DEFINITION AND INTRODUCTION

 

Patrick Haglund in 1928 described an enlarged posterior border of the os calcis.4

 

This anatomy (Haglund deformity) becomes very important when external shoeing/heel counter and repeated hyperdorsiflexion causes contact between the Achilles tendon, the posterior vertical surface of the calcaneus, and the interposed retrocalcaneal bursa.

 

 

As a result, Haglund syndrome is commonly characterized by inflammation within the retrocalcaneal or Achilles tendon bursa and often secondarily presents as insertional Achilles tendinopathy.

 

The posterior heel pain and swelling associated with Haglund syndrome is the result of mechanical irritation by the calcaneal prominence on the surrounding soft tissues and the anterior paratenon of the Achilles tendon.

 

After conservative/nonoperative measures have failed and imaging does not show significance, Achilles tendinopathy, Haglund deformity, and retrocalcaneal bursitis can be treated surgically using an endoscopic technique. General indications are pain, limp, alteration of workstyle or lifestyle, and, lastly, significant night pain.

 

 

The endoscopic technique is an outpatient treatment that is associated with low morbidity and high outpatient satisfaction. There is a short recovery time and a short time to gain prior activity level.

 

Appropriate visualization of the Achilles tendon and its paratenon and removal of the calcaneal prominence and retrocalcaneal bursa can be effectively accomplished using an endoscopic technique.

 

PATHOGENESIS

 

The retrocalcaneal space has been described as a disc space bursa covering the posterior superior angle of the calcaneus.3 The bursa walls may become diseased and hypertrophied with repeated hindfoot movement. Increased pressure can occur and become chronic with secondary calcaneal bone edema and paratenon

reactive fibrosis at the insertion.

 

Achilles tendinopathy is a degenerative process within the tendon substance causing microtears which can progress to macrotears, edema, and reactive fibrosis with scar formation. These changes can cause secondary mechanical irritation of the surrounding tissues and can even stimulate an inflammatory process.9

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Clinical evaluation may help differentiate between retrocalcaneal bursitis and Achilles tendinopathy, although the two often coexist.

 

Pathology within the retrocalcaneal space is detected on clinical examination with point tenderness along the anteromedial and anterolateral aspects of the Achilles tendon and an associated prominence of the calcaneus.

 

Palpation of the affected hindfoot often reveals tenderness at the distal portion of the Achilles tendon proximal to its insertion on the calcaneus. The pain can be reproduced with passive or active dorsiflexion. The

retrocalcaneal bursa and the more directly posterior Achilles tendon bursa can become confluent and “wrap around.”

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Imaging can assist with documenting the presence or absence of tendinopathy (FIG 1A).

 

It can be difficult to distinguish whether symptoms are caused by retrocalcaneal bursitis or insertional Achilles tendinosis or tendinitis. These two conditions often coexist.

 

Magnetic resonance imaging (MRI) should be used preoperatively to better demonstrate or differentiate coexistence of these diagnoses (FIG 1B-D).

 

 

 

Normal-appearing and diseased tendons can usually be distinguished endoscopically. Ultrasound can help rule out a distal Achilles noninsertional tendinopathy or tendinitis. Limited bone scan can help with differential diagnosis with its sensitivity (FIG 1E).

NONOPERATIVE MANAGEMENT

 

Nonoperative measures for the treatment of posterior heel pain include the use of nonsteroidal anti-inflammatory medication, shoe wear modification (such as using backless shoes and avoiding irregular counters), physical therapy for icing or other modalities, stretching exercises, pressure-release inserts, and hands-on friction massage.

 

Local injections can be given in the retrocalcaneal space for diagnostic purposes. The concomitant use of local anesthesia and corticosteroids can further weaken the substance of the Achilles tendon and risk weakness and further micro- or macrorupture of the tendon.5

SURGICAL MANAGEMENT

 

The goal of treatment for Haglund deformity and associated inflammation and tendinopathy is to remove the calcaneal prominence and to decompress the inflamed surrounding soft tissues.

 

 

Open surgical correction is an alternative for patients who have failed to respond to nonoperative measures and if there is an estimated tendinopathy with ˜25% involvement on axial

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Achilles serial images. In that case, augmentation (authors preference) or alternate open Achilles tendon surgery is advisable.

 

 

 

FIG 1 • A. Preoperative lateral foot film showing Haglund exotosis. B. MRI showing retrocalcaneal bursa involvement and insertional tendinopathy. C. Sagittal view; the Achilles tendon insertional involvement, the distinctive and extensive calcaneal response (including cystic change), and a clinical treatment nonresponse makes an open approach preferable. D. Sagittal view; the intact Achilles, the lesser reactive calcaneal signal, and a more modest functional disability, although recalcitrant to a nonoperative approach makes endoscopy preferred. Axial views are necessary to quantitate any tendinopathy component. E. Triple-phase bone scan, particularly the delayed phase, can help rule out adjacent problems and further target/quantitate the calcaneal or bursal involvement. (A,B: From Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int 2007;28:149-153, with permission.)

 

 

Open procedures generally include the following:

 

 

Resection of the calcaneal prominence (Haglund deformity) proximal to the Achilles tendon insertion

 

Retrocalcaneal bursa removal

 

Rarely, a dorsal closing wedge osteotomy can rotate the posterior calcaneus to a lesser prominent position.

 

Achilles tenolysis and partial resection of the diseased portion of the tendon may be necessary, often with augmentation by the flexor hallucis longus or flexor digitorum.

 

Complete Achilles removal at its insertion with multianchor reinsertion is occasionally necessary.

 

Complications associated with these procedures can include hematomas, tendon or skin breakdown, nonunion, Achilles tendon avulsion, tenderness around the operative scar, cosmetic problems, altered sensation around the heel, and stiffness.1,7,11,13,14 Rehabilitation following open surgery can be prolonged.

 

The endoscopic technique of decompressing the retrocalcaneal space but with an “intact” Achilles tendon insertion was developed to reduce morbidity and decrease the functional time to recovery for patients with retrocalcaneal bursitis.15

 

The endoscopic technique has been shown to have fewer complications and a better cosmetic appearance

than an open procedure.8

 

Here, we describe retrocalcaneal bursoscopy using our method of endoscopic bony and soft tissue decompression of the retrocalcaneal space and the results from our patient series.12 Hindfoot endoscopy is being increasingly used for numerous problems.

 

Positioning

 

The operation is performed with the patient in the supine position and under either general or regional anesthesia. Monitored anesthesia care (MAC) is occasionally used. The foot should be adjusted on the table until in a neutral position.

 

 

A high thigh tourniquet is inflated to 300 mm Hg after Esmarch ischemia. A sequential compression device is used on the contralateral leg, ankle, or foot.

 

The heel is positioned at the leading edge of the operating table. This enables the surgeon to place the foot against his or her body while using both hands to operate the arthroscopic instruments.

 

The leg rests on a firm padded 12-inch long and 4-inch wide diameter cylindrical (bump) that allows the surgeon ample room to use both hands and to control ankle dorsiflexion and plantarflexion.

 

Alternatively, the prone position can be used.2

 

Both positions allow the patient's foot to be controlled against the chest of the surgeon, who can then have both hands free for use of arthroscopic instruments.

 

 

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TECHNIQUES

• Portal Placement and Exposure

Make a lateral portal with a vertical incision at the level of the superior aspect of the calcaneus (TECH FIG 1A).

The incisions are slightly anterior to the Achilles tendon and posterior to the sural nerve. It is important to bluntly dissect and spread the soft tissues when making the lateral portal to minimize the risk of injury to the sural nerve.

Establish the second portal similarly just anterior to the Achilles tendon, using the light of the arthroscope or a hemostat as a guide (TECH FIG 1B).

Enter the retrocalcaneal space with a blunt trocar to develop a working space. Place a 4.0-mm arthroscope into the retrocalcaneal space.

 

 

 

 

TECH FIG 1 • Establishing landmarks and planning portal placement medially (A) and laterally (B).

• Resection and Decompression

   

  Introduce a 3.5-mm arthroscopic shaver (for larger hindfeet, a 4.5-mm arthroscope can be used) through the portal and remove the bursal tissue. This expanded working space creates visualization and access to the posterior calcaneus and the Achilles tendon attachment.

   

  Depending on the quality of the bone, use either the arthroscopic shaver and/or a 4-mm arthroscopic burr to resect the posterosuperior calcaneal prominence (TECH FIG 2).

   

  Keep the hooded portions of the instruments toward the anterior direction. A short sleeve can be helpful. Switching portals promotes symmetry of bone removal.

   

  Take special care to stop the rotating or oscillating shaver or burr usage when the instrumentation enters or exits the portal.

   

   

   

  TECH FIG 2 • A,B. An arthroscopic shaver is used to resect the posterior superior calcaneal prominence. A 4-mm arthroscopic burr is also used. (From Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int 2007;28:149-153, with permission.)

   

   

  Carry out the resection both medially and laterally into the sulcus of the calcaneal tendon (retrocalcaneal bursa) space and distally stopping at the attachment of the Achilles tendon. Old chronic scarring can make the Achilles attachment hard to identify; requiring mini C-arm check.

   

  Visually confirm adequate exposure and resection of the osseous prominence until there are no areas of Achilles tendon impingement.

   

  Protocol dictates the use of the mini C-arm (Mini 6600 series; GE OEC Medical Systems, Salt Lake City, UT or a similar unit) pre- and post-bony resection to determine bony removal, confirm adequate resection, and to document completion.

   

  Damaged or diseased Achilles tendon can be selectively exposed and with a nerve hook or probe identified. Small lesions and ossification can be removed with mixed use of the burr and/or rongeur.

   

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  Limited bone or tendinopathy can be removed with the arthroscopic shaver.

   

  An 18-gauge needle can be inserted several times into the tendon to promote blood ingress and collagen scar where there is hemosiderin deposit, myxoid, or degenerative change or frank tear.

   

  The rationale for this is to initiate a vascular response within the tendons for healing; it is performed with or without débridement. Platelet-rich plasma (PRP) is not used.

   

  Insert an image-guided arthroscopic probe into the retrocalcaneal space to confirm continuing effective attachment of the Achilles tendon. Clinical pre- and postoperative palpation of the tendon is also important.

• Completion and Wound Closure

 

Hyperplantar and dorsiflex the foot with the anterior chest and abdomen to verify any last areas of impingement. Also, medial and lateral oblique hindfoot views are taken to make sure medial and lateral corners are clear of bone.

 

 

 

Irrigate and suction the retrocalcaneal space to remove any loose bone/tissue. Close the portal sites with two 4-0 or 5-0 nylon horizontal mattress skin sutures. Inject local anesthetic (0.5% Marcaine without epinephrine) into the portal sites.

 

Apply a compression dressing and splint the foot into slight 5-degree equinus with the posterior splint and sugar tong (trilaminar splint).

 

 

 

PEARLS AND PITFALLS

Set up with heels directly at the end of operating room table so can manage position of ankle/foot in dorsiflexion and plantarflexion with chest/abdomen.

Develop operative field from posteromedial to posterolateral corner so panoramic view of Achilles tuberosity attachment in its entirety.

MRI is necessary preoperatively to document insertional tendinopathy. If more than 25% of the cross-sectional area of the tendon is involved, open repair may be necessary (author's opinion).

Do not use an “extremity” MRI, as most are ˜8 inches diameter and cannot be positioned with the ankle in a neutral “90 degrees.” Tendon distortion and crimp occurs and prevents adequate interpretation.

Experience enables removal of paratenon and further removal/débridement of small ruptures and/or ossification in selected cases and situations. The so-called “tug lesion” or exostosis present in many insertions can be partially or completely removed in many cases, that is, stress fracture at its base and

bony bulk symptoms posteriorly.10 Postoperative routine are as follows:

Non-weight bearing for 2 to 3 weeks

Walker boot with partial weight bearing for 2 to 3 weeks

Maximize posterior tibial and peroneal strength as soon as possible

Variation of rehab is necessary with condition of the tendon, premature sport-specific loading, and patient factors such as weight and compliance.

 

POSTOPERATIVE CARE

 

The average time until full weight bearing in a walker boot is 4 weeks.

 

 

Patients wear shoes with a heel counter and return to normal daily function in 6 to 8 weeks. All athletes returned to their previous level of activity in an average of 12 weeks.

 

Patients may need a longer period of cast/boot immobilization after débridement of the Achilles tendon or significant Achilles tendinopathy. Generally, an open procedure would be used in this event.

 

There are frequently small islands of calcification or ossification at the endoscopic site on postoperative lateral films of the hindfoot. They are of no consequence (FIG 2).

 

OUTCOMES

In our study of endoscopic bony and soft tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis,12 32 heels in 30 consecutive patients underwent endoscopic decompression. The timing for surgery after diagnosis of retrocalcaneal bursitis

averaged 20 months. All patients had failed to respond to nonoperative measures and none had undergone previous surgery.

Indications for operative intervention included failed nonoperative measures, history, and physical examinations consistent with retrocalcaneal bursitis and Haglund deformity causing mechanical impingement or Achilles tendinopathy.

 

 

 

Patients were prospectively followed from 1997 to 2003, with a mean follow-up of 35 months (range 3 to 62 months).

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FIG 2 • A typical postoperative lateral at 4 months postoperative.

 

 

Thirty heels completed subjective and objective measures using the American Orthopaedic Foot and Ankle

Society (AOFAS) ankle-hindfoot scale.6

 

Twenty-six patients had excellent results and three had good results. There was one poor outcome and one major complication. An excellent result was defined as pain-free activity with complete return to activity, and a poor result was defined as having persistent symptoms and inability to return to activity.

 

 

 

FIG 3 • A. An irregular and an operatively slightly deep tuberosity bone removal endoscopically. B. At 7 weeks, a radiographic lucency accompanied increased pain, limp, and tenderness with calcaneal medial/lateral compression pain compatible with stress fracture. C. At 9 weeks, clear condensation of bone further confirms stress fracture. D. Sagittal T1 optional MRI shows unequivocal stress fracture of bone.

 

 

The cohort was stratified into “daily athletic activity” and “athletic” groups and the groups were compared. No statistical differences in outcome between the two groups existed.

 

All patients reported satisfaction with the cosmetic appearance of their portal sites.

 

These results compared with those published by van Dijk et al16: Their 20 patients resumed participating in sports at an average of 12 weeks.

 

COMPLICATIONS

One major complication occurred among the 30 heels: A patient sustained a proximal Achilles tendon rupture (of an unprotected tendon) 19 days after having undergone endoscopic decompression while ambulating without a prescribed protected walker boot.12

There were no intraoperative or skin or soft tissue complications (ie., wound dehiscence and postoperative

 

infection).

No patients reported a painful scar or neuroma-type symptoms.

Stress fracture can result if there is “irregular” bony removal coupled with early leg-based activity (FIG 3A-D).

 

 

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REFERENCES

1. Angermann P. Chronic retrocalcaneal bursitis treated by resection of the calcaneus. Foot Ankle 1990;10:285-287.

    

2. Bohu Y, Lefèvre N, Bauer T, et al. Surgical treatment of Achilles tendinopathies in athletes. Multicenter retrospective series of open surgery and endoscopic techniques. Orthop Traumatol Surg Res 2009;95(8 suppl 1):S72-S77.

    

3. Frey C, Rosenburg Z, Shereff MJ, et al. The retrocalcaneal bursa: anatomy and bursography. Foot Ankle 1992;13:203-207.

    

4. Haglund P. Beitrag zur Klinik der Achillessehne. Zeitschr Orthop Chir 1928;49:49-58.

    

5. Kennedy JC, Willis RB. The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study. Am J Sports Med 1976;4:11-21.

    

6. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349-353.

    

7. Leach RE, Dilorio E, Harney RA. Pathologic hindfoot conditions in the athlete. Clin Orthop Relat Res 1983; (177):116-121.

    

8. Leitze Z, Sella EJ, Aversa JM. Endoscopic decompression of the retrocalcaneal space. J Bone Joint Surg Am 2003;85-A(8):1488-1496.

    

9. Lohrer H, Nauck T. Retrocalcaneal bursitis but not Achilles tendinopathy is characterized by increased pressure in the retrocalcaneal bursa. Clin Biomech 2014;29(3):283-288.

    

10. Lohrer H, Nauck T, Dorn NV, Konerding MA. Comparison of endoscopic and open resection for Haglund tuberosity in a cadaver study. Foot Ankle Int 2006;27(6):445-450.

     

11. Miller AE, Vogel TA. Haglund's deformity and the Keck and Kelly osteotomy: a retrospective analysis. J Foot Surg 1989;28:23-29.

     

12. Ortmann FW, McBryde AM. Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis. Foot Ankle Int 2007;28:149-153.

     

13. Pauker M, Katz K, Yosipovitch Z. Calcaneal ostectomy for Haglund disease. J Foot Surg 1992;31:588-589.

     

     

     

14. Scheider W, Niehus W, Knahr K. Haglund's syndrome: disappointing results following surgery—a clinical and radiographic analysis. Foot Ankle Int 2000;21:26-30.

     

     

15. van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy 2000;16:871-876.

     

     

16. van Dijk CN, van Dijk GE, Scholten PE, et al. Endoscopic calcaneoplasty. Am J Sports Med 2001;29:185-189.