Grand rounds: Haglund's deformity and retrocalcaneal, intratendinous spurring

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study

INTRODUCTION

Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity.

METHODS

Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures.

RESULTS

The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity.

CONCLUSION

The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise.

LEVELS OF EVIDENCE

Level IV.

Open versus endoscopic bone resection of the dorsolateral calcaneal edge: a cadaveric analysis comparing three dimensional CT scans

BACKGROUND

It has been claimed that endoscopic calcaneoplasty offers some advantages over open techniques in the surgical treatment of Haglund's deformity due to reduced postoperative complications like stiffness and pain. Bony over-resection places patients at risk of these complications. The resulting question with regard to the quantitative differences of the extent of the bone removed using these two techniques has not yet been answered. The purpose of the study was to determine the resection volume of calcaneal bone for open and endoscopic surgical techniques.

METHODS

16 feet obtained from body donors were operated on in equal parts using either open surgical or endoscopic techniques, with the technique selected on a random basis. High-resolution CT scans were obtained before and after the interventional procedure and analysed to obtain 3-D polygon models. Post-operative models were subtracted from pre-operative models to provide the volume change resulting from the intervention. This was then correlated with the bone mineral density (BMD) of the preparation.

RESULTS

The extent of bony resection was greater in open surgical techniques than in endoscopic approaches. The average volume of bone resection was 0.80 (±0.34) cm(3) in the endoscopic group and 3.04 (±2.91) cm(3) in the group that underwent open surgery. After adjustment for bone mineral density the extent of the resection was significantly larger (p = 0.018) in the group undergoing open surgery. The two groups did not differ significantly with regard to BMD (p > 0.1). The extent of the resection fell by 0.011 cm(3) per 1 mg/cm(3) areal bone mineral density, i.e., a slightly lower degree of bone resection was associated with a higher bone mineral density.

CONCLUSIONS

Assuming that the resection volume was adequate to treat the patient's complaints a smaller resection volume seen in our study using an endoscopic technique might lead to fewer postoperative complaints and faster recovery.

Endoscopic calcaneoplasty

This article describes the technique of endoscopic calcaneoplasty and the results of a consecutive group of patients that was treated in the prone position in the authors' hospital.

Results of chronic Achilles tendinopathy surgery on elite and nonelite track athletes

Twenty-seven track athletes/runners with chronic Achilles tendinopathy underwent a retrospective review of 37 surgical Achilles procedures performed between 1990 and 1999. There were 22 males and 5 females. Average age of the group was 36.6 years (range, 16-75 years). The mean "return to activity" (RTA) was 10.6 +/- 6.3 weeks. For elite athletes, RTA was 7.9 = 4.8 weeks. For nonelite athletes, RTA was 15.0 +/- 6.2 weeks, and was statistically higher (p = .003). There was no significant difference between males' and females' RTA. Average follow-up for the group was 4.7 years (range, 1-10 years). Runners on average ran more than 60 miles a week. There were 14 elite and 13 nonelite athletes, including four Olympians, five sub-4-minute milers, and four National Champions. Return to competition and "100%" were 25.0 and 25.4 weeks, respectively, for the elite group. Return to competition for the nonelite group was 27.0 +/- 11.0 weeks. Eighteen patients underwent peritenolysis with a mean RTA of 7.7 weeks. Of this group, four patients with concomitant bony procedures had significantly slower RTA as opposed to the 14 patients who had peritenolysis only (mean, 4.5 weeks). Four patients had Achilles debridement for mucoid degeneration, and a mean RTA of 12.8 weeks. Eleven patients had Haglund-type procedure (retrocalcaneal exostectomy) had a mean RTA of 15.1 weeks. Six Achilles tendocalcinosis repair patients had a mean RTA of 12.0 weeks. There were three reoperations, two of which were performed by the author. Using the Testa Achilles tendon surgery rating scale, this group of patients had 34 "excellent" and 3 "good" results. The patients who underwent a reoperation were able to achieve "good" or better results.