Patients that have insertional Achilles tendonitis with retrocalcaneal bursitis and a Haglund’s deformity, may benefit from surgical intervention. This condition can usually be managed without surgery, but there are some patients that continue to be symptomatic and will benefit from having a surgical debridement. A debridement is a “clean out” procedure designed to remove potential sources of discomfort (bone spurs, degenerated tendon, inflamed soft tissue). Surgical treatment is generally indicated when there is failure of several months of non-surgical treatment.
Several different approaches and techniques can be utilized in Haglund debridement. Commonly, this procedure is performed through an incision on the back part of the heel. This incision may be located on either side of the Achilles tendon, or even directly over the tendon. In some instances, it may be possible to perform this surgery using minimally invasive techniques.
Surgery involves removing the unhealthy, degenerative portions of the tendon, and removing the inflamed bursa (fluid-filled sac) behind the Achilles. It is also necessary to remove the prominent bone (Haglund deformity), which puts abnormal pressure on the Achilles tendon. In some instances, there may be calcifications within the Achilles tendon that need to be removed as well. Oftentimes, the tendon attachment to the heel bone needs to be partially detached in order to remove the Haglund deformity, and then reattached with sutures that attach directly into the bone. If the Achilles tendon is short, then lengthening of the tendon may also be necessary, as this puts less tension on the Achilles attachment. The goal is to remove inflamed tissue, bone spurs, and degenerated tendon that has developed over the years.
In older patients or those in which a large amount of tendon is removed, one of the other tendons at the back of the ankle may need to be transferred to the heel bone to assist the Achilles tendon with strength as well as provide a better blood supply to this area for healing.
Initial recovery involves protecting the surgical repair in a cast or a, allowing the incision to heal. You may require to use crutches or a walker. Depending on the severity of your condition, a range-of-motion program may be started once the incision has healed. Typically, after 4-6 weeks, a home exercise program or formal physical therapy program will focus on progressive strengthening and stretching. If another tendon is transferred, recovery can take longer. This can be a frustrating condition, as many patients have some degree of pain and swelling even three to six months after surgery. However, things will usually improve so that by the time they are one year after surgery, most patients are doing noticeably better than they were prior to surgery.
- Wound healing problems. Surgery on the back of the heel is associated with difficulty in wound healing. This occurs more often in certain patient populations (for example: smokers and diabetics). The initial period of immobilization ensures that your incision heals properly.
- Rupture of the Achilles. This is a serious, but fortunately, an unusual complication. If too much of the Achilles is resected, this can weaken the Achilles and cause it to rupture following surgery. Although unlikely, if this does occur, it typically requires a return to the operating room to re-attach the Achilles to the heel bone.
- Persistence of Symptoms. This is a “clean-up” procedure and it is not possible to replace all the scarred tissue with new healthy tissue, so some residual symptoms may persist.
- Sural Nerve Injury. The sural nerve runs next to the Achilles and supplies sensation to the outside of the foot. This nerve can be stretched or irritated in the course of this surgery. This can lead to pain, burning, or numbness over the course of the sural nerve.
General complications include:
- Wound healing problems
- Deep Vein Thrombosis (DVT)
- Pulmonary Embolism (PE)