Endoscopic Haglund's Resection and Percutaneous Double-Row Insertional Achilles Repair

Haglund resection versus Haglund non-resection for calcific insertional Achilles tendinopathy with Haglund deformity: A retrospective study

BACKGROUND

Calcific insertional Achilles tendinopathy(CIAT) with Haglund deformity is a type of recalcitrant tendinopathy. The necessity of concomitant removal of Haglund deformity during CIAT treatment is controversial. The present study aimed to evaluate the functional outcomes between Haglund resection and Haglund non-resection in the treatment of CIAT with Haglund deformity.

METHODS

A retrospective study included 29 patients who were underwent Achilles tendon debridement, bursal excision, and subsequent tendon reattachment.for CIAT with Haglund deformity. All patients were divided into 2 groups according to Haglund resection (resection group, n = 16) and Haglund non-resection (non-resection group, n = 13) using the parallel line method on lateral calcaneal X ray after surgery. Patients were evaluated in terms of the American Orthopedic Foot and Ankle Society (AOFAS), Visual Analog Scale (VAS) and Victorian Institute of Sports Assessment-Achilles (VISA-A) scores and the mean time of activities of daily living (ADL). Anatomy changes included the Fowler-Philip angle, calcaneal pitch angle and Achilles tendon force arm were measured with radiography preoperatively and postoperatively.

RESULTS

Both groups exhibited a significant increase in AOFAS, VAS and VISA-A scores after surgery. There were no significant differences between the resection group and the non-resection group for the AOFAS (92.38 ± 5.7 vs. 93.15 ± 12.17; P = 0.82), VAS (0.5 ± 0.52 vs. 0.61 ± 0.87; P = 0.66) and VISA-A questionnaire (82.56 ± 13.46 vs. 74.92 ± 16.4; P = 0.18) at the latest follow-up. The mean time of ADL in the non-resection group was significantly faster compared to that of the resection group (8.15 ± 2.51 weeks vs. 11.31 ± 4.06 weeks, P = 0.02). The Fowler-Philip angle of the resection group decreased from 55.55° ± 12.34° preoperatively to 44.52° ± 10.24° at the latest follow-up (P = 0.001). The Fowler-Philip angle of the non-resection group decreased from 54.38° ± 8.41° preoperatively to 46.52° ± 8.02° at the latest follow-up (P = 0.016). The calcaneal pitch angle of the resection group increased from 22.76° ± 5.37° preoperatively to 25.98° ± 6. 4° at the latest follow-up (P = 0.018). The Achilles tendon force arm of the resection group decreased from 178.50 mm ± 5.37 mm preoperatively to 173.90 mm ± 8.07 mm at the latest follow-up (P = 0.018).

CONCLUSION

Resection or non-resection of the posterosuperior calcaneal tuberosity for CIAT with Haglund deformity would both provide satisfactory functional outcomes. Haglund non-resection may expedite patients' return to their daily activities, suggesting a Haglund deformity resection may be unnecessary in the surgical treatment for CIAT with Haglund deformity.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review

Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.

Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons

There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.

Lateral approach for insertional Achilles tendinitis with Haglund deformity

Objective

The study aims to investigate the functional outcome of the lateral approach for insertional Achilles tendinitis (IAT) with Haglund deformity.

Methods

From January 2016 to September 2019, 14 cases of IAT with Haglund deformity that resisted conservative treatment received surgery in our department. A lateral approach was used to debride the bony and soft tissue and reattach the insertion of the Achilles tendon. The Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Score (AOFAS), and Victorian Institute of Sport Tendon Study Group-Achilles Tendinopathy score (VISA-A) were used to evaluate clinical outcomes.

Result

The mean patient age was 39.57 years at the time of surgery. The mean follow-up was 14.74 months. The mean VAS score significantly decreased from 4.86 ± 0.86 preoperatively to 1.21 ± 1.58 postoperatively (P < 0.001). The mean AOFAS score significantly improved from 66.64 ± 6.23 preoperatively to 90.21 ± 11.50 postoperatively (P < 0.001). The mean preoperative and the last follow-up VISA-A were 66 (range 56.75-69.25) and 86 (range 75.75-97.00) points, respectively (P < 0.05).

Conclusion

The lateral approach was effective and safe for IAT with Haglund deformity. Moreover, the mid-term functional outcome was promising.

Level of Clinical Evidence

IV.

Fluoroscopic and Endoscopic Calcaneal Exostosis Resection and Achilles Tendon Debridement for Insertional Achilles Tendinopathy Results in Good Outcomes, Early Return to Sports Activities, and Few Wound Complications

Purpose

To review the outcomes of patients with insertional Achilles tendinopathy who underwent a minimally invasive surgery: fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement.

Methods

The medical records of consecutive patients who underwent this surgery from February 2017 to July 2019 were reviewed. The inclusion criterion was ≥2-year follow-up. The exclusion criterion was another surgery performed on the ipsilateral or contralateral foot. Haglund deformity resection was not combined with this surgery. The outcomes were assessed using the visual analog scale (VAS) score and the Japanese Society for Surgery of the Foot (JSSF) scores for all patients and the Victorian Institute of Sport Assessment self-administered Achilles (VISA-A) scores for patients participating in sports activities. The Wilcoxon signed-rank test and the thresholds of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were used for statistical analyses.

Results

Forty-four patients with a mean age of 55.7 ± 11.0 years and mean body mass index of 26.0 ± 4.0 kg/m² were included. The mean follow-up duration was 2.8 ± 0.7 years. Of all participants, 22 participated in sports activities. The overall median VAS and JSSF scores improved from 64.5 to 6.5 mm and from 67.0 to 100 points, respectively (P < .001). The percentages of patients who achieved the MCID for the VAS, JSSF, and VISA-A scores were 100%, 93.2%, and 100%, respectively, and the percentages of patients who achieved the PASS for the VAS, JSSF, and VISA-A scores were 77.3%, 86.4%, and 81.8%, respectively. The median VISA-A scores improved from 40.5 to 95.0 points (P < .001). The median time to return to sport was 4.5 months. Complications included five cases of reoperation and two cases of scar sensitivity.

Conclusion

For patients with insertional Achilles tendinopathy, fluoroscopic and endoscopic calcaneal exostosis resection and Achilles tendon debridement resulted in good outcomes, early return to sports activities, and few wound complications.

Level of Evidence

IV, therapeutic case series

Management of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy is a common condition that can lead to chronic, debilitating heel pain in athletes and nonathletes alike. Conservative treatment options include activity and shoe wear modification, physical therapy, injections, and extracorporeal shock wave therapy. When nonsurgical treatment fails, surgical treatment is recommended. Although there are options aimed at preserving the tendon and débriding the retrocalcaneal bursa and excess bone formation, others are aimed at detaching the Achilles tendon to perform a thorough débridement and subsequent reattachment. Additional or alternate procedures may include a calcaneal closing wedge osteotomy, gastrocnemius lengthening, and flexor hallucis longus tendon transfer. Recent advances in suture anchor techniques further add to the complexity of available options. This review discusses the relevant anatomy, biomechanics, and pathophysiology as well as the recent available evidence for nonsurgical and surgical management of this condition to guide surgeons in selecting the most appropriate treatment for their patients.