Posterior Calcaneal Osteophyte Excision with Subsequent Achilles Tendon Repair

Posterior calcaneal osteophytes represent a significant pathological condition affecting the heel region, characterized by bony proliferations that develop at the insertion of the Achilles tendon.¹ These osteophytes are predominantly associated with chronic tendinopathy, specifically insertional tendinosis, and have been observed to cause considerable patient discomfort.² Epidemiological studies have identified these bony protrusions as a common finding in patients with persistent heel pain and limited mobility.³

Posterior calcaneal osteophytes are well-documented in the orthopaedic literature, with various treatment modalities explored.^4–6 Conservative management strategies, including physical therapy, orthotic interventions, and anti-inflammatory medications, are often initially employed.^7–10 However, when conservative treatments prove ineffective, surgical intervention becomes a necessary consideration.^11–14

The surgical management of posterior calcaneal osteophytes is a complex procedure that requires detailed surgical technique and precise anatomical understanding. Patient preparation involves positioning the individual prone, a choice made to ensure optimal access to the posterior heel. A critical initial step involves a calf tourniquet application, which is essential for creating a bloodless surgical field and enhancing visibility.

The surgical approach commences with a carefully planned incision approximately 3–4 cm long, made directly on the posterior aspect of the heel. This initial approach is executed with surgical precision, with the primary objective of minimizing tissue trauma while providing adequate exposure to the underlying structures. Dissection is methodically performed to reach the Achilles tendon sheath. A critical phase of the procedure involves the precise incision through the midportion of the Achilles tendon. This delicate maneuver requires exceptional surgical skill, as the primary goal is to expose the osteophyte while preserving as much of the tendon's structural integrity as possible. One must navigate a fine balance between obtaining comprehensive access to the osteophyte and minimizing tendon disruption. Throughout this process, great care is taken to maintain the deep attachment of the Achilles tendon to the calcaneum, which is crucial for maintaining the functional integrity of the ankle joint.

While the midline incision is effective, particularly in this case, alternative techniques may be considered for patients with high physical activity due to an increased risk of wound dehiscence associated with this approach.

Intraoperative imaging plays a pivotal role in the surgical intervention. Fluoroscopy serves as a real-time guidance tool, aiding in the visualization of the osteophyte during its removal. Specialized surgical instruments, primarily a sharp osteotome are utilized for initial bone removal, followed by a rongeur to refine and smooth any remaining sharp edges. This meticulous approach ensures the complete removal of the problematic bony proliferation while maintaining the surrounding tissue's structural integrity.

The subsequent phase of the procedure focuses on tendon repair. Two 4.7-millimeter suture anchors are precisely placed within the calcaneum, serving as robust attachment points for the Achilles tendon repair with collagen-coated multi-strand sutures. During the repair process, the ankle is maintained in a specific flexed position, which is crucial for achieving proper tendon-to-bone apposition. Special attention is given to suture placement and knot techniques, with the primary goal of burying the knots to prevent potential subcutaneous irritation. This approach minimizes the risk of postoperative complications and promotes optimal healing.

The final stage of the procedure is closure. Recognizing the delicate nature of skin incisions in the heel region, the surgeon employs an atraumatic closure method. A subcuticular closure technique is utilized, which not only provides excellent cosmetic results but also reduces the risk of wound healing complications.

Postoperatively the limb is immobilized for 6–8 weeks in a short leg cast or boot. This is essential to allow incisional and tendon healing. If a robust repair is achieved, the surgeon may elect to allow gentle ankle range of motion exercises after 2 weeks. However, full weight bearing should be delayed until tendon-to-bone healing is confirmed clinically.

This surgical demonstration offers important educational value for multiple medical professionals involved in orthopaedic and musculoskeletal care. Orthopaedic surgeons, particularly those specializing in foot and ankle surgery, will find the detailed procedural technique useful for understanding nuanced surgical approaches to posterior calcaneal osteophytes. Orthopaedic residents and surgical trainees can benefit from the step-by-step demonstration of complex surgical techniques.

Overall, this video serves as a valuable resource for continuing medical education, providing a practical demonstration of surgical decision-making, instrument selection, and advanced orthopaedic repair techniques.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.