Endoscopic Calcaneoplasty

Haglund’s deformity refers to the enlargement of the posterosuperior tuberosity of the calcaneus, which can cause debilitating posterior heel pain and swelling. Calcaneoplasty is indicated for the treatment of Haglund’s deformity following a failure of conservative treatment. Endoscopic calcaneoplasty confers a few advantages over open surgery and has been growing in popularity as the preferred technique. This Technical Note presents an endoscopic calcaneoplasty technique with bone debridement followed by treatment with a Topaz radiofrequency device, with the patient in a supine position.

Endoscopic calcaneoplasty (ECP) and gastrocnemius recession (GR) are procedures that have been described to effectively treat Haglund’s deformity and insertional Achilles tendinopathy respectively. The purpose of our manuscript is to evaluate the efficacy and safety of ECP and GR with immediate weightbearing for the treatment of Haglund’s deformity with mild to moderate insertional Achilles tendinopathy.

We performed ECP coupled with GR on 14 patients with an average age of 52 years. All patients demonstrated < 50% tendinous degeneration on MRI. All were allowed weightbearing as tolerated in a CAM boot within the first post-operative week. AOFAS scores and plain film radiographic findings were collected pre-operatively and post-operatively.

The radiographic exam of the Fowler-Philip angle significantly improved from an average 60.1–40.7° (p < 0.001). The AOFAS ankle/hindfoot score significantly improved from an average 54.7–91.4 (p < 0.001). The average return to work was 7.5 weeks. There were two cases of temporary sural nerve paresthesia, and two cases of delayed wound healing.

This is the first mid-term study evaluating the outcomes of ECP with GR. The results of our study suggest that ECP with GR followed by immediate weightbearing is a safe and effective procedure for the treatment of Haglund’s deformity and mild to moderate insertional Achilles tendinopathy.

Schmerzen am Ansatz der Achillessehne stellen mit einer Lebenszeitinzidenz von 6% ein häufiges Krankheitsbild dar. Mittels klinischer Untersuchung, Röntgen und MRT können die Pathologien entsprechend ihrer Lokalisation in drei verschiedene Kompartimente (retro-, intra-, prä-achillär) eingeteilt werden. Führt die konservative Therapie nicht zu einer ausreichenden Besserung der Beschwerden, sollte die Operation erwogen werden.

Am häufigsten wird das offene, vollständige Debridement sämtlicher im Röntgen und MRT identifizierter Pathologien über einen transachillären Zugang mit türflügelartigen Ablösen des Achillessehnenansatzes durchgeführt. Auch wenn die meisten Autoren bei einer Ablösung der Achillessehne von mehr als 50% die Refixation der Achillessehne mittels Anker empfehlen, fehlen hierfür valide Daten. Ebenso limitiert ist die Studienlage für einen zusätzlichen Transfer der Flexor Hallucis Longus (FHL) Sehne bei Sehnendebridement von mehr als 50% des Sehnendurchmessers oder höherem Patientenalter. In dem einzigen vorhandenen RCT wurden ausschließlich Patienten > 50 Jahre eingeschlossen unabhängig vom Ausmaß des Debridements. Mit und ohne FHL Transfer zeigten sich keine signifikanten Unterschiede für die subjektive Patientenzufriedenheit. Grundsätzlich führt die offene Operation zu guten bis sehr guten subjektiven Behandlungsergebnissen. Teilweise werden aber Komplikationsraten von bis 38% beschrieben. Eine Möglichkeit diese zu senken, stellt die endoskopische Operation dar. Allerdings kann mittels Endoskopie nur das retro-achilläre Kompartiment behandelt werden. Sieben Studien berichteten bei kumulativ 377 Patienten über gute bis exzellente subjektive Behandlungsergebnisse mit geringer Komplikationsrate.

Auf Basis der vorhandenen Literatur führen die Autoren bei isolierter retro-achillärer Pathologie ein endoskopisches Debridement und Kalkaneoplastie durch. Bei klinisch retro-achillären Beschwerden, aber in der Bildgebung zusätzlich intra-achillären Pathologien, wird eine retro-achilläre Testinfiltration durchgeführt. Kommt es dadurch zu einer deutlichen Beschwerdebesserung wird dem Patienten eine endoskopische Operation angeboten. Führt dies nicht zu einer Beschwerdebesserung, oder ist die Beschwerdelokalisation / Pathologie inträ- bzw. prä-achillär, wird eine offene Operation empfohlen. Wird dabei aufgrund intratendinöser Veränderungen eine Ablösung der Achillessehne über 50% notwendig, wird eine Refixation mittels Fadenankern in Betracht gezogen. Ein FHL-Transfer wird bei Verlust von über 50% des Sehnendurchmessers erwogen. Wann und ob diese beiden Strategien durchgeführt werden sollten ist aber aufgrund der eingeschränkten Studienlage nicht eindeutig zu beantworten.

With a lifetime incidence of 6%, insertional tendinopathy of the Achilles tendon is a common pathology in orthopaedic practice. By clinical examination, radiographs and MRI, pathologies can be divided into three different compartments (retro-, intra-, pre-achillary) according to their localization. If the non-operative therapy does not lead to a sufficient improvement of the symptoms, operative treatment should be considered.

Most frequently, open, complete debridement of all pathologies identified in X-rays and MRI is performed via a trans-achillary approach and central tendon splitting of the Achilles tendon. Even if most authors recommend refixation of the Achilles tendon with suture anchors in case of an Achilles tendon detachment of more than 50%, valid data are missing. Similarly, no valid studies are available clearly supporting the transfer of the flexor hallucis longus tendon in case of tendon debridement of more than 50% of its diameter. The only RCT available included only patients > 50 years independent of the amount of tendon debridement. With and without FHL transfer no significant differences were observed for patient rated outcome parameters. Taken together, open surgery leads to good to excellent subjective results. However, some studies reported complication rates of up to 38%. Endoscopic surgery is an option to reduce these complication rates. Nevertheless, endoscopy can only address the retro-achillary compartment. Seven studies reported good to excellent subjective treatment results with a low complication rate for retro-achillary pathologies in a cumulative total of 377 patients.

Based on the studies currently available, the authors perform endoscopic debridement and calcaneoplasty for isolated retro-achillary pathologies. In the case of contradictory results, meaning retro-achillary symptoms on clinical examination, but additional intra-achillary pathologies in imaging, retro-achillary test infiltration is performed. If this leads to a significant improvement of pain, the patient is offered endoscopic surgery. If this does not lead to a sufficient improvement of the complaints, or if the localization of the complaints/pathology is intra- or pre-achillary, open surgery is recommended. If due to intratendinous changes, a detachment of more than 50% of the Achilles tendon becomes necessary, a refixation using suture anchors can be performed. A flexor hallucis longus transfer can be considered if 50% of the tendonś diameter was debrided, even though these two strategies cannot be clearly recommended due to the limited amount and quality of studies available.

Haglund’s deformity is characterized as an enlarged prominence of the superior aspect of the posterior calcaneus, which can cause painful inflammation within the retrocalcaneal bursa and anterior surface of the Achilles tendon as a result of mechanical irritation. This may ultimately lead to the development of insertional Achilles tendinopathy. Operative treatment is indicated if conservative therapy, including shoe wear modification, physical therapy, and newer modalities including shockwave therapy, fails to relieve the pain. Endoscopic surgery has the advantages of fewer complications and shorter recovery times in comparison with the open technique. Endoscopic calcaneoplasty is performed using 2 portals, through which the Haglund’s prominence and the degenerative portion of the anterior Achilles tendon are debrided, providing better visualization compared to the open procedure. Endoscopic surgery has demonstrated good to excellent outcomes in the short to medium term. This article describes technique of endoscopic calcaneoplasty and Achilles tendoscopy.

Insertional and non-insertional Achilles tendinopathy is usually treated conservatively. Surgery is indicated if conservative treatment fails to relieve the pain. Endoscopic surgery has the advantages of less morbidity, a shorter operating time, reduced postoperative pain, and a lower rate of wound and soft-tissue healing problems. Patients will have a short recovery time and quickly resume work and sports because of less soft-tissue disruption. Moreover, the pathology can be better differentiated and precisely treated. Achilles tendoscopy is classically performed with the patient in the prone position, whereas endoscopic calcaneoplasty can be performed with the patient in the prone or supine position. This technical note describes the technique of Achilles tendoscopy and endoscopic calcaneoplasty with the patient in the supine position. This has the advantages of more ergonomic hand motion for the Achilles tendon debridement, easier access to the ventral surface of the Achilles tendon, and better orientation of the inside structures; moreover, concomitant chondral lesions of the ankle can be dealt with arthroscopically.

Detachment with reattachment of the Achilles tendon is a common surgery for debridement of retrocalcaneal exostosis, bursitis, and other insertional pathologic entities. The technique involves a midline skin incision on the posterior Achilles to the tendon. The distal Achilles attachment is removed in a U-shaped manner, leaving the medial and lateral flares, but exposing the posterior spur. This midline approach provides excellent exposure and allows for rapid and efficient surgical debridement. The tendon is reapproximated and repaired with a suture anchor to facilitate fixation to the posterior calcaneus. Some surgeons have expressed concerned that the rupture risk could be increased in the postoperative period using this technique. The present study was a retrospective medical record review of 98 patients (100 feet) who had undergone a midline approach with Achilles reattachment after insertional Achilles debridement during a 3-year period. The demographic and comorbidity data were collected and analyzed. The outcome measures were postoperative rupture and the need for revision surgery. The mean age was 51.9 years, and the patients included 59 females (60.2%) and 39 males (39.8%). The complications included 4 rupture or avulsion revisions (4.0%) and 2 recurrent pain and tendinitis revisions (2.0%). The most common repeat repair procedure included hardware removal and a flexor hallucis longus transfer or augmentation. Nine patients (9.0%) had wound complications, 7 (77.8%) of which necessitated incision and drainage. The midline approach with Achilles detachment and reattachment is a safe and effective method of surgical treatment of insertional Achilles pathologic entities. The low reoperation rate of 4.0% will allow foot and ankle surgeons to safely rely on this approach.