Achilles tendon: Haglunds deformity, central approach using Arthrex Speedbridge
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There are three main varities of pathology effecting the area of the achilles tendon insertion and to which the description of a Haglunds’ deformity is commonly(and loosely) applied.
Most often the pathology is one of degenerative change at achilles the insertion associated intra-tendinous calcification. There may or may not be an element of anatomical prominence of the postero-lateral calcaneus associated. This tends to produce a fairly broad based swelling across the back of the heel. Usually the painful area is located laterally but it can on occasion be postero-medial.
Less commonly the achilles tendon is normal and the issue is an anatomical prominence of the postero-lateral corner of the calcaneus, causing pressure when in shoe-wear.
The third variation is a calcaneus that is anatomically prominent posteriorly, laterally and also superiorly. This can cause direct impingement upon the deep(anterior) aspect of the Achilles in the retro-calcaneal area.
These cases should be imaged using cross sectional imaging to determine the location of both bony deformity and tendinopathy. This will assist in deciding upon the surgical approach to be taken. This will also on occasion show evidence of associated retro-calcaneal bursitis which should be intercurrently treated.
These variations in pathology can be treated using the same surgical principles and with successful outcome expected in the majority of patients. The key is to identify the exact location and nature of the pathology causing symptoms. Non-operative treatment is somewhat less successful when adopted here than for problems with the main body of the achilles tendon.
In my practice I use the Speedbridge for cases of insertional achilles tendinosis where there is significant intra-tendinous calcification that will require extensive detachment of the tendon for adequate access. The Speedbridge provides a far more robust level of fixation for the achilles than any alternatives. One can be as extensive as required therefore with the level of dissection. The technique is though without doubt more involved than simply using a postero-lateral or postero-medial approach and fixing the tendon back with a Bio-corkscrew anchor, which covered on OrthOracle at Haglunds deformity: Arthrex Bio-corkscrew fixation and a postero-lateral approach.Generally the surgery is easier performed with the patient prone but as this technique demonstrates it cab be done with the patient well supported in a lateral position.
The Arthrex SpeedBridge implant itself is very much a really useful part of the surgical armamentarium available to treat Haglunds cases. It should be remembered however that of greater importance is identifying the various potential sources of symptoms and treating them all. Also whatever the operative technique used careful skin handling throughout is required as well as in the post-operative period. The soft tissue cover here is thin and prone to delayed healing.
Author: Mr Mark Herron FRCS
Institution: The Wellington Hospital, London, UK.
Clinicians should seek clarification on whether any implant demonstrated is licensed for use in their own country.
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