Master Techniques in Orthopaedic Surgery: The Foot and Ankle

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24 Haglund Deformity With Flexor Hallucis Longus Tendon Transfer

deformity débridement have been described but thus far have been limited from widespread use for cases when significant tendon detachment may be necessary due to limitations of percutaneous reat tachment and/or FHL transfer. Minimally invasive techniques are rapidly evolving, and there may be accepted such alternatives to the presently described technique in the not too distant future. SURGICAL TECHNIQUE Technique 1: Haglund Excision Through Tendon-Splitting Approach ●● The patient is placed in a prone position, with the foot elevated with a bolster or blankets under the leg (Fig. 24.3A). ●● The approach is through a posterior midline incision (Fig. 24.3B). Care should be taken to avoid injury to the sural nerve, which may be seen lying along the tendon’s lateral border in the subcu taneous tissue. ●● Alternatives to the posterior midline approach have been described, although they are less com monly used. J-Shaped, transverse, medial, and lateral approached have all been reported. ●● A tendon-splitting approach (Fig. 24.4A) is used, and the tendon carefully dissected to expose degenerative tissue, intrasubstance tears, and intrasubstance calcifications (Fig. 24.4B). A primary goal of this procedure is to perform a thorough débridement of the degenerative areas of tendon and calcifications. This tendon-splitting approach provides excellent access to FHL should aug mentation be required. ●● Varying degrees of tendon detachment may be required in order to gain sufficient exposure of the degenerative areas of tendon insertion and Haglund deformity. By some reports, 70% to 80% tendon detachment is usually needed to gain sufficient exposure. 8 Where possible, leaving the most medial and lateral extents of the tendon attachment intact is very helpful to maintain resting tendon tension and is feasible in all but the most severe cases. ●● Abnormal tendon is excised (Fig. 24.5A). While it may be challenging to distinguish normal from abnormal tendon, uniform tissue that has lost the natural tendon striations and is much thicker in texture than normal tendon should be excised. One way of describing the abnormal tendon has been like the texture of “crab meat,” which is meant to describe disorganization of the fibers and FIGURE 24.2 A. Axial cut of magnetic resonance imaging (MRI) showing intrasubstance degeneration. B. Sagittal MRI image of Achilles tendon insertion showing thickening of the tendon at the insertion and large calcaneal prominence.

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