SLR - May 2012 - Rotem Ben-Ad
Reference: Wu, Z., et al. (2012). Endoscopic Treatment of Haglund’s Syndrome with a Three Portal Technique. International Orthopaedics. Online First; March 2012.
Scientific Literature Review
Reviewed by: Rotem Ben-Ad, DPM
Residency Program: Cambridge Health Alliance; Cambridge, MA
Podiatric Relevance:
Posterior heel pain is a common symptom encountered in the podiatric field. Pain may be associated with derangement of the Achilles tendon, prominence of the posterosuperior calcaneus, and/or retrocalcaneal bursitis. The open procedure involves relatively extensive surgery with violation of the Achilles tendon, prolonged healing time and a risk of wound complications secondary to an avascular region. This article describes an endoscopic approach for excision of a Haglund’s deformity. This method may reduce the above-mentioned complications and allow patients to return to normal function earlier.
Methods:
This study is a retrospective analysis of 25 feet in 23 patients between the dates of January 2007 and June 2009. The mean length of symptoms was 14.9 months and mean age was 27.7 years. Diagnosis was made based on assessment of symptomatology, physical exam, plain radiographs and MRI. All patients exhausted at least six months of conservative treatment. Exclusion criteria included Achilles tendinopathy, partial and full rupture of the Achilles tendon, cavus foot, varus foot, and posterior heel pain resulting from rheumatoid arthritis.
Surgical Technique: In the three portal technique, the first portal was made just lateral to the Achilles tendon and 5cm proximal to the Achilles tendon insertion. With a 4mm 30 degree endoscope, this portal was used to visualize the entrance point of the two distal portals; one being medial to the Achilles tendon and the other lateral. These were placed adjacent to the Achilles tendon at the level of the superior border of the calcaneus. First, the retrocalcaneal bursa was excised with a shaver through both distal portals with the scope placed at the proximal portal. View of the calcaneal prominence was also mainly acquired through the proximal portal. It was found that fibrous cartilage covering the calcaneal prominence and the anterior aspect of the Achilles tendon formed a joint-like structure. The location of the impingement was found when the foot was maximally dorsiflexed. Excision of the calcaneal prominence was again performed via the distal portals using a burr. This was done with the foot maximally plantarflexed. The foot was placed through range of motion to determine the amount of bony resection necessary. Elimination of impingement in maximal dorsiflexion was indicative of adequate resection. Lastly, the Achilles tendon was inspected and debrided as necessary. Postoperatively, the patients were instructed to perform range of motion exercises. After two weeks of partial weight bearing, patients were allowed to gradually increase weight-bearing status. At eight weeks, normal footwear was allowed and physical activity was prohibited for the first three months. Outcomes were evaluated based on parallel pitch lines on radiographs, AOFAS scores, as well as the Ogilvie Harris score.
Results:
Average follow-up was 41 months. In 22 feet, the lateral radiographs showed adequate bony excision with negative parallel pitch lines. Three heels still demonstrated a positive parallel pitch line. The average AOFAS score improved from 63.3 points pre-operatively to 86.8 points at last follow-up. AOFAS scores included 14 excellent results, seven good results, two fair and two poor results. There were 15 excellent results, seven good, one fair, and two poor results for the Ogilvie Harris score. It should be noted that both poor results in both scoring systems came from the same patient with bilaterally affected heels. No neurovascular damage or infections were encountered.
Conclusions:
The endoscopic approach to excision of Haglund’s deformity seems to be a viable, less traumatic means of treatment for this diagnosis. Even as compared to a two portal system, the three portal approach allows easy manipulation with good visualization of the calcaneal prominence. To truly be confident in this technique, however, more randomized controlled studies are required with more patients and a longer follow up period.