SLR - October 2020 - Nishit Vora

Transtendinous Approach Calcaneoplasty Versus Endoscopic Calcaneoplasty for Haglund’s Disease

Reference: Cusumano A, Martinelli N, Bianchi A, Bertelli A, Marangon A, Sansone V. Transtendinous Approach Calcaneoplasty Versus Endoscopic Calcaneoplasty for Haglund’s Disease [published online ahead of print, 2020 Aug 7]. Int Orthop. 2020;10.1007/s00264-020-04761-0. doi:10.1007/s00264-020-04761-0

Scientific Literature Review

Reviewed By: Nishit Vora, DPM, MPH
Residency program: St. Mary’s Medical Center – San Francisco, CA

Podiatric Relevance: Haglund’s disease is characterized by a clinical triad of retrocalcaneal bursitis, posterosuperior calcaneal deformity and insertional Achilles tendinopathy. It is a very common disease treated by podiatrists. Conservative treatment is initiated primarily but more than fifty percent of patients require surgical intervention. The surgical procedure has historically been an open procedure, but recent advancements have allowed for endoscopic repair with favorable results in patients. This paper focuses on the comparison of the two surgical methods.

Methods: This was a retrospective review of patients with Haglund’s disease between 2014 and 2018. Patients with ipsilateral ankle OA, previous foot surgery, hindfoot valgus/varus of more than 10 degrees, and Achilles insertional spurring over 50 percent were excluded. Patients were placed in the prone position using regional anaesthesia. The endoscopic group used 2 4.0mm arthroscopic para-Achilles portals. Bursectomy was performed followed by calcaneoplasty using a shaver. In the open group, a longitudinal medial incision was performed follow by bursectomy and retrocalcaneal exostoses resection. The tendon was reattached with non-absorbable suture anchors. Post-operatively, patients were casted and non-weightbearing for 2 weeks until sutures were removed. In the open group, patients were non-weightbearing for another two weeks and in the endoscopic group patients were allowed partial weightbearing the day after surgery with crutches. AOFAS, FFI, VAS, and satisfaction scores were recorded for both groups. 

Results: This study compared 54 patients, 28 of which underwent the open calcaneoplasty and 26 underwent endoscopic surgery. Mean follow up was 66.8 months in the open group and 39.9 months in the endoscopic group. AOFAS scores improved in both groups; from an average of 65.67 to 91.78 in the open group, and 66.69 to 93.69 in the endoscopic group, both statistically significant (P < 0.05). VAS and FFI scores also improved tremendously in both groups with statistical significance (P < .001). Twenty-five of 28 patients were very satisfied with the open procedure and 23 of 26 in the endoscopic group. There was one major complication in the open group of an acute Achilles tendon rupture that was treated conservatively. 

Conclusions: The authors concluded that their study was able to illustrate favorable clinical and functional outcomes in the endoscopic and the open groups which were statistically significant but there was no statistical significance found between the two groups. The limitations in this study include the small sample size and no randomization. The post-operative periods were also not standardized, and the longer post-operative period could correlate to further discomfort. There were few complications in both groups rendering them both viable surgical options. The endoscopic group allows for quicker return to activity and the open option allows for better visualization and resection of the retrocalcaneal exostosis. Historically, aggressive resection of the exostosis/enthesiophyte is necessary for relief of symptoms but can be very difficult endoscopically. Open repair is likely to be the most beneficial in most patients with both a large exostosis and insertional enthesiophyte, but endoscopic debridement is also viable for just a retrocalcaneal exostectomy.   

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