Haglunds deformity: Endoscopic calcaneoplasty
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Endoscopic calcaneoplasty is an operation for achilles pain secondary to a Haglund’s deformity, which is often due to the superior calcaneal process impinging upon the soft tissue posterior to it, often an associated retrocalcaneal bursitis. The term “impingement achilles pain” is being used for the condition more recently, which seems appropriate.
Once conservative measures such as shoewear modification, physiotherapy, heel raises and injection therapy have failed, surgery is the next step.
The traditional surgical procedure is an open excision of the Haglunds deformity, performed by a longitudinal posterior approach, with the Achilles being split down the middle. The Achilles is partially or fully reflected from its insertion, to expose the superior calcaneal surface and associated retrocalcaneal bursa. The prominent bone and bursa are then removed with an osteotome. It is a successful operation but has a long recovery due to the careful rehabilitation required after achilles detachment. There can also be issues with delayed wound healing and irritation to the superficial nerves, due to the location of the approach.
The endoscopic procedure combines the advantages of minimally invasive surgery and arthroscopic techniques, allowing immediate weight-bearing and potentially light sporting activity from 3 weeks.The surgery is performed through two small “arthroscopy portals” on the lateral side of the heel, and under X-ray guidance. The initial procedure is to remove the Haglunds “bump” with a minimally invasive burr, followed by the endoscopy to clear debris and excise the bursa, under direct vision. The achilles tendon and insertion is not interrupted and so recovery is very rapid.
One limitation of the technique to be aware of is that it is not possible to deal with areas of intra-tendinous calcification or insertional tendinosis, so this needs to be excluded pre-operatively.
In general it is very successful, but as with all achilles surgeries, the outcomes can be variable as often the pain from any achilles tendinitis can go on for sometime afterwards.
It is important to assess the patient for any concomitant problems such as gastrocnemius tightness, that can be addressed at the same time.
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Author:Pete Rosenfeld FRCS (Tr & Orth)
Institution: St Marys Hospital & The Fortius clinic, London, UK.