MRI demonstrated “distal Achilles tendinopathy with a small partial tear at its calcaneal insertion.”
Five years following the initial MRI, an additional MRI just prior to surgery revealed “significant chronic Achilles tendinopathy with associated insertional enthesophyte formation, retrocalcaneal bursitis and posterior-superior calcaneal edema deep to the insertion site.”
The patient had multiple comorbidities from well-controlled, non-insulin dependent type 2 diabetes. She had hyperlipidemia, hypertension, hypothyroidism, cerebrovascular accident, depression, heart disease, asthma and had survived breast cancer. The patient’s previous surgical history consisted of bunion surgery, a midfoot exostectomy and a mastectomy. The family history of consisted of diabetes and heart disease.
Five years after the patient’s initial visit, we performed a retrocalcaneal exostectomy with the Achilles tendon flap technique due to the lack of viable tendon once the calcified tendon was resected. The postoperative course was unremarkable at one year and the patient had no pain or restriction in activity.
In Conclusion
We have proposed a new technique for reattachment of the Achilles tendon when the tendon is not long enough after debridement of the posterior Achilles calcification. It has been our experience that this new technique lengthens the tendon so full dorsiflexion and plantarflexion may occur via the triceps surae insertion.
Dr. Mozena is in private practice at the Town Center Foot Clinic in Portland, Ore. He is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified in foot and ankle surgery. He is a Clinical Assistant Professor of Surgery at Western University of Health Sciences.
Dr. Jones is in private practice at the Town Center Foot Clinic in Portland, Ore. He is board certified by the American Board of Foot and Ankle Surgery. Dr. Jones is a Clinical Assistant Professor of Surgery at the College of Podiatric Medicine at the Western University of Health Sciences in Pomona, Calif.
References
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