Technique

The procedure is performed under spinal anaesthesia using a thigh tourniquet for haemostasis. The patient is placed in a prone position on the operating theatre table. Two converging semi-elliptical incisions are made surrounding the ulcer. The incisions are carried deep to bone, and the ulcer is completely excised. The incision is extended proximally, to expose the posterior aspect of the calcaneus, and deepened to the fascia overlying the Achilles tendon (Fig. 8.20). A No. 15 blade is used to transect the tendon at its insertion on the posterior tubercle of the heel. The tendon is dissected free, grasped with an Allis clamp and reflected out of the wound. Dissection is then directed close to bone, exposing the body of the calcaneus. In the case cited above, the posterior aspect of the heel was resected, using a sagittal saw, in a plane entering the posterior superior aspect of the calcaneus and exiting plantarly at the insertion of the plantar fascia. Inspection of the residual calcaneus revealed healthy cancellous bone. The wound was thoroughly irrigated using 2 L of normal sterile saline solution containing an antibiotic. Three drill holes were then made in the posterosuperior aspect of the calcaneus, for reattachment of the Achilles tendon, using 3-0 Ethibond non-absorbable sutures. A tube low suction (TLS) drain was inserted, exiting through the lateral aspect of the heel. The deep tissues were closed with 2-0 absorbable sutures. The skin was closed using a

Fig. 8.20 The heel ulcer has been excised and the incision extends proximally over the Achilles tendon.

the foot. Dressings are held in place by gauze bandage. A well-padded plaster splint is applied to immobilize the foot and ankle. Drains are generally removed after 48 h. Moderate bleeding from the cut cancellous bone is to be expected, especially over the first 12-24 h, and dressings may need to be reinforced with additional absorbent material. After 7 days, a well-padded short-leg non-weightbearing cast is applied. The cast is changed at 2-week intervals for inspection of the wounds. Sutures are left in place for 3-4 weeks. Once the skin is healed, the patient is placed in a walking brace for 4 weeks and is then allowed to ambulate in a therapeutic shoe with an ankle-foot orthosis (AFO).

Fig. 8.20 The heel ulcer has been excised and the incision extends proximally over the Achilles tendon.

Fig. 8.21 Partial calcanectomy of the right foot. Postoperative lateral radiograph of the same patient shown in Figs 8.19 and 8.20.

combination of 3-0 nylon vertical and horizontal mattress sutures, and simple interrupted sutures. (Caution— infected wounds should be packed open and allowed to heal by secondary intention, or brought back to the operating theatre for delayed wound closure.) Figure 8.21 is the postoperative lateral radiograph, which reveals the amount of bone that was removed.

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