Posteromedial, Posterolateral, and Posterior Midline Approaches for Excision of Calcaneal Exostosis (Haglund’s Deformity)These approaches are used for the removal of a Haglund’s deformity (“pump bumps”). This deformity may occur in a medial, lateral, or posterior midline position in relation to the insertion of the Achilles tendon onto the calcaneal tuberosity. The choice of approach will be determined by the position of the lump.
Position of the Patient
Place the patient prone on the operating table. This will give access to both sides. If only one side is to be done, use a lateral position if the deformity is on the lateral side of the hindfoot. In either case, exsanguinate the leg and apply a tourniquet to the mid-thigh (see Fig. 6-1).
Landmarks and Incision
The posterior aspect of the calcaneus has variable anatomy. Palpate the Achilles tendon, which will be felt in the midline. The deformity to be resected may present medially, laterally, or directly posteriorly in relation to the insertion of the tendon. Laterally, palpate the lateral malleolus and medially palpate the medial malleolus. Make a 2- to 3-cm longitudinal incision directly over the deformity (Fig. 20-1). If possible, keep the incision away from the insertion of the Achilles tendon, staying on the medial aspect or the lateral side of the tendon and preserving the anatomy of the insertion of the Achilles tendon into the calcaneus. If the incision is in the midline of the Achilles tendon, the posterior sheath of the tendon (paratenon) will be incised after the skin is cut. Preserving the tendon and its bony insertion is paramount.
