Gastroc recession with Achilles tendon debridement?

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PMG03470

PMG03470

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Wondering what everyone here does with severe equinus on a patient with Achilles insertional spur.

I’m going to debride the tendon, spur resection, possible FHL transfer… but I have never lengthened the tendon with this. Wondering if anyone has experience with this or what they do instead? I just feel like this patient is doomed to fail if I don’t do some sort of release.
 
I do a really aggressive resection. And advance the tendon with fiber wire/anchor (4 anchor system) at to more anterior calcaneus. For mild equines it’s more like a mini Murphy… severe equines, I think it’s very easy to cause over lengthening. Every time in training we did that it cause a brief calcaneal gait and weakness. Although not permanent these patients complained a lot. I may be wrong but that’s my thought.
 
I always do a gastroc with haglunds combined with severe equinus. It takes 5 minutes and is an extremely powerful procedure. It theory it prevents the haglunds from coming back since it decreases the tension of the achilles on the calc. Do it. Since the patient is already prone I just do a prone open approach
 
MIS zadek
James Sawyer Reaction GIF
 
I've transitioned all my Achilles insertional tendinopathy patient's to MIS Zadek. They have been some of the happiest people I see post op as they tend to be quite miserable prior to intervention and have very little swelling/pain compared to open. I have a few outside provider trainwrecks from open detach reattach with awful scarring and continued reactive edema at the anchor sites. I trust two 7.0 screws and the intact plantar cortex over anchors in cancellous bone after the resection. Allows them to weightbear immediately if they want, otherwise WBAT at 2 weeks and regular shoe at 6 weeks. The dorsiflexion gain and decreased prominence at the posterior heel is quite impressive afterwards.
 
Bluecollarmed said:
I've transitioned all my Achilles insertional tendinopathy patient's to MIS Zadek. They have been some of the happiest people I see post op as they tend to be quite miserable prior to intervention and have very little swelling/pain compared to open. I have a few outside provider trainwrecks from open detach reattach with awful scarring and continued reactive edema at the anchor sites. I trust two 7.0 screws and the intact plantar cortex over anchors in cancellous bone after the resection. Allows them to weightbear immediately if they want, otherwise WBAT at 2 weeks and regular shoe at 6 weeks. The dorsiflexion gain and decreased prominence at the posterior heel is quite impressive afterwards.
Click to expand...

How would you rate the learning curve on the MIS Zadek? I'm interested. I've done a fair number of MIS bunions and have done a couple MIS haglunds resections. However, I'm a bit nervous that I'll screw up that osteotomy and then have to come up with a bail out.
 
+1 for aggressive haglund resect, de/reattach per standard technique, you can lengthen a bit based on how you re-attach, don't need gastroc in 90-95% of cases. Gastroc (strayer mini open) rarely with bad equinus Haglund resects for me... gastroc is several cm higher, so don't want to just extend Haglund incision typically.

But dtrack does them together a lot more if you want to pm him or tag in this thread.

Regardless, you end up with no hardware in there long term, takes 45min or so, recovery is fairly smooth (NWB for a month to get well incision healed). I've never had the 4-anchor system fail (add another if you want tho). Wound issues, sure... occasional but none catastrophic. Having large hardware in the calc is real annoying for future surgery.... I'd avoid or minimize it if easy to do.

With anything significant you do to the calc (osteotomy, fusion, ostectomy, ORIF, harvest a graft, whatever), there will be pain for 3 months or so... there is just no getting around that, so tell ppl that. They can walk sooner, but it'll hurt against shoes or with much walking. It's a big bone, major weightbear bone, bleeds a lot, heals a lot, many nerves adjacent.
 
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shadesofgrey said:
How would you rate the learning curve on the MIS Zadek? I'm interested. I've done a fair number of MIS bunions and have done a couple MIS haglunds resections. However, I'm a bit nervous that I'll screw up that osteotomy and then have to come up with a bail out.
Click to expand...
It's not bad honestly if you have experience with MIS procedures in general. I put converging wires in under fluoro (think bowling bumpers). Takes a minute to do and verifies you don't scallop and get the correct amount of resection. I have them lateral with operative leg 90degress posterior, resting on mini C arm, rolled towel under so I can grasp medial side and feel when the burr gets through cortex easier. Little tip would be to make that lateral incision juuuust a little longer to get a pituitary rongeur in the there to remove the central triangle once you make the posterior and anterior arms of the cut. Takes 2 seconds rather than trying to burr it down, minimizes fluoro time. It takes me about the same amount of time to do it MIS as it does open detach reattach at this point.
 
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Gastroc pretty much always with retro. Speedbridge. Aggressive resect...if you cant see individual fibers...it's no good
 
Feli said:
But dtrack does them together a lot more if you want to pm him or tag in this thread.
Click to expand...

Correct

I can’t say that I can remember an obvious cavus foot where I’ve done insertional achilles work, so maybe that’s why, but I don’t think it’s possible to overlengthen people who have insertional pathology with a gastroc recession alone. Nearly all of them that wind up requiring surgery in my practice have associated equinus. So yeah, I can count on one hand the number of times I’ve treated insertional achilles pathology without doing a gastroc recession.

I should do a Zadek. I don’t think that all of the retrocalc pathology that I see would be appropriate for a Zadek. But I do a lot of MIS so it’s not necessarily a comfort thing working with a burr through small incisions. I’ve done a few MIS speedbridges with the ripstop/knotless fibertak systems. Meh. They did fine but their recovery and results weren’t noticeably better than open procedures and honestly debriding with the bur and shuttling all of the suture doesn’t save me time (yet) compared to an open procedure. Even the small incisions are tender with pressure from shoes for a few months after surgery (hey look, I agree with Feli on something!). I’m an old dog that’s happy to learn new tricks. They don’t all end up making sense or working as well for me as I’d like though.
 
Thank you all for the great suggestions! I generally just re-anchor the tendon with a little slack and have never had an issue before. But this particular patient is so contracted I feel I need more.

Get this… once an Arthrex rep had the nerve to question me while re-anchoring with speed bridge which I wasn’t placing it under tension.
 
PMG03470 said:
Thank you all for the great suggestions! I generally just re-anchor the tendon with a little slack and have never had an issue before. But this particular patient is so contracted I feel I need more.

Get this… once an Arthrex rep had the nerve to question me while re-anchoring with speed bridge which I wasn’t placing it under tension.
Click to expand...
yeah. Do what you think is best. Do the haglund then if it’s still more tight than usual just release the medial aponeurosis of the gastroc. If still tight do the lateral. Can also do PT before surgery to increase rom.

At the end of the day, all procedures listed are good options. I tell my reps to stfu unless i speak to them lol.
 
PMG03470 said:
Get this… once an Arthrex rep had the nerve to question me while re-anchoring with speed bridge which I wasn’t placing it under tension.
Click to expand...
Maybe it's because I don't do big cases, and maybe it's because I take myself less and less seriously by each passing day, but I don't mind when reps ask questions about why I'm doing what I'm doing. In residency, you're always having this exchange of ideas, but as an attending, it all stops. Obviously, reps are primarily there to move product, but it's in their long-term interest for the patient to have a good result (so you keep using their product in future cases) and therefore they may have some useful advice.

Obviously if this person was being arrogant or disrespectful to you, that's bad, because there may be other implicit dynamics at play. But I personally never want to grow into a surgeon/business owner that people are not comfortable questioning because I'll end up committing some grave error that others could have easily stopped me from doing.
 
Considering most products are the same especially when it comes to hardware, I just choose who I want to chat with between cases as the company I use. Cost is second on the list because I like when my hospital overlords like me.
 
The equinus caused the excessive pulling of the insertion of the achilles which turned into tendinosis/calcification which = the spur you see.

I always do a strayer with the achilles debridement/repair and ostectomy of haglunds. If the achilles is significantly degenerated and I have to remove a lot of it then my threshold for an FHL tendon transfer is very low.
 
Retrograde_Nail said:
The equinus caused the excessive pulling of the insertion of the achilles which turned into tendinosis/calcification which = the spur you see.

I always do a strayer with the achilles debridement/repair and ostectomy of haglunds. If the achilles is significantly degenerated and I have to remove a lot of it then my threshold for an FHL tendon transfer is very low.
Click to expand...
This
 
PMG03470 said:
Thank you all for the great suggestions! I generally just re-anchor the tendon with a little slack and have never had an issue before. But this particular patient is so contracted I feel I need more.

Get this… once an Arthrex rep had the nerve to question me while re-anchoring with speed bridge which I wasn’t placing it under tension.
Click to expand...
I tell every rep say whatever you want in the OR. I can't see everything at once. I may not listen to you but you are free to say it.
 
Adam Smasher said:
Maybe it's because I don't do big cases, and maybe it's because I take myself less and less seriously by each passing day, but I don't mind when reps ask questions about why I'm doing what I'm doing. In residency, you're always having this exchange of ideas, but as an attending, it all stops. Obviously, reps are primarily there to move product, but it's in their long-term interest for the patient to have a good result (so you keep using their product in future cases) and therefore they may have some useful advice.

Obviously if this person was being arrogant or disrespectful to you, that's bad, because there may be other implicit dynamics at play. But I personally never want to grow into a surgeon/business owner that people are not comfortable questioning because I'll end up committing some grave error that others could have easily stopped me from doing.
Click to expand...
I agree 100%.

My Stryker rep has been around awhile.

He occasionally has suggestions mid case.

The reason I use him is he knows his stuff (and isnt pushy)
 
Same for not caring what the reps do.... I am out in the middle of nowhere.
I saw the Synthes rep maybe once (in office to shake hands) in 2yrs at IHS hospital - never in the OR. Never saw the Arthrex rep (they just mailed kits).
I think that in my current small town, I see these reps maybe 3-5x per year (biggest cases and occasional talk/meet or new product for Synthes)... even less than that for Arthrex (anchors are anchors... OR equip person just orders back to pars as we consume brace/bridge/anchors/suture/etc).

If they restock the kits/parts/trays, that's what I need.
If they want to show up, cool. (prefer they don't if they're not good)
If they have input, even better. (they should know their stuff better than me if they're good)

Most reps are time wasters. They can toddle the questionable scrub techs along or help with new/complex sets, but it's our skills that do the work. You will probably notice you have less and less need for reps as you become more busy and exp.
 
Feli said:
Same for not caring what the reps do.... I am out in the middle of nowhere.
I saw the Synthes rep maybe once (in office to shake hands) in 2yrs at IHS hospital - never in the OR. Never saw the Arthrex rep (they just mailed kits).
I think that in my current small town, I see these reps maybe 3-5x per year (biggest cases and occasional talk/meet or new product for Synthes)... even less than that for Arthrex (anchors are anchors... OR equip person just orders back to pars as we consume brace/bridge/anchors/suture/etc).

If they restock the kits/parts/trays, that's what I need.
If they want to show up, cool. (prefer they don't if they're not good)
If they have input, even better. (they should know their stuff better than me if they're good)

Most reps are time wasters. They can toddle the questionable scrub techs along or help with new/complex sets, but it's our skills that do the work. You will probably notice you have less and less need for reps as you become more busy and exp.
Click to expand...
When you do corkscrew anchors and synthes screws for everything you don't need reps bro. Us pod tech bros with the newest fancy systems need reps
 
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Adam Smasher said:
Maybe it's because I don't do big cases, and maybe it's because I take myself less and less seriously by each passing day, but I don't mind when reps ask questions about why I'm doing what I'm doing. In residency, you're always having this exchange of ideas, but as an attending, it all stops. Obviously, reps are primarily there to move product, but it's in their long-term interest for the patient to have a good result (so you keep using their product in future cases) and therefore they may have some useful advice.

Obviously if this person was being arrogant or disrespectful to you, that's bad, because there may be other implicit dynamics at play. But I personally never want to grow into a surgeon/business owner that people are not comfortable questioning because I'll end up committing some grave error that others could have easily stopped me from doing.
Click to expand...

For sure, I have never been rude in return. That’s just not how I want to come across, but this guy was saying it like I was about to mess something up. I explained why I was doing it that way and he just said “I have never seen anyone else do that”. But it’s whatevs, every other rep has been very respectful and trying to butter me up to get me to use their products lol
 
heybrother said:
My bigger problem is reps saying "it looks great" when it doesn't. I've got cases where I'm hard on myself trying to make things perfect, but a rep will tell you a botched lapidus looks great when it doesn't. To me there's no worse feeling than an undercorrected bunion in the post-op.
Click to expand...
Bitcoin fixes this.
 
heybrother said:
My bigger problem is reps saying "it looks great" when it doesn't. I've got cases where I'm hard on myself trying to make things perfect, but a rep will tell you a botched lapidus looks great when it doesn't. To me there's no worse feeling than an undercorrected bunion in the post-op.
Click to expand...

I’ve had this happen w screw length. Patients ended up being fine but long bunion screws still bother me
 
heybrother said:
My bigger problem is reps saying "it looks great" when it doesn't. I've got cases where I'm hard on myself trying to make things perfect, but a rep will tell you a botched lapidus looks great when it doesn't. To me there's no worse feeling than an undercorrected bunion in the post-op.
Click to expand...
It's like when your mom tells you how handsome you are
 
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