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Landmarks and Incision
Palpate the posterior border of the distal fibula and the lateral border of the
Achilles tendon. Make an 8- to 10-cm longitudinal incision beginning
halfway between the posterior aspect of the fibula and the lateral aspect of
the Achilles tendon at the level of the top of the calcaneum. Extend this
incision distally to the point where the smooth skin of the dorsum of the
foot and the wrinkled skin of the sole of the foot meet (Fig. 19-2).
Figure 19-2. Make an 8- to 10-cm longitudinal incision beginning halfway
between the posterior aspect of the fibula and the lateral aspect of the Achilles
tendon at the level of the top of the calcaneum. Extend this incision distally to
the point where the smooth skin of the dorsum of the foot and the wrinkled skin
of the sole of the foot meet.
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Internervous Plane
There is no true internervous plane for this incision. The dissection consists
of a direct approach to the subcutaneous calcaneal bone.
Superficial Surgical Dissection
Deepen the skin incision through subcutaneous tissue, taking care not to
elevate any flaps. Full-thickness dissection should be used. Dissect straight
down to the lateral surface of the posterior part of the calcaneum by sharp
dissection (Fig. 19-3).
Deep Surgical Dissection
Incise the periosteum of the lateral wall of the calcaneum and develop a
full-thickness flap consisting of periosteum, subcutaneous tissues, and skin.
Be aware that the sural nerve lies in the anterior flap.1 Ensuring that the flap
is full thickness will protect the nerve. It is in danger only if skin flaps are
created (Fig. 19-4). Incise only sufficient soft tissue to allow access to the
osteotomy site. Soft tissue should be left on the bone either distally or
proximally to avoid devitalizing the bone. The position of the osteotomy is
determined by a preoperative plan and needs to be confirmed during
surgery by using an image intensifier.
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Figure 19-3. Dissect straight down to the lateral surface of the posterior part of
the calcaneum by sharp dissection, making a full-thickness flap and do not
undermine.
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Figure 19-4. Incise the periosteum of the lateral wall of the calcaneum and
develop a full-thickness flap consisting of periosteum, subcutaneous tissues,
and skin. Be aware that the sural nerve lies in the anterior flap.
Dangers
Nerves
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The sural nerve is vulnerable if the skin incision is too far anterior or if
extensive skin flaps are developed. The soft tissues are vulnerable during
this approach, especially distally. Skin necrosis can occur, especially in
older patients who are medically compromised. Accurate assessment of the
patient's preoperative vascular status is critical. Most surgery in this area
has to be delayed for a significant period of time after acute injuries to
allow soft tissue swelling to diminish.
REFERENCE
1. Ortigüela ME, Wood MB, Cahill DR. Anatomy of the sural nerve
complex. J Hand Surg Am. 1987;12:1119–1123.
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20
Posteromedial, Posterolateral, and
Posterior Midline Approaches for
Excision of Calcaneal Exostosis
(Haglund’s Deformity)
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
Nerves
How to Enlarge the Approach
Extensile Measures
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Introduction
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 calcaneum 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 calcaneum. If the incision is
in the midline of the Achilles tendon, incise the posterior sheath of the
tendon (paratenon) after the skin is cut. Preserving the tendon and its bony
insertion is paramount.
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Figure 20-1. Make a 2- to 3-cm longitudinal incision directly over the deformity.
Internervous Plane
The approach uses no true internervous plane, being an incision down onto
a subcutaneous bone.
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Superficial Surgical Dissection
If the incision is medially or laterally placed, incise the periosteum
overlying the calcaneum and carefully define the bony prominence,
ensuring that the Achilles tendon and its insertion into the calcaneum is
preserved using subperiosteal dissection (Figs. 20-2 and 20-3). If the
incision is midline based, incise the peritenon in the line of the skin incision
to expose the tendon itself. Divide the tendon in the midline and, finally,
incise the anterior paratenon (Fig. 20-4A). The deformity on the calcaneum
is now exposed using subperiosteal dissection (Fig. 20-4B). It is imperative
that the insertion of the tendon is preserved. If this tendinous insertion is
ever ruptured, reattachment is very difficult.
Deep Surgical Dissection
This is truly a subcutaneous approach, thus there is no deep surgical
dissection. Note that a Haglund’s deformity may be quite large and the
subperiosteal dissection around the deformity for its resection can be
extensive. If necessary, extend the surgical incision proximally or distally to
ensure easy resection of a large deformity, rather than compromise the soft
tissues by stretching them in an attempt to remove the deformity through a
very small incision.
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Figure 20-2. Careful dissection allows the periosteum to be incised immediately
beneath the skin on the lateral aspect of the calcaneum.
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