Posterior Calcaneal Osteophyte Excision with Subsequent Achilles Tendon Repair

CHAPTER 1

Hi, my name is Sudhir Rao, and I'm going to describe a procedure that was recorded. This was a patient who had a large posterior calcaneal osteophyte, otherwise known as a bone spur. This typically results in patients who have chronic tendinopathy, what is otherwise referred to as insertional tendinosis. Patients who have chronic tendon injury can sometimes develop an osteophyte, which grows in size and then causes local symptoms due to pressure and impingement. The osteophyte is within the tendon, so excision of the osteophyte usually requires repair of the tendon. So in this surgical procedure, I will demonstrate how the osteophyte is excised and the Achilles tendon reattached to the calcaneum. So this individual is placed in a prone position because it allows easy access. I prefer this to a lateral position. After a prep and drape, we inflate a calf tourniquet, and then I make a direct posterior incision about three to four centimeters long on the posterior aspect of the heel. And the dissection is carried straight down to the Achilles tendon sheath, which is split. I then make a direct incision through the mid substance of the tendon, and at the distal end, the knife will identify the osteophyte. Now, at this point, it is really important to keep the dissection close to the osteophyte and release as little tendon as possible, but at the same time, the release must be enough so that you expose the entire osteophyte. On the deep surface, the Achilles tendon is still attached to the calcaneum and every attempt is made to preserve this deep attachment. So once the medial and lateral flaps of the Achilles tendon have been raised, the full extent of the osteophyte can be appreciated, and it really extends from the medial to the lateral border of the posterior calcaneum. Now, I performed this procedure under C-arm fluoroscopy, so I can confirm complete excision of the osteophyte. I excise the osteophyte using a sharp osteotome, and then removing any sharp or prominent edges with a rongeur. I confirm complete excision by visualizing under fluoroscopy. Once complete excision is confirmed, I also palpate the area to make sure there are no sharp, bony edges. Once I'm satisfied with the excision, the second part of the procedure involves a repair of the elevated Achilles tendon. And I perform this by placing two suture anchors within the calcaneum. These were Arthrex 4.7-millimeter anchors, to which a #2 FiberWire suture is already attached. Once the anchors are placed, I pass the suture ends through the tendon and then repair the tendon down to bone, keeping sure that the ankle is in a flexed position to allow adequate apposition of the tendon to bone. I make sure that the knot is buried so it doesn't present subcutaneously and cause irritation at a later stage. The other key to this operation is meticulous wound closure. I find that posterior incisions may sometimes not heal very well, and therefore, I make it a point to perform a subcuticular closure reinforced with the Steri-Strips. This is far better than placing staples or sutures on the outside of the skin. I think the healing is far better if you place subcuticular sutures and avoid traumatizing the posterior skin. Once the skin is repaired, we apply a sterile dressing, and I always immobilize the ankle in about 10 degrees of flexion with a short leg cast. This cast is often changed at two weeks, but the patient will be in some form of immobilization for six to eight weeks to allow complete healing of the repaired tendon.

CHAPTER 2

Let's get two Senns, please. Get the big pickups as well. Okay. Okay. So that's the Achilles tendon. I'm just going to incise the sheath and expose the tendon a little better. Lift up on that. I don't need that right now. Did you open that?

CHAPTER 3

So if you look at the x-ray, he's got that huge osteophyte on the posterior aspect of the calcaneum, and we're gonna try and excise that without stripping too much tendon. So this is an incision right through the middle of the tendon. I'm gonna try and peel the tendon off the osteophyte. Let's have a fresh blade, please. And take that tendon. And you can see the osteophyte showing up right there under the tendon. Take that. And switch hands. All right, so it extends from one end of the calcaneus to the other. It's a pretty big osteophyte, which is causing him a lot of pain. So we're gonna excise that and try and retain as much of the tendon attachment as possible. Right, let's have some osteotomes please.

CHAPTER 4

Okay, mallet. Let's have a shorter rongeur. And a knife. Let's take a look there. Pretty big. I'd like to feel and make sure that it's all gone, but the only way to be absolutely certain is to get an x-ray and take that off. I think he's got a little bit here. You can feel that. Yeah, it's... Shorter rongeur. Knife, please. Take that. Okay, let's look at the other side. We've peeled off the superficial part of the Achilles tendon, but the deep part is still intact. Right there. That's the superficial part. That's the deep. So hopefully if we've excised everything, then we can reattach that tendon back to where it belongs.

CHAPTER 5

Okay, shoot. That's good. Yeah, go ahead. This one right here too. Gimme one size up. Rongeur. Knife. Okay, x-ray, come back please. Shoot. That looks a lot better compared to the pre-op films. You know, most of the osteophyte is gone. I'm happy with it. We're done. You wanna start with that x-ray? Yeah. Okay.

CHAPTER 6

So I think we have the entire osteophyte excised. We're gonna go ahead and repair it by placing two anchors. Are you tapping? I will for this hard bone. All right, let's do the same thing on the other side. So when we insert anchors in really dense bone, it's always good to tap before we insert the threaded anchor. All right, you have free needles? Let's put some water on this, please. So this is #2 FiberWire, a pretty robust, strong suture material. Snap this please. Okay, so I'm gonna have you remove those things, both of them. Flex the foot. We may need a step. I have it. You can let go. Step on it. Thank you. Hand me that needle please. I like to bury the ends of these sutures so they don't stick underneath the skin, so... Can cut with a small tail here. Let's do the same thing. We'll put him in a cast. Retract that for me. The fiberglass cast? Yeah. Okay, fiberglass. So they'll have to get warm water when we're closing. I'm going to use 0 Vicryl. What do you want for skin? 3-0 Vicryl and Steris. Yeah, so by doing this, there's no big knot sticking underneath the skin and all the sutures are sort of away from the midline. There's less scar irritation if you do it this way. Let's have some more Vicryl. So we're just closing the split in that Achilles tendon.

CHAPTER 7

All right, let's try and... Step on that. So skin incisions here don't heal very well, and I think it's really important to do an atraumatic closure. And I try not to use staples if I can avoid it. Let's have some 3-0 Vicryl and go ahead and cut that. So I'll do a subcuticular closure here. I'll take the fine Adsons, please. We will put a stat on the other end. I'm gonna have you stretch there. The other end too. Benzoin, please. Dry sponge. Yeah. If I close it this way, I find I almost never have any wound healing problems. Let's let it dry off. So that big bump that he had on his heel is gone now, and hopefully when it all heals up, he should be a happy camper. You have one up. Two, three, four, five, six. I think we should be good. Go ahead. Seven, eight, nine, 10. You good? Mm-hmm. He's had a block? Yes. If you have some with epi, I can use it. You got my needle. I did. You're so good. I usually inject some marcaine with epinephrine. It helps with the post-op pain relief and also lessens the bleeding. All right, let's have dressings, please. Watch that, yeah.

CHAPTER 8

Let the tourniquet down. Okay, deflating tourniquet. Yeah. 11:14 for a total of 29 minutes. We'll try not to extend it too much. All right, I'm gonna hold this. I'll let you cut the dressings off. Take the tourniquet off. Hold everything. Okay. Now we're gonna have you put your hand inside and you can hold it right there. And then there's a wet six-inch in water. Oh, then it's okay. We don't need another one. Just support him right there. Okay. Do you know how to dip? I can sure try. You dunk it and then squeeze. Not - no, just a gentle squeeze. A dunk and a... Yeah. Peel it open. Okay. Take it off. Okay. Let it soak. Okay. Light squeeze. Sounds good. And yeah. Yeah. Should go take a break. I sent Christine. Oh. Thank you. Ready? Another four-inch? Yeah. Okay. We're not doing bad for time. Uh-uh. Three? Yeah. And I'll take the ACE bandage after that.