Master Techniques in Orthopaedic Surgery: The Foot and Ankle

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Haglund Deformity With Flexor Hallucis Longus Tendon Transfer

Kelly K. Hynes

INTRODUCTION Insertional tendinopathy makes up about 30% of all causes of Achilles tendon pain. 1 Haglund defor mity is a prominent posterior superior border of the calcaneus and is considered part of the spectrum of calcific insertional tendinopathy. Patients present with painful swelling in the posterior aspect of the heel and ensuing problems with rubbing and discomfort from the posterior part of the shoe occurs. True Haglund syndrome is caused by a mechanically induced irritation of the Achilles ten don and associated retrocalcaneal bursa. Patients may present at a younger age with calcific inser tional tendinopathy, sometimes bilateral, which should alert the clinician to the possibility of a more generalized inflammatory arthropathy. The terms “tendinopathy” and “tendinosis” are now widely accepted in the literature as histopath ologic studies of débrided tendon have shown a lack of inflammatory response; mucoid degenera tion and collagen disorganization, fatty infiltration, and increased thickness are the more common findings. 2 Conservative treatments include reducing pressure on the affected area with soft heel counters, open back shoes, and heel lifts. Night splints may be used in the setting of an equinus contracture; however, their efficacy has not been shown in the literature. 3 Repetitive weight-bearing activities should be limited and eccentric Achilles stretching with formal physical therapy is encouraged. We do not advocate the use of steroid injections around the Achilles tendon due to concerns regarding rupture. Studies of extracorporeal shockwave therapy have revealed varying results, but some ben efit has been shown when combined with a physical therapy program. 4 The majority, around 80%, of patients can be reassured regarding the success of nonoperative treatments. 5 Surgical treatment of insertional Achilles tendinopathy in the form of Achilles tendon débride ment, tendon detachment, Haglund excision, and tendon reattachment with or without flexor hallu cis longus (FHL) tendon transfer augmentation has been the mainstay of operative treatment of this condition with generally good outcomes. An FHL tendon transfer may also be used in other presen tations of Achilles tendon deficiency such as a delayed presentation of an Achilles tendon rupture. INDICATIONS AND CONTRAINDICATIONS The decision to operate will ultimately depend on the duration of symptoms, the level of discomfort, and the disability that this causes.

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●● Stiffness/pain especially after a period of rest ●● Disability limiting daily or recreational activities ●● Failure of conservative treatments (greater than 3 to 6 months) ●● Difficulty with comfort in shoe wear ●● Degenerative rupture of the Achilles tendon

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