Posterior Heel Complications

Fig. 19.1

The subtle posterior heel bump can be visualized. In this particular patient, the bump was present directly posterior to the Achilles tendon insertion due to calcification here and bursitis which can be seen in Fig. 19.2

Fig. 19.2

Insertional Achilles calcification . Calcification appearing as spurring is present along this patient’s posterior heel. As the calcifications worsen and become larger, the bump on the posterior heel becomes more prominent. This leads to rubbing on shoes and inflammation of the bursal sac all while the Achilles tendon is remodeling and becoming tighter

Insertional Achilles Tendinopathy

Pain at the insertion of the Achilles tendon is indicative of insertional tendinopathy. As the disease progresses, the Achilles tendon will attempt to remodel. The remodeling however is inadequate and results in unequal and irregular crimping of collagen which can eventually be replaced by calcification. This intratendinous calcification is easily visualized on routine radiographs (Fig. 19.2). The calcification can appear as one or many spurs off the posterior heel; however, it is important to remember that this is intratendinous. Any swelling or convex changes to the posterior heel will be located directly posterior (as opposed to the lateral and more superior Haglund’s deformity). On occasion, swelling of the tendon may be present due to the intratendinous inflammation and remodeling.

Bursitis

There are two bursa in the posterior heel which act to protect the Achilles tendon from external forces (i.e., shoe gear) and internal forces (i.e., calcaneal tuberosity). The deeper of the two is named the bursa tendinis calcanei (or retrocalcaneal bursa) and the superficial bursa named bursa subcutanea calcanea (superficial calcaneal bursa) [4]. It is common for bursitis to present in conjunction to insertional Achilles tendinopathy and Haglund’s deformity (i.e., Haglund’s triad) [2]. If primarily involved, likely causes include infection or inflammation due to an arthropathy, both of which are best treated conservatively with oral medications.

Failed Conservative Therapies

Prior to performing surgery on any patient with posterior heel pain, a conservative treatment algorithm should be in place. In no specific order, the patient should fail conservative options with use of heel lifts/pads, stretching, NSAIDs, immobilization, and physical therapy. Physical therapy intervention is especially useful preoperatively as it can help retrain poor mechanics in athletes. Physical therapists are also a valuable member of the treatment postoperatively for recovery and return to activities.

Contraindications/Limitations

Elective surgery should be performed through the skin that has been thoroughly cleaned, is free of infection, and is well perfused. The amount of soft tissue coverage available over the Achilles tendon in the posterior heel is minimal, and any local infection must be treated and resolved prior to surgical intervention to avoid infection of the Achilles tendon . In addition, the presence of peripheral vascular disease warrants an appropriate workup and optimization before performing surgery. The skin to the posterior heel is supplied by calcaneal branches of the posterior tibial and peroneal arteries [5]. If either vessel is diseased, this can lead to poor wound healing or wound dehiscence, infection of soft tissue, and potentially infection of the calcaneus.

Technique Pearls and Pitfalls to Avoid Complications

Incision Placement and Tissue Handling

Many incisional approaches have been reported for posterior heel surgery with some studies specifically observing outcomes related to this alone. To better understand placement of the incision, one must understand the angiosomes of the posterior heel.

There are two angiosomes to consider on the posterior heel. The division between these two lies directly central on the heel with each supplying 50 % and significant overlap exists between the two. On the medial side, calcaneal branches of the posterior tibial artery provide perfusion and calcaneal branches of the peroneal artery perfuse the lateral side. The plantar heel is also supplied by the calcaneal branches peroneal artery. With this in mind, incisions are best made midline over the Achilles tendon [5] (Figs. 19.3 and 19.4). This will fulfill the four principles set forth by Attinger [5] when considering incision placement:

1.

Incision must provide adequate exposure for the planned procedure.
2.

There must be adequate blood supply on either side to optimize healing.
3.

Incision should spare sensory and motor nerves.
4.

Incision should not be perpendicular to a joint.

In the event that exposure is needed to continue into the heel pad, it is suggested that the incision curve laterally to follow the distal angiosome boundary and avoid damage to the medial calcaneal neurovascular structures [6]. In a systematic review performed in 2011 by Highlander and Greenhagen, the incidence of wound complications related to incision placement was recorded [7]. Their findings revealed an overall complication rate of 7 % for posterior midline incisions and 8.3 % for posterior medial incisions, concluding they have similar complication rates. Interestingly, they did report there were no incidences of painful scar or skin necrosis in the midline incision group; there was 1.2% incidence for the former and 0.6% for the latter in the medial incision group.

In procedures such as the retrocalcaneal exostectomy, arthroscopy, and the Keck and Kelly osteotomy, the incision placement can also be made on the lateral posterior ankle. The greater concern in this region is the sural nerve and its calcaneal branches. The sural nerve typically lays 17.5 mm lateral to the Achilles tendon insertion and gives off an average of three branches to the lateral heel as lateral calcaneal branches in the retromalleolar region [7]. An overall incidence of sensory deficits has not been reported in the literature aside from individual case studies. The anatomy of this region affords patient education of the risk of sensory alterations postoperatively. The few cases that have been reported have either gone on to resolve spontaneously or were treated with gabapentin, corticosteroid injections, or additional surgery [8–11] (Fig. 19.5).

Fig. 19.3

Angiosomes of the posterior heel . The blue area, laterally, is supplied by the calcaneal arteries from the peroneal artery. The red area is supplied by the calcaneal arteries from the posterior tibial artery. There exists some overlap between these two distally; however, they predominantly meet exactly midline over the Achilles tendon

Fig. 19.4

Incision placement : (a) Incisions on the posterior heel should be precisely midline. (b) Past the glabrous junction, incision lateral to the Achilles tendon (c) is better tolerated with fewer healing complications. Incisions medial to the Achilles tendon should be avoided. The star indicates the medial malleolus

Fig. 19.5

Note the lateral neurovascular structures

With any incision that is at an increased risk of delayed wound healing, a “no-touch” technique is advocated for handling the skin edges throughout the procedure. Full thickness flaps should be created and secured using suture (Fig. 19.6). This technique will minimize accidental aggressive retraction by assistant or retraction device. Minimal tissue handling and soft tissue trauma will result in improved healing results.

Fig. 19.6

No-touch technique : After creating a full thickness flap incision, the skin edges are sutured back to facilitate surgical exposure and minimize skin trauma/handling

Patient Positioning

The patient should be positioned prone when performing posterior heel surgery through a posterior incision. In the event that a lateral approach will be utilized, a prone/lazy lateral can be used. It is important to maintain access for exposure of the Achilles tendon or medial structures in the event that further exposure is needed or adjunct procedures must be performed. When positioning the patient in the prone position, the foot should hang over the end of the table on a pillow. This positioning will allow natural plantar flexion of the foot by elevating the leg and flexing the knee to remove tension on the Achilles tendon and allow ease of exposure of the calcaneal tuberosity. When positioning the patient in the lateral position, the foot should be elevated off the table to allow assessment of ROM with the leg, knee, and hip in appropriate alignment (Fig. 19.7).

Fig. 19.7

Patient positioning. A patient positioned in prone and a pillow under the ankles. This allows a gentle flexion of the knees and eliminates tension on the gastro-soleal complex. In addition, this position provides superior visualization

Tourniquet

A thigh tourniquet should be utilized for posterior heel surgery to allow full ROM of the ankle during surgery. For ease of application, we have found it best to apply this while the patient is supine just prior to positioning into the prone position. The application of a calf tourniquet will compress and restrict motion within the gastro soleus complex. It may be surgeon preference to use no tourniquet, but this may lead to longer operative times and increased anesthesia requirements for the patient.

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