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Keck and Kelly Heel Osteotomy for Haglunds Deformity: When and how? Troy J. Boffeli, DPM, FACFAS Department Head, Foot & Ankle Surgery, HealthPartners Medical Group Director, Foot & Ankle Surgical Residency Training, Regions Hospital I have no financial disclosures and will not discuss off label or investigative use of products or devices Foot & Ankle Surgical Symposium April 25-26, 2014

Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

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Page 1: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Keck and Kelly Heel Osteotomy for Haglunds Deformity: When and how?

Troy J. Boffeli, DPM, FACFAS Department Head, Foot & Ankle Surgery,

HealthPartners Medical Group

Director, Foot & Ankle Surgical Residency Training, Regions Hospital

I have no financial disclosures and will not

discuss off label or investigative use of

products or devices

Foot & Ankle Surgical Symposium

April 25-26, 2014

Page 2: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Anatomic Effect of Keck & Kelly Osteotomy

1. Tilts heel prominence forward away from the shoe

2. Elevates insertion of Achilles (reduces equinus stress)

3. Straight orientation of Achilles fibers at the calcaneal insertion

Page 3: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Indications for Keck & Kelly Osteotomy

1. Haglund’s Deformity

2. Combined Haglunds & Retrocalcaneal exostosis?

Page 4: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Indications for Keck & Kelly Osteotomy

1. Haglund’s Deformity

2. Combined Haglunds & Retrocalcaneal exostosis?

Page 5: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Local vs. Global Haglunds (Haglunds resection vs.

Keck osteotomy)

Page 6: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Localized vs. Global Posterior Heel Bump

Page 7: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Preop vs. Postop Layover Comparison

Page 8: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Heel Views for Haglunds

Page 9: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Lateral Oblique Heel View for Haglunds

Page 10: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Ideal Keck and Kelly osteotomy technique?

• “Angle of osteotomy is important, if the angle is incorrect, the amount of shortening will be insufficient”

McGlamry

Perlman

Perlman, J Foot Surg 1992

Page 11: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Keck and Kelly Template Technique

Boffeli and Peterson, JFAS 2012

Page 12: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

1. Invert Contrast and Print Lateral View

Page 13: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

2. Determine Posterior Superior Exit Point (anterior to the Achilles)

Page 14: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

3. Determine Plantar Apex (posterior to WB area of tuberosity)

Page 15: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

4. Draw Posterior Osteotomy

Page 16: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

5. Draw Anterior Osteotomy (vertical to the WB surface)

Page 17: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

6. Photocopy Template and Cut out Posterior Fragment

Page 18: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

7. Tape Posterior Fragment in Place to Demonstrate Impact of Wedge

Page 19: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

8. Reproduce Osteotomy in the OR

Page 20: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Draw Outline of Calcaneus (flatfoot vs. cavus foot)

Page 21: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Identify Sural Nerve

Page 22: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Mark Lateral Edge of Achilles

Page 23: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Mark Incision

Page 24: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Layover Technique Can be Misleading due

to Thick Soft Tissue

Page 25: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Identify Plantar Apex of Osteotomy

Page 26: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Identify Dorsal Exit Point of Anterior Osteotomy

Page 27: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Proposed Osteotomy

Page 28: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Full Depth Incision (Like calc fracture)

Page 29: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Blunt Dissection By Achilles

Page 30: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Isolated Periosteal Elevation (at wedge, no need to touch Achilles)

Page 31: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Expose Dorsal Cortex of Calcaneus

Page 32: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Confirm Plantar Apex and Exit Point of Posterior Osteotomy

Page 33: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Free Dorsal Periosteum

Page 34: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Free Medial Periosteum

Page 35: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Insert Osteotomy Guide Pin

Page 36: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

2nd Parallel Osteotomy Guide Pin

Page 37: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Image Osteotomy Guide for Posterior Cut

Page 38: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Align Saw with Osteotomy Guide and Guide Pin

Page 39: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Switch to Long Saw (mark at 3cm)

Page 40: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Use Existing Cut to Maintain Angle

Page 41: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Carefully Finish Plantar Medial Apex

Page 42: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Posterior Osteotomy Completed

Page 43: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Location of Anterior Cut for 7mm Wedge

Page 44: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Osteotomies Completed

Page 45: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Remove Wedge in One Piece (V8351)

Page 46: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Size of Wedge (7-9 mm)

Page 47: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Finish Distal Apex

Page 48: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Dorsiflex Foot to Compress (note intact plantar hinge)

Page 49: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Reduce Osteotomy (9187, B3)

Page 50: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Reduction of Osteotomy (v8352)

Page 51: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Insert Guide Pins

Page 52: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Countersink Issues Thru the Achilles

Page 53: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Screw Fixation

Page 54: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

6 Weeks Postop (return to WBAT)

Page 55: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Preop vs. Postop Comparison

• Global remodeling without touching the Achilles

Page 56: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Alternative Posterior Pin Fixation

Page 57: Keck and Kelly Heel Osteotomy for Haglunds Deformity: When ......• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical treatment of eighteen patients

Questions / Comments?

• 1. Keck S, Kelly P. Bursitis of the posterior part of the heel, evaluation of surgical

treatment of eighteen patients. J Bone Joint Surg [Am] 47A:267, 1965. • 2. Aronow MS. Posterior heel pain (retrocalcaneal bursitis, insertional and

noninsertional Achilles tendinopathy). Clin Podiatr Med Surg. 2005 Jan;22(1):19-43. Review.

• 3. Green AH, Hass MI, Tubridy SP, Goldberg MM, Perry JB. Calcaneal osteotomy for retrocalcaneal exostosis. Clin Podiatr Med Surg. 1991 Jul;8(3):659-65. Review.

• 4. Miller AE, Vogel TA. Haglund's deformity and the Keck and Kelly osteotomy: a retrospective analysis. J Foot Surg. 1989 Jan-Feb;28(1):23-9. Review.

• 5. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. 3rd Ed. Edited by Alan S. Banks, DPM, Michael S. Downey, DPM, Dennis E. Martin, DPM, and Stephen J. Miller, DPM. 2,304 pages, illustrated. Lippincott Williams and Wilkins, Philadelphia, 2001.

• 6. Boffeli T, Peterson M. The Keck & Kelly Wedge Calcaneal Osteotomy for Haglund’s Deformity: A Technique for Reproducible Results. J Foot Surgery. 51 (2012) 398–401.