Master Techniques in Orthopaedic Surgery: The Foot and Ankle

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PART V Achilles

FIGURE 24.6 The abnormal tendon is débrided as there are areas of thickening, calcification within the tendon, and tendon degeneration giving a clear view of the Haglund deformity. If significant tendon is detached, repair with suture anchors with or without flexor hallucis longus tendon transfer (described below) is performed.

FIGURE 24.7 The calcaneal prominence is resected with a saw showing the fragment of bone removed from the incision approximately 2 × 3 cm in diameter.

●● Once suture form each side is passed to the other, creating a suture bridge type pattern over the repair site (Fig. 24.9). Each pair of sutures is then loaded onto a suture anchor, tensioned, and inserted into the predrilled distal holes while maintaining appropriate plantar flexion of the foot to restore appropriate repair tension (Fig. 24.10). ●● The tendon split is repaired with a running suture (see Fig. 24.8A), and the wound is closed with a 4-0 subcuticular monocryl suture (see Fig. 24.8B). Technique 2: FHL Tendon Transfer (Augmentation) ●● If it is determined that a significant portion of the tendon attachment was dissected, augmenta tion may be required with FHL tendon. The literature usually describes a number of this being indicated when less than 50% of the insertion remains and this is the guidance used by this author. ●● Any fat overlying the FHL is excised, and then the deep fascia between the superficial and deep compartments is released. ●● The hallux is flexed and extended to help identify the muscle belly of FHL (Fig. 24.11A). ●● Great care should be taken while dissecting around the tendon of the FHL because the tibial nerve is immediately to the medial side (Fig. 24.11B). ●● A tendon hook or curved clamp is placed around the tendon, and the ankle and hallux are plan tarflexed to deliver maximal tendon from the fibro-osseous tunnel (Fig. 24.12A). The tendon is followed as it travels between the medial and lateral tubercles of the posterior talus, and the FHL tendon is released from its sheath (fibro-osseous tunnel). The tendon is cut as distally as possible; a small tendon stripper may help. Great care must be taken to avoid injury to the tibial nerve (Fig. 24.12B). A whip stitch is inserted into the FHL tendon. The tendon size is measured using a standard tendon sizer. The reamer size selected is typically 1 mm greater than the tendon diameter. ●● A threaded guide wire is passed plantarly through the prepared calcaneus approximately 1 cm anterior to the posterior border of the calcaneus. This increases the mechanical advantage by maximizing the lever arm of the transferred tendon (Fig. 24.11A and B).

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