Endoscopic calcaneoplasty combined with Achilles tendon repair

Endoscopic calcaneoplasty is a minimally invasive technique for resection of inflamed retrocalcaneal bursa as well as the posterosuperior part of the calcaneus. A relative contra-indication for this technique is a tear of the Achilles tendon. In this report, we describe the treatment of a patient with Haglund’s deformity associated with a tear of the Achilles tendon. Both the lesions are treated endoscopically. The technique is described and the pitfalls are discussed.     

Endoscopic surgery of the Achilles tendon

The value of endoscopic surgery as a minimally invasive treatment is well recognized and includes less perioperative pain, less scarring, minimal blood loss, and faster recovery. While open surgery on the Achilles tendon is notorious for wound complications, the tendon is situated in a well-formed tunnel allowing surgical procedures to be performed endoscopically. Various endoscopic techniques have been successfully applied to the treatment of non-insertional Achilles tendinopathy, Haglund's syndrome, Achilles tendon rupture, and equinus contracture. Although the evidence is currently limited, results from authors acquainted with the techniques have been encouraging. Both an understanding of surgical anatomy of the hindfoot and familiarity in soft tissue endoscopy are required to achieve successful outcomes while minimizing complications.     

The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: Its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores

The Zadek osteotomy is a therapeutic option in Haglund’ syndrome for patients with a X/Y ratio measurement of the calcaneus under 2.5. We hypothesized that Zadek osteotomy would lead to improvement in ankle dorsiflexion and functional scores.Twenty-two patients (mean age: 48.5 years) with Haglund’s syndrome underwent a Zadek osteotomy and were enrolled in a prospective study investigating the proposed hypothesis. Radiological measurements included the X/Y ratio and the pitch angle. Measurements of the dorsiflexion of the ankle, using a hand-made frame, were performed twice by 2 independent observers. Inter and intra classes correlations were calculated. Functional results were assessed using AOFAS, EFAS and EFAS sport. Correlation between ankle dorsiflexion and functional scores were determined using linear regression curves.Our hypothesis was validated with a mean improvement of dorsiflexion of 7.27° (54.98% improvement from pre-operative measurement) (p < 0.0001). Ankle dorsiflexion measurements were highly reproducible with an interclass correlation coefficient(ICC)> 0.95 (0.98–0.99). All mean values of functional scores were significantly improved(p < 0.05) [AOFAS (61.95–94), EFAS (14–21.82), EFAS sport (7.68–13.69)] and were strongly correlated to the dorsiflexion values with a coefficient of determination of 0.82 for AOFAS and EFAS and of 0.86 for EFAS sport, respectively. The mean values of X/Y ratio and pitch angle improved from pre to postoperative conditions, 2.18–2.75 and 28.95–19.77° (p < 0.05), respectively.The angle correction obtained from modifiying the shape of the calcaneus, due to the Zadek osteotomy, confirms it as a safe and reliable treatment, with improvements of both ankle dorsiflexion and functional scores.     

The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy

Local debridement or decompression of the posterior heel in Haglund's syndrome yields variable results. This condition is sometimes due to an excessively long calcaneus rather than simply a large posterosuperior bony prominence. Failure to address this abnormality may explain the poor results in some series. We recently published a new measurement (the X/Y ratio) which, combined with the calcaneal pitch angle, assesses the abnormality of the shape of the calcaneus. The Zadek osteotomy strongly modifies that shape. We retrospectively reviewed 50 patients treated by a Zadek osteotomy at a mean 7 years follow-up using the AOFAS ankle-hindfoot score, the VISA-A score and Tegner scale. We measured only the X/Y ratio and the calcaneal inclination angle, as the classically described radiographic measurements in Haglund's syndrome are unreliable. We then assessed the condition of the distal end of the Achilles tendon with an MRI. Our results demonstrate excellent outcomes(40/50, 80%) following Zadek osteotomy and correspond to the change in pre- and post-operative measurements, especially the X/Y ratio. An algorithm using those geometrical measurements of the calcaneus is proposed for decision making in Haglund's syndrome.Level of clinical evidence: Level 3.     

Endoscopic calcaneoplasty (ECP) as a surgical treatment of Haglund’s syndrome

Posterior calcaneal exostosis treatment modalities showed many controversial opinions. After failure of the conservative treatment, surgical bursectomy and resection of the calcaneal exostosis are indicated by many authors. But clinical studies also show a high rate of unsatisfactory results with a relative high incidence of complications. The minimal surgical invasive technique by an endoscopic calcaneoplasty (ECP) could be an option to overcome some of these problems. We operated on 81 patients with an age range between 25 and 55 years, 40 males and 41 females. The radiologic examination prior to surgery documented in all cases a posterior superior calcaneal exostosis that showed friction to the Achilles tendon. All patients included in the study had neither clinical varus of the hind foot nor cavus deformities. All patients had undergone a trial of conservative treatment for at least 6 months and did not show a positive response. The average follow-up was 35.3 months (12–72). According to the Ogilvie–Harris–Score, 34 patients presented good and 41 patients excellent results, while three patients showed fair results, and three patients only poor results. All the post-operative radiographs showed sufficient resection of the calcaneal spur. Only minor postoperative complications were observed. ECP is an effective and of minimal-invasive procedure for the treatment of patients with calcaneal exostosis. After a short learning curve, the endoscopic exposure is superior to the open technique has less morbidity, less operating time, and nearly no complications; moreover, the pathology can better be differentiated.