The skin was incised with a #10 blade. Full-thickness flaps were created with minimal trauma and no-touch technique. Dissection was carried down through the paratenon, which was split longitudinally. The paratenon was then reflected off the distal Achilles tendon. The distal portion of the tendon was carefully exposed. The tendon was then split longitudinally and inspected.
The distal most insertion had some mild degenerative changes identified within the tendon along with a large posterior-superior Haglund prominence. The distal insertion was partially detached and peeled back in the split. The degenerative portion of the tendon was debrided. This was a minimal portion of the tendon and the overall strength was felt not to be compromised. As such, it was not deemed necessary for a flexor hallucis longus tendon transfer. The deep surface of the tendon was meticulously debrided. The insertion site was exposed.
The oscillating saw and osteotomes were used to perform an exostectomy of the posterior-superior Haglund prominence. This was carefully contoured medially and laterally. Small pump-type bump laterally was debrided and taken down. The tendon was not detached in its entirety. Following adequate decompression of the posterior-superior calcaneus and debridement of the Achilles tendon, the tendon was then reattached with three G-2 Mitek bone anchors.
The Achilles tendon was then stabilized down to the bone anchors and oversewn. The lateral border and lateral pump bump area were reinforced then with #2 Ethibond suture through bone and oversewn with #0 PDS suture. The longitudinally split portion of the tendon was partially reapproximated with the bone anchors and the #2 Ethibond. Final repair was with #0 PDS suture.
A solid insertion site was obtained having been thoroughly debrided and the retrocalcaneal bursa debrided. The wound was copiously irrigated throughout the course of the procedure. The paratenon subcutaneous tissues were reapproximated with 4-0 Vicryl and final skin closure with interrupted 4-0 nylon sutures with good apposition and minimal tensioning.